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• W2148951878 abstract "We report 2 patients who were referred for treatment of hemodynamically significant symptomatic stenosis of the aorta at the thoracoabdominal transition (coral reef aorta) that was causing abdominal angina and intermittent claudication. Both patients underwent successful transfemoral endovascular stent-graft placement and are free of symptoms, with regular findings at 6-month follow-up completion computed tomography scan. We report 2 patients who were referred for treatment of hemodynamically significant symptomatic stenosis of the aorta at the thoracoabdominal transition (coral reef aorta) that was causing abdominal angina and intermittent claudication. Both patients underwent successful transfemoral endovascular stent-graft placement and are free of symptoms, with regular findings at 6-month follow-up completion computed tomography scan. Hemodynamically significant symptomatic stenosis of the aorta—in particular at the thoracoabdominal transition—is rare [1Qvarford P.G. Reilly L.M. Sedwitz M.M. Ehrenfeld W.K. Stoney R.J. “Coral reef” atherosclerosis of the suprarenal aorta: a unique clinical entity.J Vasc Surg. 1984; 1: 903-908PubMed Google Scholar]. In symptomatic patients, treatment options include conventional surgical repair and extraanatomic revascularization with or without opening of the thorax and the abdomen [2Di Centa I. Coggia M. Javerliat I. et al.Total laparoscopic suprarenal aortic coral reef removal.J Vasc Surg. 2006; 44: 194-197Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar]. Endovascular stent-graft placement is the treatment modality of first choice in various acute and chronic thoracic and abdominal aortic pathologies [3Eggebrecht H. Nienaber C.A. Neuhauser M. et al.Endovascular stent-graft placement in aortic dissection: a meta-analysis.Eur Heart J. 2006; 27: 489-498Crossref PubMed Scopus (452) Google Scholar, 4Blum U. Voshage G. Lammer J. et al.Endoluminal stent-grafts for infrarenal abdominal aortic aneurysms.N Engl J Med. 1997; 336: 13-20Crossref PubMed Scopus (610) Google Scholar]. The procedure points out its merits especially in elderly patients and in patients with multiple comorbidities, who are generally more frail and have a diminished physiologic reserve compared with their younger counterparts [5Czerny M. Fleck T. Zimpfer D. et al.Risk factors of mortality and permanent neurologic injury in patients undergoing ascending aortic and arch repair.J Thorac Cardiovasc Surg. 2003; 126: 1296-1301Abstract Full Text Full Text PDF PubMed Scopus (86) Google Scholar].We report 2 patients who were referred to the Medical University of Vienna for treatment of hemodynamically significant symptomatic stenosis of the aorta at the thoracoabdominal transition (coral reef aorta), which had caused abdominal angina and intermittent claudication. Both patients underwent successful transfemoral endovascular stent-graft placement.TechniquePatient 1In March 2007, a 76-year-old man was admitted with a symptomatic coral reef aorta (Fig 1). The patient had undergone coronary artery bypass grafting in 2001 due to ischemic cardiomyopathy and multivessel coronary artery disease. Because of abdominal angina, a weight loss of 15 kg body weight could be observed within 3 months. His walking capacity was limited to 50 m.A thoracoabdominal computed tomography (CT) scan revealed a hemodynamically significant stenosis of the aorta at the thoracoabdominal transition as the underlying pathology. Because of his general condition and a high the European System for Cardiac Operative Risk Evaluation (EuroSCORE; numeric, 16; logistic, 66), he was not deemed suitable for conventional surgical repair. Outcome after axillobifemoral bypass grafting is not that satisfying, so an alternative approach was chosen.The patient underwent transfemoral endovascular stent-graft placement with a Gore TAG 34/150 mm prosthesis (W. L. Gore & Associates, Flagstaff, AZ). In order not to enhance embolization of atherosclerotic debris into downstream vascular beds, supportive alignment with a balloon dilatation was not performed.The patient experienced an uneventful clinical course and showed immediate relief of symptoms after the procedure. Completion CT scan before discharge revealed the stent-graft in place, restored antegrade distal perfusion, as well as already advanced expansion of the stent-graft (Fig 2). The patient was discharged 5 days after stent-graft placement and is free of symptoms, with regular findings at the 6-month follow-up completion CT scan.Fig 2A completion computed tomography scan in patient 1 taken after stent-graft was placed.View Large Image Figure ViewerDownload (PPT)Patient 2In April 2007, shortly after the first case, an 84-year-old man was admitted with a symptomatic