Improving outcomes in proximal anastomosis: A challenging case of coronary revascularization in Takayasu arteritis

Use of Dacron patch for coronary revascularization in Takayasu arteritis.

Central Message.

The use of a Dacron patch in coronary revascularization surgery for Takayasu arteritis aims to overcome the challenges in proximal anastomosis. Immunosuppression is crucial for disease control and may contribute to lesion regression.

A 29-year-old female diagnosed with Takayasu arteritis (TA), already under immunosuppressive therapy due to severe involvement of the ascending aorta and supra-aortic trunks, presented with typical angina. Coronary anatomy revealed a left main artery (LMA) ostial occlusion and severe right coronary artery (RCA) stenosis. The patient underwent coronary artery bypass (CABG) surgery with 3 vein grafts proximally anastomosed to a Dacron graft sutured onto the ascending aorta. Coronary computed tomography imaging at 12 months revealed patency of the left coronary tree grafts with regression of native ostial RCA disease and RCA graft occlusion after anti-IL-6 therapy.

Case Presentation

A 29-year-old Bangladeshi woman diagnosed with TA was being followed by Rheumatology as an outpatient. She had prior documented supra-aortic trunk involvement with left subclavian occlusion and right subclavian stenosis with bilateral superior limb claudication. Her immunosuppression therapy included mycophenolate mofetil 1500 mg daily and prednisolone 20 mg daily. She was referred to cardiology for outpatient evaluation of typical chest pain episodes (Cardiovascular Society angina score of 3). Physical examination was remarkable for absent superior limb pulses. Electrocardiography showed normal sinus rhythm with anterolateral ST depressions (Figure E1). Laboratory tests revealed normal troponin T level and an elevated erythrocyte sedimentation rate (56 mm/hour).

Figure E1.

12-lead electrocardiogram.

Computed tomography coronary angiography (CTCA) revealed thickening of the aortic wall (∼3-4 mm) causing ostial occlusion of the left main artery (LMA) and severe ostial stenosis in the right coronary artery (RCA). The Agatston calcium score was 0. Coronary angiography confirmed ostial LMA occlusion with collateral flow from the RCA, which also showed a 50% to 70% ostial stenosis (Video 1). The patient was admitted for further management.

A carotid Doppler study demonstrated wall thickening of both carotid arteries, causing bilateral lumen narrowing, with a 50% to 69% stenosis on the right. Femoral artery assessment was unremarkable, which allowed accurate blood pressure monitoring in the lower limbs. Transthoracic echocardiography (Video 2) showed a low normal left ventricular ejection fraction (49%) and moderate aortic regurgitation. Aortic and cardiac magnetic resonance imaging revealed severe circumferential aortic wall thickening across its ascending segment, related to the inflammatory process (Figure 1, A and B). Milder wall thickening was observed in the proximal and middle segments of the descending thoracic aorta.

Figure 1.

A, Aortic and cardiac magnetic resonance, Dixon water-only sequence, showing the presence of edema in the aortic wall (A1) and supra-aortic trunks (A2). B, One-year follow-up computed tomography angiography showing patency of venous bypasses to the obtuse marginal (OM) and left anterior descending (LAD) arteries (B1 and B2) and absence of significant lesions in native right coronary artery (RCA) (B3 and B4). Venous bypass was not visualized.

After review by the Heart and Rheumatology teams, immunosuppression therapy failure was deemed to be the cause. The patient was proposed for anti–IL-6 therapy and surgical revascularization was chosen, taking into consideration the patient's age and multivessel involvement despite the need for a complex approach, given that severe upper limb involvement due to the TA precluded the use of arterial grafts.

Surgical Technique

The surgical team used a previously described technique¹ that has been little applied and rarely performed in multivessel disease but aimed to help overcome early bypass failure due to progression of ascending aortic inflammation by using prosthetic material to undertake proximal anastomosis. Off-pump surgery was performed. Although thickened, aortic tissue quality was reasonable, allowing partial aortic clamping. An oblong longitudinal portion of the anterior wall of the ascending aorta was resected and replaced with a patch of similar dimensions, tailored from a 10-mm diameter Dacron conduit sutured with a 3/0 polypropylene running suture, using a standard technique (Figure 2, A). The Dacron patch was incised with an 11-blade scalpel, and then a circular hole was made with a 4-mm punch. Three proximal venous graft anastomoses were done in a standard fashion (Figure 2, B). Finally, 3 distal anastomoses were performed to the left anterior descending artery (LAD), first obtuse marginal (OM) artery, and posterior descending artery (PD) (Figure 2, C). Hemostasis was readily achieved.

Figure 2.

