Waves Across the Coral Reef Aorta: Intravascular Lithotripsy in Juxtarenal Aortic Occlusive Disease

Background: Coral reef aorta (CRA) is a rare disease characterised by rock hard intraluminal calcifications primarily localised to the visceral and juxtarenal aorta, which can cause significant stenoses, leading to visceral, renal, and lower limb ischaemia. Intravascular lithotripsy (IVL) is an innovative and promising endovascular tool for the treatment of high grade calcified stenoses. Report: A 73 year old woman presented with bilateral Rutherford class 5 chronic limb threatening ischaemia and an ankle brachial pressure index (ABPI) of 0.4 right and 0.5 left. The patient had undergone kissing iliac stenting for lifestyle limiting intermittent claudication 20 years before at another centre. Computed tomography angiography showed proximal extension of the aorto-iliac occlusive disease with near occlusive CRA in the juxtarenal aorta, and patent iliac and lower limb arteries. The patient was treated with kissing balloon IVL (two 7 x 60 mm Shockwave M5 catheters; Shockwave Medical Inc, Santa Clara, CA, USA) through bilateral percutaneous femoral access, and concomitant inflation of two 4 mm balloons to protect both renal arteries through surgical left axillary access. Patency of the aorta and iliac stents was obtained with palpable femoral and peripheral pulses. No intraprocedural complication occurred. At the six month follow up, the lesions had healed, and the patient was alive with improvement in four Rutherford classes (ABPI 0.9 for both limbs). Conclusion: Intravascular lithotripsy without any adjunctive iliac stenting could be a safe and effective therapeutic option in patients with juxtarenal CRA.