Takayasu's Arteritis Involving the Ostia of Three Large Coronary Arteries.

Abstract

Takayasu's arteritis can involve the ostia of coronary arteries. We report a patient with Takayasu's arteritis involving the ostia of three large coronary arteries who was successfully treated by percutaneous coronary intervention (PCI) with a drug-eluting stent (DES) and had a good clinical outcome after 12 months. A 37-year-old male with unstable angina was admitted to our cardiovascular center. The patient had Takayasu's arteritis and an aortic valve replacement with a metallic valve due to severe aortic regurgitation 7 years previously. Coronary angiography (CAG) showed a 95% discrete eccentric luminal narrowing at the ostia of the large left anterior descending (LAD) and left circumflex (LCX) arteries, and a 99% discrete eccentric luminal narrowing at the ostium of the large right coronary artery (RCA). The patient was treated with prednisolone for 14 days. Two large paclitaxel-eluting stents (PES) were then implanted in the distal left main coronary artery using the kissing stent technique. After 6 months, a CAG did not reveal restenosis or recurrent coronary artery disease. Thus, PCI with a DES for patients with significant coronary involvement secondary to Takayasu's arteritis is an effective and an alternative treatment when coronary bypass grafting is not option.

Full text

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551
CASE REPORT
DOI 10.4070 / kcj.2009.39.12.551
Print ISSN 1738-5520 / On-line ISSN 1738-5555
Copyright ⓒ 2009 The Korean Society of Cardiology
Open Access
Takayasu’s Arteritis Involving the Ostia
of Three Large Coronary Arteries

Jin-Sup Park, MD, Han Cheol Lee, MD, Sang-Kwon Lee, MD, Sang-Pil Kim, MD,
Yeong Dae Kim, MD, Min Soo Ahn, MD and Taek Jong Hong, MD
Department of Internal Medicine/Cardiac Catheterization Laboratory, Pusan National University Hospital, Busan, Korea

ABSTRACT

Takayasu’s arteritis can involve the ostia of coronary arteries. We report a patient with Takayasu’s arteritis involv-
ing the ostia of three large coronary arteries who was successfully treated by percutaneous coronary intervention
(PCI) with a drug-eluting stent (DES) and had a good clinical outcome after 12 months. A 37-year-old male with
unstable angina was admitted to our cardiovascular center. The patient had Takayasu’s arteritis and an aortic valve
replacement with a metallic valve due to severe aortic regurgitation 7 years previously. Coronary angiography (CAG)
showed a 95% discrete eccentric luminal narrowing at the ostia of the large left anterior descending (LAD) and
left circumflex (LCX) arteries, and a 99% discrete eccentric luminal narrowing at the ostium of the large right cor-
onary artery (RCA). The patient was treated with prednisolone for 14 days. Two large paclitaxel-eluting stents (PES)
were then implanted in the distal left main coronary artery using the kissing stent technique. After 6 months, a
CAG did not reveal restenosis or recurrent coronary artery disease. Thus, PCI with a DES for patients with signi-
ficant coronary involvement secondary to Takayasu’s arteritis is an effective and an alternative treatment when cor-
onary bypass grafting is not option. (Korean Circ J 2009;39:551-555)

KEY WORDS: : Takayasu arteritis; Stents; Angioplasty; Unstable angina.


Introduction

Takayasu’s arteritis can affect the ostia of the left main
and right coronary arteries.1-3) Involvement of a coro-
nary artery is associated with chronic inflammation, pre-
mature atherosclerosis, and systemic vasculitis. A coro-
nary artery bypass graft (CABG) with internal thoracic
arteries is not used because the internal thoracic arteries
are also involved in the inflammatory process and the
subclavian arteries are occluded. Large saphenous venous
grafts are usually grafted from the aorta to the affected
coronary artery.4)5) Percutaneous coronary intervention
(PCI) with a bare metal stent (BMS) has been perform-
ed successfully in patients with Takayasu’s arteritis, but
there is a high rate of restenosis due to inflammation.6)7)
There is limited data available on PCI with drug-elut-
ing stent (DES) in patients with coronary involvement
secondary to Takayasu’s arteritis.1)3) We describe a pa-
tient with Takayasu’s arteritis involving the ostia of three
large coronary arteries who was successfully treated by
PCI with DES and had a good clinical outcome after
12 months.

Case

A 37-year-old male with unstable angina was admit-
ted to our cardiovascular center. The patient had Taka-
yasu’s arteritis and an aortic valve replacement with a
metallic valve due to severe aortic regurgitation 7 years
previously. The patient had no risk factors for cardiovas-
cular disease, such as diabetes mellitus, hypertension, hy-
percholesterolemia, alcohol abuse, or smoking. He had
mild claudication in the right leg. There was no history
of immunosuppressive drug use. The blood pressure
was 70/40 mmHg in an arm and 120/80 mmHg in a
Received: July 19, 2009
Accepted: July 31, 2009
Correspondence: Han Cheol Lee, MD, Department of Internal Medicine/
Cardiac Catheterization Laboratory, Pusan National University Hospital, 10
Ami-dong 1-ga, Seo-gu, Busan 602-739, Korea
Tel: 82-51-240-7794, Fax: 82-51-240-7796
E-mail: glaraone@hanmail.net

○ cc This is an Open Access article distributed under the terms of the Creative
Commons Attribution Non-Commercial License (http://creativecommons.
org/licenses/by-nc/3.0) which permits unrestricted non-commercial use,
distribution, and reproduction in any medium, provided the original work is
properly cited.