A, Dacron patch (arrows) sutured to the ascending aorta, under partial clamping. B, Three venous bypass grafts proximally anastomosed to the Dacron patch (circle). C, Venous bypass grafts to the left anterior descending (LAD) artery and posterior descending (PD) artery; distal anastomosis to the LAD is visible (circle). D, Computed tomography 3-dimensional reconstruction.

Outcome and Follow-Up

The patient was discharged home on day 6 post-CABG, on dual antiplatelet therapy (aspirin and clopidogrel). She developed saphenectomy site and mild sternum infections due to Serratia marcescens, which were treated effectively with an 8-week course of antibiotics.

She was started on monthly anti–IL-6 (tocilizumab, 8 mg/kg) after the infection resolved. The mycophenolate mofetil dose was kept as before, and the prednisone dose was tapered to 5 mg daily. She has remained asymptomatic, without complications or hospital readmissions. CTCA screening for bypass failure at 6 and 12 months showed patent venous LAD and OM grafts and occlusion of the venous graft to the RCA by 12 months, along with ostial RCA stenosis regression to <25% (Figure 1, B), perhaps related to reduced inflammation after adjustment of the immunosuppression regimen. A positron emission tomography scan performed at 18 months confirmed improved inflammation control.

Discussion

A low threshold for suspicion of coronary involvement in TA is required for early diagnosis and intervention.^1,2 Although both percutaneous coronary intervention (PCI) and surgery have been used for revascularization, CABG is preferred in these cases, given the coronary ostial involvement. PCI reportedly has been associated with higher rates of adverse events and need for reintervention.1, 2, 3

The limitations of CABG in TA are often related to the lack of arterial vessels for grafting1, 2, 3 and the proximal anastomosis to an inflamed aortic tissue,1, 2, 3 which can compromise the results. The use of in situ arterial conduits has been associated with favorable outcomes, although with a risk of TA involvement, and should be considered if patent. Nevertheless, this patient presented with severe bilateral subclavian lesions, which prevented the use of internal mammary arteries. This was corroborated by preoperative CT documenting bilateral proximal occlusion of the mammary arteries.

Cardiac magnetic resonance demonstrated significant edema of the aortic wall, suggesting the presence of active inflammation that could lead to early bypass failure. The use of a patch for proximal anastomosis (Dacron or pericardial tissue, as no superiority was established and both have shown good results in this setting) is recommended by some authors to overcome these challenges¹; however, little data on long-term outcomes have been reported to date. We report 12-month clinical and imaging follow-up and details on tailored immunosuppression strategy. Despite verifying the occlusion of the venous bypass to RCA, its late timing is suggestive of flow competition rather than a complication from the anastomosis, possibly as a result of improved flow in the RCA.

Appropriate immunosuppression remains the cornerstone of inflammation control in TA, preventing novel lesions from developing and promoting regression of preexisting lesions.⁴ Control of disease activity, often with glucocorticoids, prior to surgery has been shown to improve outcomes and to decrease the rate of complications and should be attained when possible.^4,5 Furthermore, case reports and small studies have demonstrated lesion regression with anti–IL-6 therapy, suggesting that an intervention may be avoided or delayed in some cases⁴; however, the evidence is scanty, and not all patients achieved this result with immunosuppression alone. Additionally, in presence of myocardial ischemia, guidelines recognize that intervention may be warranted before immunosuppression intensification.⁵

After multidisciplinary discussion, a course of revascularization surgery and later introduction of an anti–IL-6 agent was selected, given that the patient was deemed high-risk for a major cardiovascular event to wait for immunosuppression effect owing to critical anatomy and recurring symptoms.

Conclusions

TA can lead to complex coronary anatomies at young age, causing severe morbidity and death. Achieving proper long-term revascularization can be challenging, especially when arterial conduits are unavailable owing to significant upper limb involvement and the presence of a severely inflamed aorta, as depicted in this case. The use of a Dacron patch to perform proximal anastomosis overcomes the major limitations of CABG in patients with TA, although long-term outcomes are scarcely described in literature. Appropriate immunosuppressive management is crucial for disease control, to prevent further events, and possibly contribute to coronary stenosis regression.

Informed Consent and Ethics Statement

The patient verbally consented to the publication of her medical case in a peer-reviewed medical journal. The authors of this article, who actively participated in the decision process and management, obtained written informed consent from the patient in accordance with COPE guidelines. Institutional Review Board approval was not required. The authors declare that the figures and videos in the article, including supplementary material, do not allow the identification of the patient. Dates were omitted to comply with confidentiality.

Conflict of Interest Statement

The authors have no conflicts of interest to report.

The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.

Supplementary Data

Video 1

Coronary angiography. Video available at: https://www.jtcvs.org/article/S2666-2507(25)00364-5/fulltext.

Video 2

Transthoracic echocardiogram, 4- and 2-chamber, and PLAX with color. Video available at: https://www.jtcvs.org/article/S2666-2507(25)00364-5/fulltext.