IVUS-Assisted Intravascular Lithotripsy for the Treatment of a Paravisceral Coral Reef Aorta With a New Large Diameter Balloon Catheter: Case Report.

Background: Coral reef aorta (CRA) is a rare and complex form of atherosclerosis, characterized by heavily calcified plaques in the abdominal aorta mainly infrarenal. In case of affecting the orifice of the superior mesenteric artery and the celiac trunk, treatment harbors the high risk of aortic rupture and 2-cavity urgent repair, peripheral, and visceral embolization.

Case summary: We report a novel endovascular treatment for a paravisceral CRA in a 78-year-old female patient with severe peripheral arterial disease, consisting of a combination of intravascular ultrasound (IVUS) and lithotripsy-assisted angioplasty with the new low-pressure large (L6, Shockwave^®) balloon catheter. The balloon catheter reached 12 mm diameter with a low pressure of only 2 atm, avoiding high pressure and the risk of aortic rupture in an area in which a thoracoabdominal urgent repair and clamping would be associated with high morbidity and mortality. This approach resulted in an increase of the luminal gain based on IVUS measurements and improved infrastenotic blood pressure of 30 mmHg. The patient experienced resolution of the clinical symptoms, pulpable peripheral pulses, and sustained primary patency at the 6-month follow-up. This first reported case illustrates the effectiveness and safety of IVUS-assisted intravascular lithotripsy for paravisceral CRA with a new low-pressure balloon.Clinical ImpactTreatment of coral reef aorta affecting the renovisceral segment could be complex as endarterectomy at this level requires 2-cavity surgery and an endovascular treatment with angioplasty/ stent implantation includes the risk of rupture. Endovascular treatment of such lesions with the use of the new L6 ultralow-pressure IVL balloon (Shockwave Medical) with IVUS assessment could be a significant minimally invasive treatment option due to luminal gain with the use of a large (up to 12mm) IVL Balloon, inflated at 2-4 atmosphares minimizing the risk of rupture.