"Coral reef" atherosclerosis of the suprarenal aorta: a unique clinical entity

Localized obstruction in a suprarenal aorta of normal diameter is rare. Between 1970 and 1983, nine patients (all women, mean age 51 years) required aortic reconstruction to relieve severe lower extremity ischemia (nine patients), hypertension (nine), visceral ischemia (two), and congestive heart failure (three) caused by an eccentric, heavily calcified polypoid lesion originating from the posterior surface of the suprarenal aorta. This mass typically began at the level of the diaphragm and extended to the level of the renal arteries, almost totally occluding the aortic lumen. The rock-hard, irregular, gritty, whitish surface strongly resembled a coral reef. Elective revascularization was carried out in eight patients, and an emergency procedure was necessary in one patient who had acute aortic thrombosis with catastrophic visceral, renal, and lower extremity ischemia. The suprarenal atheroma was removed en bloc through a retroperitoneal thoracoabdominal aortic endarterectomy. Concomitant aortoiliofemoral revascularization was necessary in seven patients (five prosthetic grafts, two endarterectomies). Two patients died postoperatively. The seven long-term survivors remain asymptomatic at a mean follow-up interval of 4 years after revascularization, without evidence of recurrence of this lesion. Suprarenal "coral reef" atherosclerosis should be considered if visceral, renal, and limb ischemia is not adequately explained by the arteriographic pattern of conventional atherosclerosis. This unusual atheroma exhibited extensive calcification and metaplastic bone formation, although its precise pathophysiology remains to be defined.