coral reef aorta (Fig 3). The patient had no prior cardiovascular interventions. A complete workup, however, revealed several other signs of systemic obliterative atherosclerosis such as asymptomatic borderline internal carotid artery stenosis, hemodynamically nonsignificant multivessel coronary artery disease, and chronic occlusion of the celiac trunk.Fig 3A computed tomography scan shows the coral reef aorta in patient 2.View Large Image Figure ViewerDownload (PPT)The clinical symptoms in this patient were fully comparable to the symptoms of patient 1, including weight loss. Owing to his age and to the high EuroSCORE (numeric, 13; logistic, 45) conventional surgical repair was not deemed suitable. The distal end of the lesion extended down to the origin of the celiac trunk. Conveniently, the celiac trunk was chronically occluded; therefore, a sufficient distal landing zone became available. This patient also underwent transfemoral endovascular stent-graft placement with a Gore TAG 28/100 mm prosthesis.Completion CT scan before discharge revealed the stent-graft in place, restored antegrade distal perfusion, and already advanced expansion of the stent-graft (Fig 4). The patient was discharged 6 days after stent-graft placement and is free of symptoms, with regular findings at the 6-month follow-up completion CT scan.Fig 4A completion computed tomography scan in patient 2 taken after the stent-graft was placed.View Large Image Figure ViewerDownload (PPT)CommentHemodynamically significant symptomatic stenosis of the aorta at the thoracoabdominal transition is a rare finding [1Qvarford P.G. Reilly L.M. Sedwitz M.M. Ehrenfeld W.K. Stoney R.J. “Coral reef” atherosclerosis of the suprarenal aorta: a unique clinical entity.J Vasc Surg. 1984; 1: 903-908PubMed Google Scholar, 2Di Centa I. Coggia M. Javerliat I. et al.Total laparoscopic suprarenal aortic coral reef removal.J Vasc Surg. 2006; 44: 194-197Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar]. Similar to other varieties of aortic pathologies such as perforating ulcers, this so-called coral reef aorta represents an advanced stage of a severe chronic obliterative atherosclerotic systemic process. The general condition of these patients at the time of referral is usually weak, thereby potentially prohibiting conventional surgical repair consisting of multilevel invasive surgical exposure of the target vessels [6Schulte K.M. Reiher L. Grabitz K. Sandmann W. Coral reef aorta: a long-term study of 21 patients.Ann Vasc Surg. 2000; 14: 626-633Abstract Full Text PDF PubMed Scopus (39) Google Scholar].As a consequence, less invasive approaches such as axillobifemoral bypass grafting have been applied [7Agrifoglio G. Agus G.B. Castelli P. Costantini A. Bypass procedures in the management of juxtarenal aortic occlusion.J Cardiovasc Surg (Torino). 1984; 25: 43-46PubMed Google Scholar]. This approach, however, is associated with an increased risk of early and late graft failure that can potentially lead to acute malperfusion of all downstream vascular beds. Furthermore, extensive anticoagulation is required when using this approach, thus increasing the risk of coagulation-related adverse events.Endovascular stent-graft placement is the treatment modality of first choice in various acute and chronic thoracic and abdominal aortic pathologies [3Eggebrecht H. Nienaber C.A. Neuhauser M. et al.Endovascular stent-graft placement in aortic dissection: a meta-analysis.Eur Heart J. 2006; 27: 489-498Crossref PubMed Scopus (452) Google Scholar, 4Blum U. Voshage G. Lammer J. et al.Endoluminal stent-grafts for infrarenal abdominal aortic aneurysms.N Engl J Med. 1997; 336: 13-20Crossref PubMed Scopus (610) Google Scholar]; however, few experiences on the treatment of a coral reef aorta are available in the literature. Stent-graft placement may be limited by the lack of self-expanding capacity of the graft itself thereby not enabling sufficient restoration of antegrade perfusion. Detachment of atherosclerotic debris may also cause deleterious consequences by distal embolization irrespective of the affected region. In addition, owing to the location of the lesion at the thoracoabdominal transition and the anatomic proximity to vessels supplying the spinal cord, paraplegia may occur after stent-graft placement. Cerebrospinal fluid drainage in advance may therefore serve as a protective measure against this dreadful complication. Without doubt, this remains an issue with the need to be aware of.Finally, another potential concern is that the severely calcified aorta may induce accelerated fracture of the stent-graft. Nevertheless, even if a lesion within the fabric occurs, it might remain without clinical consequence, as the aim of the therapy, namely restoration of regular antegrade perfusion, has already been achieved. None