Coronary angioplasty of left main coronary artery in patient with Takayasu's arteritis

Dear Editor

We are here with presenting our recent experience with left main coronary angioplasty in a young girl with Takayasu' arteritis.

A 15-year-old female, without exposure to traditional risk factors for coronary artery disease, was hospitalized with recurrent chest pain at rest for the previous seven days. There was associated generalized weakness and malaise for the last three months. Physical examination was unremarkable except absence of right brachial and radial pulses. Electrocardiogram (ECG) showed 3 mm ST segment depression in the anterior precordial and inferior leads. The TropT test was positive and CPK-MB was raised. Routine biochemical and hematological investigations were normal except presence of mild normochromic normocytic anemia and raised ESR (40 mm in first hour). Serologic tests were negative for both C-reactive protein and syphilis. Indices of collagen disorders were negative. CT angiography revealed normal arch vessels, renal arteries and aorto-iiliac systems, but right axillary and brachial vessels showed diffuse narrowing. Coronary angiography revealed 90% stenosis of ostium of left main coronary artery (LMCA) and normal left anterior descending (LAD), left circumflex (LCx) and right coronary (RCA) arteries (Fig. 1). After discussing the option of CABG and coronary angioplasty (PTCA), the patient refused surgery and opted for PTCA. She underwent PTCA and stenting of LMCA (Fig. 2) with 3.5 × 12 Zotarolimus eluting stent (Endeavor^® Drug-Eluting Coronary Stent, Medtronic). The procedure was uneventful and she was advised dual antiplatelet therapy (DAPT) with aspirin and clopidogrel along with oral corticosteroid. After one year of intervention she underwent CT-coronary angiography which showed patent stent in LMCA. The patient is asymptomatic in four year follow-up.

Fig. 1.

LAO and RAO caudal views showing stenosis of left main coronary ostium (selective engagement not done to avoid pressure damping).

Fig. 2.

Coronary stent placement (A) and final result (B).

Takayasu's arteritis (TA), which predominantly involves the aorta and its major branches, can affect coronary artery in 9–12% of cases.¹ Although rare, isolated coronary arterial involvement with normal aorta and its major branches has been reported.¹ Axillary artery involvement, as present in our case, is uncommon but reported.²

Besides atherosclerosis, the commonest cause, isolated coronary ostial stenoses have also been reported due to congenital anomaly and also due to syphilis, Takayasu disease and radiation exposure.¹ In our case, the patient, without any atherosclerotic risk factors, presented with both coronary ostial and axillary artery involvement. The indices of collagen vascular diseases and syphilis were negative. So TA was considered as the most probable etiology.

Although CABG has been considered the “gold standard” for unprotected left main atherosclerotic disease revascularization, results of CABG have not been satisfactory in patients with TA. Though internal mammary artery (IMA) graft has excellent patency rate in atherosclerotic CAD, there is substantial risk of progressive subclavian artery stenosis in patients with TA.^3,4 Besides a low patency rate, SVG graft has the added disadvantage of occlusion and aneurysm formation at the proximal anastomotic site since arterial inflammation is persistent in over 40% of cases even after treatment.⁵ Thickened aortic wall makes it difficult to create aortotomy incision.⁵

More recently PCI has emerged as a possible alternative mode of revascularization in carefully selected patients especially in those with left main ostium or trunk disease. It has been shown that the stenotic lesions of aorta and its major branches can be satisfactorily treated with angioplasty and stenting.⁶ There are few reports of PTCA with or without stenting in symptomatic coronary artery disease with TA (Table 1). However, data regarding long term results are limited because of paucity of cases. However, drug eluting stent (DES) can reduce the restenosis by inhibiting the proliferation of inflammatory and smooth muscle cells.

Table 1.

Coronary angioplasty data in patients with Takayasu's arteritis (TA).

Report	No of patients	Procedure	Follow-up
Lee HY (Yonsei Medical Journal 1995;36(5):462–465)	One	PTCA without stent	One year clinical follow-up: asymptomatic
Lee HY, Rao PS (American Heart Journal 1996;132(5):1084–1086)	One	PTCA without stent	Angiographic follow-up at 27 month: no restenosis
Punamiya K, Bates ER et al (Catheterization and Cardiovascular Diagnosis 1997;40:272–275)	Two	PTCA and stenting with bare metal stents (BMS)	Angiographic follow-up at 3 month: instent-restenosis in one patient
Haridas KK, Kumar V et al (Indian Heart J 2001;53:490–492)	One	Cutting balloon angioplasty and stenting with bare metal stents (BMS)	2 month clinical follow-up: asymptomatic
Malik IS, Harare O et al (Heart 2003;89:e9: 1–4)	One	PTCA and stenting	Angiographic follow-up at 3 month showed instent-restenosis
Lee HK, Namgung J et al (Korean Circ J 2011;41:34–37)	One	PTCA and stenting with paclitaxel eluting DES	Angiographic follow-up at three months: instent restenosis

As in our case, isolated coronary ostial and axillary artery involvement is a rare presenting feature of TA.^1,2 Acute success along with evident long term patency of stent in our case suggests that angioplasty and DES implantation will be an effective alternative method to CABG for coronary artery stenosis in Takayasu's arteritis.