Intravascular lithotripsy for coral reef aortic stenosis: a case series assessing feasibility, hemodynamic effects, imaging and clinical outcomes

Coral reef aorta (CRA) is defined by the presence of heavily calcified exophytic plaques that protrude into the aortic lumen. Open surgery remains the standard treatment but is associated with substantial morbidity, particularly in high-risk patients. Endovascular approaches, including intravascular lithotripsy (IVL), have emerged as less invasive alternatives. This case series aimed to evaluate the feasibility, safety, and hemodynamic impact of IVL combined with fractional flow reserve (FFR) in the treatment of calcified aortic stenoses. We present a case series of three patients with severe calcified abdominal aortic stenosis treated with IVL under FFR guidance. Pre- and post-procedural FFR measurements were used to assess lesion hemodynamic significance and treatment efficacy. All procedures were technically successful, with significant improvement in FFR values following IVL, indicating restoration of hemodynamic flow. One case was complicated by an aortic dissection, successfully managed with stent placement. In the remaining cases, IVL achieved adequate luminal gain without the need for stenting. At follow-up (up to 12 months), all patients demonstrated sustained clinical improvement and maintained vessel patency. IVL combined with FFR appears to be a feasible and effective minimally invasive approach for the management of heavily calcified aortic lesions. This strategy allows both morphological plaque modification and objective physiological assessment, potentially reducing the need for stent implantation. Larger studies are required to validate these findings.