Modern Open Surgery for Coral Reef Aorta with Visceral Artery Involvement.

Objective: Coral reef atherosclerosis of the visceral aorta (CRA) is associated with renovascular hypertension (RVH), chronic mesenteric ischaemia (CMI), and malperfusion of the lower limbs. The outcomes of open surgery for this rare disease are described in this paper.

Methods: This retrospective study included all patients who underwent open surgical repair of CRA at a single high volume referral centre between January 2009 and June 2023. The operation was preceded by pre-operative computed tomography angiography (CTA). Follow up was carried out to assess clinical improvement regarding walking, blood pressure control, and visceral and renal ischaemia. Post-operative survival and patency of the aorta and revascularised visceral arteries were evaluated by the Kaplan-Meier method.

Results: Thirty eight patients, with a mean age of 65 years and predominantly women (57.9%), were included in the study. The surgical indication was RVH in 40.6%, CMI in 25%, and malperfusion of the lower limbs in 71.9% of patients. All procedures were performed by left lumbotomy, with re-implantation or visceral and or renal artery bypass in 15 patients (39.5%) and 17 (44.7%) cases of simultaneous infrarenal aortic revascularisation. One death (2.6%) secondary to acute mesenteric ischaemia occurred post-operatively. Three patients (7.9%) presented with myocardial infarction and 11 (28.9%) with post-operative acute kidney failure without haemodialysis. Median follow up was 32.5 months. Post-operatively, all patients with CMI and claudication became asymptomatic, and 17 (56.7%) showed improved hypertension. Six patients needed repeat visceral artery revascularisation. No CRA related death occurred during follow up. Survival rates were 91.9% and 61.6% at one and five years, respectively.

Conclusion: Visceral aortic endarterectomy by left sided lumbotomy, preceded by multiplanar reconstruction CTA, is a safe and effective procedure for CRA, with low operative mortality and acceptable morbidity rates. Long term clinical monitoring by colour duplex scan or CTA is recommended due to a risk of re-stenosis of the endarterectomised visceral arteries.