of these potential adverse events have been observed in these 2 patients; nevertheless, a careful and critical case-by-case evaluation remains mandatory.In summary, endovascular stent-graft placement may turn out to serve as the treatment modality of first choice in hemodynamically significant symptomatic stenosis of the aorta at the thoracoabdominal transition by minimizing morbidity and by maximizing effectiveness and durability. Hemodynamically significant symptomatic stenosis of the aorta—in particular at the thoracoabdominal transition—is rare [1Qvarford P.G. Reilly L.M. Sedwitz M.M. Ehrenfeld W.K. Stoney R.J. “Coral reef” atherosclerosis of the suprarenal aorta: a unique clinical entity.J Vasc Surg. 1984; 1: 903-908PubMed Google Scholar]. In symptomatic patients, treatment options include conventional surgical repair and extraanatomic revascularization with or without opening of the thorax and the abdomen [2Di Centa I. Coggia M. Javerliat I. et al.Total laparoscopic suprarenal aortic coral reef removal.J Vasc Surg. 2006; 44: 194-197Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar]. Endovascular stent-graft placement is the treatment modality of first choice in various acute and chronic thoracic and abdominal aortic pathologies [3Eggebrecht H. Nienaber C.A. Neuhauser M. et al.Endovascular stent-graft placement in aortic dissection: a meta-analysis.Eur Heart J. 2006; 27: 489-498Crossref PubMed Scopus (452) Google Scholar, 4Blum U. Voshage G. Lammer J. et al.Endoluminal stent-grafts for infrarenal abdominal aortic aneurysms.N Engl J Med. 1997; 336: 13-20Crossref PubMed Scopus (610) Google Scholar]. The procedure points out its merits especially in elderly patients and in patients with multiple comorbidities, who are generally more frail and have a diminished physiologic reserve compared with their younger counterparts [5Czerny M. Fleck T. Zimpfer D. et al.Risk factors of mortality and permanent neurologic injury in patients undergoing ascending aortic and arch repair.J Thorac Cardiovasc Surg. 2003; 126: 1296-1301Abstract Full Text Full Text PDF PubMed Scopus (86) Google Scholar]. We report 2 patients who were referred to the Medical University of Vienna for treatment of hemodynamically significant symptomatic stenosis of the aorta at the thoracoabdominal transition (coral reef aorta), which had caused abdominal angina and intermittent claudication. Both patients underwent successful transfemoral endovascular stent-graft placement. TechniquePatient 1In March 2007, a 76-year-old man was admitted with a symptomatic coral reef aorta (Fig 1). The patient had undergone coronary artery bypass grafting in 2001 due to ischemic cardiomyopathy and multivessel coronary artery disease. Because of abdominal angina, a weight loss of 15 kg body weight could be observed within 3 months. His walking capacity was limited to 50 m.A thoracoabdominal computed tomography (CT) scan revealed a hemodynamically significant stenosis of the aorta at the thoracoabdominal transition as the underlying pathology. Because of his general condition and a high the European System for Cardiac Operative Risk Evaluation (EuroSCORE; numeric, 16; logistic, 66), he was not deemed suitable for conventional surgical repair. Outcome after axillobifemoral bypass grafting is not that satisfying, so an alternative approach was chosen.The patient underwent transfemoral endovascular stent-graft placement with a Gore TAG 34/150 mm prosthesis (W. L. Gore & Associates, Flagstaff, AZ). In order not to enhance embolization of atherosclerotic debris into downstream vascular beds, supportive alignment with a balloon dilatation was not performed.The patient experienced an uneventful clinical course and showed immediate relief of symptoms after the procedure. Completion CT scan before discharge revealed the stent-graft in place, restored antegrade distal perfusion, as well as already advanced expansion of the stent-graft (Fig 2). The patient was discharged 5 days after stent-graft placement and is free of symptoms, with regular findings at the 6-month follow-up completion CT scan.Patient 2In April 2007, shortly after the first case, an 84-year-old man was admitted with a symptomatic coral reef aorta (Fig 3). The patient had no prior cardiovascular interventions. A complete workup, however, revealed several other signs of systemic obliterative atherosclerosis such as asymptomatic borderline internal carotid artery stenosis, hemodynamically nonsignificant multivessel coronary artery disease, and chronic occlusion of the celiac trunk.Fig 3A computed tomography scan shows the coral reef aorta in patient 2.View Large Image Figure ViewerDownload (PPT)The clinical symptoms in this patient were fully comparable to the symptoms of patient 1, including weight loss. Owing to his age and to the high EuroSCORE (numeric, 13; logistic, 45) conventional surgical repair was not deemed suitable. The distal end of the lesion extended down to the origin of the celiac trunk. Conveniently, the celiac trunk was chronically occluded; therefore, a sufficient distal landing zone became available. This patient also underwent transfemoral endovascular stent-graft placement with a Gore TAG 28/100 mm prosthesis.Completion CT scan before discharge revealed the stent-graft in place, restored antegrade distal perfusion, and already advanced expansion of the stent-graft (Fig 4). The patient was discharged 6 days after stent-graft placement and is free of symptoms, with regular findings at the 6-month follow-up completion CT scan.Fig 4A completion computed tomography scan in patient 2 taken after the stent-graft was placed.View Large Image Figure ViewerDownload (PPT) Patient 1In March 2007, a 76-year-old man was admitted with a symptomatic coral reef aorta (Fig 1). The patient had undergone coronary artery bypass grafting in 2001 due to ischemic cardiomyopathy and multivessel coronary artery disease. Because of abdominal angina, a weight loss of 15 kg body weight could be observed within 3 months. His walking capacity was limited to 50 m.A thoracoabdominal computed tomography (CT) scan revealed a hemodynamically significant stenosis of the aorta at the thoracoabdominal transition as the underlying pathology. Because of his general condition and a high the European System for Cardiac Operative Risk Evaluation (EuroSCORE; numeric, 16; logistic, 66), he was not deemed suitable for conventional surgical repair. Outcome after axillobifemoral bypass grafting is not that satisfying, so an alternative approach was chosen.The patient underwent transfemoral endovascular stent-graft placement with a Gore TAG 34/150 mm prosthesis (W. L. Gore & Associates, Flagstaff, AZ). In order not to enhance embolization of atherosclerotic debris into downstream vascular beds, supportive alignment with a balloon dilatation was not performed.The patient experienced an uneventful clinical course and showed immediate relief of symptoms after the procedure. Completion CT scan before discharge revealed the stent-graft in place, restored antegrade distal perfusion, as well as already advanced expansion of the stent-graft (Fig 2). The patient was discharged 5 days after stent-graft placement and is free of symptoms, with regular findings at the 6-month follow-up completion CT scan. In March 2007, a 76-year-old man was admitted with a symptomatic coral reef aorta (Fig 1). The patient had undergone coronary artery bypass grafting in 2001 due to ischemic cardiomyopathy and multivessel coronary artery disease. Because of abdominal angina, a weight loss of 15 kg body weight could be observed within 3 months. His walking capacity was limited to 50 m. A thoracoabdominal computed tomography (CT) scan revealed a hemodynamically significant stenosis of the aorta at the thoracoabdominal transition as the underlying pathology. Because of his general condition and a high the European System for Cardiac Operative Risk Evaluation (EuroSCORE; numeric, 16; logistic, 66), he was not deemed suitable for conventional surgical repair. Outcome after axillobifemoral bypass grafting is not that satisfying, so an alternative approach was chosen. The patient underwent transfemoral endovascular stent-graft placement with a Gore TAG 34/150 mm prosthesis (W. L. Gore & Associates, Flagstaff, AZ). In order not to enhance embolization of atherosclerotic debris into downstream vascular beds, supportive alignment with a balloon dilatation was not performed. The patient experienced an uneventful clinical course and showed immediate relief of symptoms after the procedure. Completion CT scan before discharge revealed the stent-graft in place, restored antegrade distal perfusion, as well as already advanced expansion of the stent-graft (Fig 2). The patient was discharged 5 days after stent-graft placement and is free of symptoms, with regular findings at the 6-month follow-up completion CT scan. Patient 2In April 2007, shortly after the first case, an 84-year-old man was admitted with a symptomatic coral reef aorta (Fig 3). The patient had no prior cardiovascular interventions. A complete workup, however, revealed several other signs of systemic obliterative atherosclerosis such as asymptomatic borderline internal carotid artery stenosis, hemodynamically nonsignificant multivessel coronary artery disease, and chronic occlusion of the celiac trunk.The clinical symptoms in this patient were fully comparable to the symptoms of patient 1, including weight loss. Owing to his age and to the high EuroSCORE (numeric, 13; logistic, 45) conventional surgical repair was not deemed suitable. The distal end of the lesion extended down to the origin of the celiac