Serial computed tomography (CT) documented progressive coral reef aorta leading to near-complete abdominal aortic obstruction in a patient whose lower extremity symptoms were initially attributed to lumbar disc herniation.
In a case report, researchers described a 50-year-old male patient with a history of smoking, hypertension, and hyperlipidemia who presented with progressively worsening bilateral lower extremity symptoms. Four years prior to presentation, he developed bilateral leg numbness and was diagnosed with lumbar disc herniation based on magnetic resonance imaging. About 1 year prior to presentation, he developed intermittent claudication after 10 minutes of walking, followed by severe bilateral rest pain 1 month prior to presentation. The researchers reviewed serial CT scans obtained over 6 years to evaluate the progression of aortic calcification.
Clinical assessments included physical examination, ankle-brachial index (ABI) measurements, and abdominal CT to characterize the extent of vascular obstruction. Postoperative evaluations assessed restoration of lower extremity perfusion, symptom resolution, and graft patency. At 1-year follow-up, repeat ABI measurements and contrast-enhanced CT were used to evaluate sustained improvement.
At presentation, the patient had weak bilateral femoral pulses and barely palpable distal lower extremity pulses. His ABI was 0.49 bilaterally compared with measurements of 0.99 on the right and 1.07 on the left obtained 6 years earlier. Abdominal CT demonstrated dense, protruding calcified plaques extending more than 4 cm along the infrarenal abdominal aorta, resulting in near occlusion. Review of earlier scans showed progressive calcification originating from the posterior aortic wall and extending into the aortic lumen.
Because extensive circumferential calcification raised concerns about distal embolization and inadequate stent expansion, endovascular treatment was considered unsuitable. The patient underwent open aortic graft replacement from below the renal arteries to the proximal aortic bifurcation, with reconstruction of the inferior mesenteric artery, 14 days postpresentation.
By postoperative day 4, the ABI had improved to 1.13 on the right and 1.19 on the left, with restoration of palpable femoral and dorsalispedis pulses. Intermittent claudication and rest pain resolved, and the patient was discharged without complications. At 1-year follow-up, the ABI was 1.07 bilaterally, and the patient remained asymptomatic with sustained improvement in daily physical activity. Contrast-enhanced CT confirmed patency of the prosthetic graft and reconstructed inferior mesenteric artery.
Coexisting lumbar disc herniation likely masked the underlying vascular disorder, contributing to delayed diagnosis. They emphasized that coral reef aorta should be considered in patients with unexplained lower extremity ischemia, particularly when symptoms are bilateral, progressive, or disproportionate to peripheral arterial findings. Serial CT helped characterize the extent and progression of calcification, informing treatment selection.
Endovascular treatment may be considered in selected patients with high surgical risk or limited disease extent. However, extensive calcification can restrict stent expansion and increase the risk of distal embolization or vessel injury, making open surgical reconstruction a more suitable option in advanced cases.
The findings were limited by the single-patient design, which prevented conclusions about the comparative effectiveness of open surgery vs. endovascular treatment. The extent to which the initial diagnosis delayed recognition of vascular disease also could not be established definitively. The 1-year follow-up did not establish longer-term graft durability or the risk of recurrent vascular complications.
The case highlighted the importance of considering coral reef aorta in patients with progressive bilateral lower extremity ischemic symptoms, particularly when coexisting conditions may obscure vascular disease. “Treatment selection should be individualized based on anatomical characteristics and patient risk profile,” wrote lead study authorTsuneakiKawashima, MD, PhD, and Masaki Harada, MD, both of the Department of Cardiology at Tango Central Hospital in Japan, and colleagues.
The study authors reported no conflicts of interest and no funding.
