Case of the month : Infrarenal Aortic Calcification: A Wolf in Sheep’s Clothing.

This case was contributed by 

1 Dr Nadia Qazi ,Rutgers University New Brunswick USA

2.Dr Munaza Afaq 3 Dr.Pravin Patil, and 4.Dr. Riyaz Bashir 

(Temple University Hospital, Heart and Vascular Institute. )

For any queries email (nadianqazi@gmail.com) 

Clinical scenario :

A 62-year-old male with end-stage renal disease and peripheral arterial disease (PAD) status post two-failed kidney transplants was scheduled for a coronary angiogram during the redo transplant workup.

The interventional cardiologist, who was concerned about aortoiliac disease, reviewed the patient’s prior CT abdomen and pelvis.

This demonstrated severe calcification of the infrarenal aorta, prompting dedicated subtraction angiography and hemodynamic assessment.

The initial anterior-posterior view of the infrarenal aorta did not reveal any significant stenosis.

However, a critical stenosis was detected on the lateral view and confirmed with an

intravascular ultrasound 1.

An angioplasty was performed, and a 10x39mm Palmaz bare metal stent (Johnson & Johnson Interventional Systems Co., Warren, NJ) was deployed.

Teaching message

Clinicians should consider infrarenal aortic stenosis in patients with severe aortic calcification in a renal transplant workup, as it may lead to allograft hypo-perfusion and failure.

CT imaging can help identify this calcification, which should then prompt an investigation for a hemodynamic assessment of the stenosis.

In addition, we should have a low threshold for performing aortograms in lateral view, as it is crucial to identifying the infrarenal aortic stenosis due to a posterior plaque.

References

Steven E. Nissen, MD; Paul Yock. Intravascular Ultrasound: Novel Pathophysiological Insights and Current Clinical Applications. Circulation. 2001; 103: 604-616.

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