trunk. Conveniently, the celiac trunk was chronically occluded; therefore, a sufficient distal landing zone became available. This patient also underwent transfemoral endovascular stent-graft placement with a Gore TAG 28/100 mm prosthesis.Completion CT scan before discharge revealed the stent-graft in place, restored antegrade distal perfusion, and already advanced expansion of the stent-graft (Fig 4). The patient was discharged 6 days after stent-graft placement and is free of symptoms, with regular findings at the 6-month follow-up completion CT scan.Fig 4A completion computed tomography scan in patient 2 taken after the stent-graft was placed.View Large Image Figure ViewerDownload (PPT) In April 2007, shortly after the first case, an 84-year-old man was admitted with a symptomatic coral reef aorta (Fig 3). The patient had no prior cardiovascular interventions. A complete workup, however, revealed several other signs of systemic obliterative atherosclerosis such as asymptomatic borderline internal carotid artery stenosis, hemodynamically nonsignificant multivessel coronary artery disease, and chronic occlusion of the celiac trunk. The clinical symptoms in this patient were fully comparable to the symptoms of patient 1, including weight loss. Owing to his age and to the high EuroSCORE (numeric, 13; logistic, 45) conventional surgical repair was not deemed suitable. The distal end of the lesion extended down to the origin of the celiac trunk. Conveniently, the celiac trunk was chronically occluded; therefore, a sufficient distal landing zone became available. This patient also underwent transfemoral endovascular stent-graft placement with a Gore TAG 28/100 mm prosthesis. Completion CT scan before discharge revealed the stent-graft in place, restored antegrade distal perfusion, and already advanced expansion of the stent-graft (Fig 4). The patient was discharged 6 days after stent-graft placement and is free of symptoms, with regular findings at the 6-month follow-up completion CT scan. CommentHemodynamically significant symptomatic stenosis of the aorta at the thoracoabdominal transition is a rare finding [1Qvarford P.G. Reilly L.M. Sedwitz M.M. Ehrenfeld W.K. Stoney R.J. “Coral reef” atherosclerosis of the suprarenal aorta: a unique clinical entity.J Vasc Surg. 1984; 1: 903-908PubMed Google Scholar, 2Di Centa I. Coggia M. Javerliat I. et al.Total laparoscopic suprarenal aortic coral reef removal.J Vasc Surg. 2006; 44: 194-197Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar]. Similar to other varieties of aortic pathologies such as perforating ulcers, this so-called coral reef aorta represents an advanced stage of a severe chronic obliterative atherosclerotic systemic process. The general condition of these patients at the time of referral is usually weak, thereby potentially prohibiting conventional surgical repair consisting of multilevel invasive surgical exposure of the target vessels [6Schulte K.M. Reiher L. Grabitz K. Sandmann W. Coral reef aorta: a long-term study of 21 patients.Ann Vasc Surg. 2000; 14: 626-633Abstract Full Text PDF PubMed Scopus (39) Google Scholar].As a consequence, less invasive approaches such as axillobifemoral bypass grafting have been applied [7Agrifoglio G. Agus G.B. Castelli P. Costantini A. Bypass procedures in the management of juxtarenal aortic occlusion.J Cardiovasc Surg (Torino). 1984; 25: 43-46PubMed Google Scholar]. This approach, however, is associated with an increased risk of early and late graft failure that can potentially lead to acute malperfusion of all downstream vascular beds. Furthermore, extensive anticoagulation is required when using this approach, thus increasing the risk of coagulation-related adverse events.Endovascular stent-graft placement is the treatment modality of first choice in various acute and chronic thoracic and abdominal aortic pathologies [3Eggebrecht H. Nienaber C.A. Neuhauser M. et al.Endovascular stent-graft placement in aortic dissection: a meta-analysis.Eur Heart J. 2006; 27: 489-498Crossref PubMed Scopus (452) Google Scholar, 4Blum U. Voshage G. Lammer J. et al.Endoluminal stent-grafts for infrarenal abdominal aortic aneurysms.N Engl J Med. 1997; 336: 13-20Crossref PubMed Scopus (610) Google Scholar]; however, few experiences on the treatment of a coral reef aorta are available in the literature. Stent-graft placement may be limited by the lack of self-expanding capacity of the graft itself thereby not enabling sufficient restoration of antegrade perfusion. Detachment of atherosclerotic debris may also cause deleterious consequences by distal embolization irrespective of the affected region. In addition, owing to the location of the lesion at the thoracoabdominal transition and the anatomic proximity to vessels supplying the spinal cord, paraplegia may occur after