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552·Takayasu’s Arteritis Involving Coronary Arteries

A A
B B
Fig. 1. Initial coronary angiography. A: selective left coronary angiography shows 95% discrete eccentric luminal narrowing at the ostium of
the large LAD and large LCX. B: selective right coronary angiography shows 99% discrete eccentric luminal narrowing at the ostium of the
large RCA. LAD: left anterior descending, LCX: left circumflex, RCA: right coronary artery.
A A
B B
C C
D D
Fig. 2. Angiography of systemic vessels. A and B: right and left subclavian arteries reveal total occlusion. C: ostium of the right renal artery
shows 80% luminal narrowing. D: right superficial femoral artery shows total occlusion with collateral flow.

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Jin-Sup Park, et al.·553

leg. The right and left radial pulses were not palpable.
An electrocardiography (ECG) revealed a left ventricle
hypertrophy pattern; there were T wave inversions at V3-
V6, I, and aVL, and ST segment depression in II, III,
and aVF. The cardiac enzymes were normal (troponin-
I, 0.01 ng/mL; and creatine kinase-MB, 3 mg/L). The
2-D echocardiography showed an ejection fraction (EF)
of 44%, the left ventricle end diastolic dimension (LV-
EDD) was 68 mm, the left ventricle end systolic dimen-
sion (LVESD) was 56 mm, and there was a mild decrease
in left ventricle systolic function and global hypokinesia.
Coronary angiography (CAG) showed a 95% discrete ec-
centric luminal narrowing at the ostium of the large left
anterior descending (LAD) and left circumflex (LCX)
arteries, and 99% discrete eccentric luminal narrowing
at the ostium of the large right coronary artery (RCA)
(Fig. 1). The diameter of each coronary artery was >5
mm. The right and left subclavian arteries were com-
pletely occluded (Fig. 2A and B). There was no stenosis
noted in the left and right carotid arteries. The ostium of
the right renal artery had 80% luminal narrowing (Fig.
2C). The right superficial femoral artery was totally oc-
cluded with flow through a number of collateral vessels
(Fig. 2D). The erythrocyte sedimentation rate (ESR) and
C-reactive protein (CRP) level were 72 mm/h and 8.2
mg/dL, respectively.
Based on the clinical and angiographic findings, the
patient was diagnosed with Takayasu’s arteritis. We re-
commended CABG, but the patient did not want to un-
dergo surgery. We delayed PCI because the disease was
in an active stage. The patient was treated with predni-
solone (60 mg/day) for 14 days. The ESR and CRP de-
creased to 32 mm/h and 1.2 mg/dL, respectively, after 2
weeks of treatment. An intra-aortic balloon pump (IABP)
was used prior to the PCI. The ostium of the RCA was
predilated with an undersized balloon {4.0 mm×20 mm
at 8 atmosphere (atm)}. A large 5.0×12 mm paclitaxel-
eluting stent (TAXUS Liberte; Boston Scientific, USA)
was implanted at 16 atm (Fig. 3A). The ostia of the LAD
and LCX arteries were sequentially predilated with an
undersized balloon (4.0 mm×20 mm at 8 atm). Two
large paclitaxel-eluting stents were implanted from the
distal left main coronary artery to the LAD and LCX
using the kissing stent technique (LAD, 5.0 mm×24
A A
B B
CC
DD
E E
F F
Fig. 3. Coronary angiography (A-D) and IVUS (E and F) during PCI. A and B: a large 5.0×12 mm paclitaxel-eluting stent is implanted in the os-
tium of the RCA. C and D: two large paclitaxel-eluting stents are implanted from the distal left main coronary artery to the LAD and LCX
by the kissing stent technique (LAD: 5.0 mm×24 mm at 14 atm, LCX; 5.0×16 mm at 14 atm). E and F: IVUS show good apposition of
kissing stents minimally overlapped from the distal left main coronary artery to the LAD and LCX. RCA: right coronary artery, LAD: left
anterior descending, LCX: left circumflex, IVUS: Intravascular ultrasound, PCI: percutaneous coronary intervention.