stent-graft placement. Cerebrospinal fluid drainage in advance may therefore serve as a protective measure against this dreadful complication. Without doubt, this remains an issue with the need to be aware of.Finally, another potential concern is that the severely calcified aorta may induce accelerated fracture of the stent-graft. Nevertheless, even if a lesion within the fabric occurs, it might remain without clinical consequence, as the aim of the therapy, namely restoration of regular antegrade perfusion, has already been achieved. None of these potential adverse events have been observed in these 2 patients; nevertheless, a careful and critical case-by-case evaluation remains mandatory.In summary, endovascular stent-graft placement may turn out to serve as the treatment modality of first choice in hemodynamically significant symptomatic stenosis of the aorta at the thoracoabdominal transition by minimizing morbidity and by maximizing effectiveness and durability. Hemodynamically significant symptomatic stenosis of the aorta at the thoracoabdominal transition is a rare finding [1Qvarford P.G. Reilly L.M. Sedwitz M.M. Ehrenfeld W.K. Stoney R.J. “Coral reef” atherosclerosis of the suprarenal aorta: a unique clinical entity.J Vasc Surg. 1984; 1: 903-908PubMed Google Scholar, 2Di Centa I. Coggia M. Javerliat I. et al.Total laparoscopic suprarenal aortic coral reef removal.J Vasc Surg. 2006; 44: 194-197Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar]. Similar to other varieties of aortic pathologies such as perforating ulcers, this so-called coral reef aorta represents an advanced stage of a severe chronic obliterative atherosclerotic systemic process. The general condition of these patients at the time of referral is usually weak, thereby potentially prohibiting conventional surgical repair consisting of multilevel invasive surgical exposure of the target vessels [6Schulte K.M. Reiher L. Grabitz K. Sandmann W. Coral reef aorta: a long-term study of 21 patients.Ann Vasc Surg. 2000; 14: 626-633Abstract Full Text PDF PubMed Scopus (39) Google Scholar]. As a consequence, less invasive approaches such as axillobifemoral bypass grafting have been applied [7Agrifoglio G. Agus G.B. Castelli P. Costantini A. Bypass procedures in the management of juxtarenal aortic occlusion.J Cardiovasc Surg (Torino). 1984; 25: 43-46PubMed Google Scholar]. This approach, however, is associated with an increased risk of early and late graft failure that can potentially lead to acute malperfusion of all downstream vascular beds. Furthermore, extensive anticoagulation is required when using this approach, thus increasing the risk of coagulation-related adverse events. Endovascular stent-graft placement is the treatment modality of first choice in various acute and chronic thoracic and abdominal aortic pathologies [3Eggebrecht H. Nienaber C.A. Neuhauser M. et al.Endovascular stent-graft placement in aortic dissection: a meta-analysis.Eur Heart J. 2006; 27: 489-498Crossref PubMed Scopus (452) Google Scholar, 4Blum U. Voshage G. Lammer J. et al.Endoluminal stent-grafts for infrarenal abdominal aortic aneurysms.N Engl J Med. 1997; 336: 13-20Crossref PubMed Scopus (610) Google Scholar]; however, few experiences on the treatment of a coral reef aorta are available in the literature. Stent-graft placement may be limited by the lack of self-expanding capacity of the graft itself thereby not enabling sufficient restoration of antegrade perfusion. Detachment of atherosclerotic debris may also cause deleterious consequences by distal embolization irrespective of the affected region. In addition, owing to the location of the lesion at the thoracoabdominal transition and the anatomic proximity to vessels supplying the spinal cord, paraplegia may occur after stent-graft placement. Cerebrospinal fluid drainage in advance may therefore serve as a protective measure against this dreadful complication. Without doubt, this remains an issue with the need to be aware of. Finally, another potential concern is that the severely calcified aorta may induce accelerated fracture of the stent-graft. Nevertheless, even if a lesion within the fabric occurs, it might remain without clinical consequence, as the aim of the therapy, namely restoration of regular antegrade perfusion, has already been achieved. None of these potential adverse events have been observed in these 2 patients; nevertheless, a careful and critical case-by-case evaluation remains mandatory. In summary, endovascular stent-graft placement may turn out to serve as the treatment modality of first choice in hemodynamically significant symptomatic stenosis of the aorta at the thoracoabdominal transition by minimizing morbidity and by maximizing effectiveness and durability." @default.
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