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554·Takayasu’s Arteritis Involving Coronary Arteries

mm at 14 atm; and LCX, 5.0×16 mm at 14 atm) (Fig. 3B,
C and D). An intravascular ultrasound (IVUS) showed
good apposition of the kissing stents with minimal over-
lapping from the distal left main coronary artery to the
LAD and LCX (Fig. 3E and F). The patient was dis-
charged 5 days later on warfarin, aspirin, clopidogrel, a
beta-blocker, a statin, nitrate, and prednisolone. There
was no discomfort except for skin ecchymoses. We per-
formed a follow-up CAG, two-dimensional (2D) echo-
cardiography, and IVUS 6 months later. The CAG did
not show restenosis or recurrence of coronary artery dis-
ease (Fig. 4A and B). The IVUS showed little neointimal
proliferation and stent malapposition in the distal part
of the LAD stent (Fig. 4C and D). The 2D echocardio-
graphy showed that the EF was 52%, the LVEDD was
64 mm, and the LVESD was 50 mm with global hypo-
kinesia. We decreased the dose of prednisolone. The pa-
tient took 20 mg of prednisolone after discharge with-
out complication. There no adverse clinical event after
12 months.

Discussion

Takayasu’s arteritis is an idiophatic large vessel vas-
culitis that is characterized by involvement of the aorta
and its major branches. Clinically, cardiac involvement
is manifested as dyspnea, palpitations, angina, myocar-
dial infarction, heart failure, and sudden death. Of pa-
tients with Takayasu’s arteritis, 10-30% develop coronary
artery stenosis and an even greater number of patients
develop aortic valve dilatation and regurgitation due to
the sustained high vascular resistance.8)9) Involvement of
coronary arteries is associated with chronic inflamma-
tion, premature atherosclerosis, and systemic vasculitis.
Narrowing of the coronary arteries mainly develops due
to the progression of the inflammatory process of the
A A
BB
CC
D D
Fig. 4. Follow up coronary angiography (A and B) and IVUS (C and D). A and B: coronary angiography does not show restenosis or recurrence
of coronary artery disease in LAD, LCX, and RCA. C and D: IVUS shows little neointimal proliferation and stent malapposition in the distal part
of the LAD stent. LAD: left anterior descending, LCX: left circumflex, RCA: right coronary artery, IVUS: Intravascular ultrasound.

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Jin-Sup Park, et al.·555
intima and contraction of the fibrotic media and adven-
titia from the ascending aorta.10)
The optimal method of revasculariztion for coronary
involvement of Takayasu’s arteritis has not been deter-
mined. The presence of ostial coronary artery disease
with concomitant inflammation of the aorta and subcla-
vian arteries makes the decision regarding the best ther-
apeutic approach extremely complex. The optimal meth-
od of revascularization and timing for treatment has not
been established. Internal thoracic arteries are not used
in CABG procedures because internal thoracic arteries
are also involved in the inflammatory process and sub-
clavian arteries are occluded. Large diameter saphenous
venous grafts are usually grafted from the aorta to the
coronary artery.4)5) CABG is difficult because active in-
flammation and severe calcifications are usually involv-
ed in the aorta of patients with Takayasu’s arteritis;10)
therefore, PCI could be beneficial. PCI with BMSs in
patients with Takayasu’s arteritis has been performed
successfully, but is associated with high rates of reste-
nosis due to inflammation.6)7) Using a DES has a po-
tential therapeutic benefit in Takayasu’s arteritis due to
its local anti-inflammatory properties and resulting de-
crease in neointimal hyperplasia. There is limited data
regarding PCI with DES in patients with Takayasu’s ar-
teritis;1)3) however, the short-term clinical results are fa-
vorable and there are no recurrences. DES has a risk of
late stent malapposition, stent thrombosis, and long-
term antiplatelet therapy. The long-term effects of DES
in the coronary arteries of patients with Takayasu’s arte-
ritis are unknown.
In the case herein, we considered CABG using sa-
phenous veins due to occlusion of subclavian arteries
in the active inflammatory phase, but the patient did
not want to undergo surgery. We therefore delayed PCI
to reduce inflammation in the coronary arteries with
immunosuppressive therapy. The optimal time for PCI
in the active inflammatory phase of Takayasu’s arteritis
is unknown. It is best to defer surgery until the patient
is in a non-active phase of the disease.11-14) In the case
described herein, the three coronary arteries were very
large in size, especially the left main coronary artery (>9
mm). We placed minimally overlapping kissing stents
from the distal left main coronary artery to the LAD
and LCX to reduce malapposition in the left main cor-
onary artery. A follow-up IVUS showed stent malap-
position in the distal part of the LAD stent. We suspect
that the inflammatory process in the coronary arteries
was involved in the ostial lesions, forming an aneurysm,
and in the current case, leading to stent malapposition
in the distal part of LAD stent. We do not have any data




regarding the long-term prognosis of stent malapposi-
tion in patients with Takayasu’s arteritis. Long-term du-
al antiplatelet therapy and adequate immunosuppressive
therapy may be helpful for this patient.
In conclusion, PCI with DESs for patients with sig-
nificant coronary involvement secondary to Takayasu’s
arteritis may be an effective and alternative treatment
when coronary bypass grafting is not option. Long-term
clinical follow up is required and the clinical outcomes
of more cases managed with DES to establish the safe-
ty and efficacy of DESs in the coronary artery involve-
ment of Takayasu’s arteritis.

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