Abstract
We present the first case report of coronary-carotid artery collateral formation in Takayasu's arteritis. There was a vasculitic involvement of both subclavian and carotid arteries with critical stenosis; cerebral perfusion was supported with collaterals arising from the mesenteric arteries and coronary artery.
<Learning objective: A case of coronary-carotid artery collateral formation in Takayasu's arteritis is presented. Such an angiographic finding has not been reported previously, and this case could be the first description of coronary-carotid artery collaterals development. The learning objective of the article is to evaluate collateral circulation in Takayasu's arteritis from different vasculature including the coronary system.>
Keywords: Carotid stenosis, Collaterals, Coronary artery, Takayasu's arteritis
Introduction
Collateral vessel formation is an adaptive response to chronic ischemia with the formation of either new vasculature or the growth of pre-existing small non-significant vessels [1]. It becomes important especially in coronary ischemia, limb ischemia, and also cerebral ischemia; hence, this limits the ischemia and plays an important role in the salvage of jeopardized tissue [2]. Cerebral circulation has a unique character with anterior and posterior circulation which meet in the Circle of Willis. Occlusive aortic arch disease is one of the major clinical conditions threatening cerebral circulation. Herein, we present a case of Takayasu's arteritis with critical carotid stenosis. Coronary angiography showed collateral formation between the left coronary circulation and carotid artery. To the best of our knowledge, this case is the first description of coronary-carotid artery collaterals; hence, there were no similar cases identified in the Medline database.
Case report
A 27-year-old woman was admitted to an out-patient clinic with a complaint of recurrent syncope. On anamnesis, she was diagnosed as having Takayasu's arteritis 4 years previously and she was not taking any medication at the time of presentation. Carotid-vertebral artery Doppler ultrasonography showed critical stenosis in the carotid arteries and vertebrobasilar system insufficiency. Therefore, selective carotid angiogram was scheduled. Aortography showed total occlusion of both brachiocephalic trunk and left subclavian artery, as well as critical stenosis in the osteal segment of the left common carotid artery (Fig. 1, video 1). After that, coronary and peripheral angiogram was performed to show collateral cerebral circulation. Prominent collaterals were observed from branches originating from the superior and inferior mesenteric arteries (Fig. 2, videos 2 and 3). In addition, there were coronary-carotid collaterals originating from circumflex artery and left anterior descending artery (Fig. 3, video 4). The patient did not describe any anginal symptoms and subsequent nuclear imaging was also free from ischemia. Left carotid stenosis was segmental and typically showed the active vasculitic infiltration with initial segmental infiltration and post-stenotic dilatation. Medical follow-up including immunosuppressive treatment was scheduled for the patient.
Fig. 1.
Aortography showing total occlusion of brachiocephalic trunk and critical stenosis of left carotid artery. Critical stenosis in the initial segment of the left common carotid artery followed by the ectatic segment can be seen in the middle and right side of the figure.
Fig. 2.
Collateral vessels from abdominal vasculature supporting the carotid circulation were demonstrated.
Fig. 3.
Antero-posterior projection showing collaterals extending between left anterior descending artery, circumflex artery and carotid circulation.
Discussion
Collateral vessel formation is relevant in the different clinical conditions including coronary, cerebral, or peripheral vessel occlusive disease. The major triggering factor is chronic ischemia and varied mediators play a role in the formation of collateral vessels. Collateral vessels supply the ischemic tissue with an alternative circulation pathway and protect the jeopardized tissue [1], [2], [3]. Carotid artery stenosis is the major clinical condition that impairs the cerebral circulation. In such cases, posterior circulation via vertebral arteries is the major collateral pathway of cerebral circulation. However, occlusive aortic arch disease affecting subclavian arteries may diminish the posterior cerebral circulation, which may lead to cerebral ischemia. Thus, unusual cerebral collateral pathways from the abdomen or thoracic vasculature could be more clinically relevant. In addition, coronary-carotid collaterals were not reported before and collaterals from the coronary system may also trigger myocardial ischemia by the stealing effect. Similar to our case, asymptomatic patients can be followed with medical treatment. Collaterals with stealing syndrome can be treated with percutaneous embolization, graft stent deployment, and surgical ligation according to the extent and anatomical features of collateral vessels.
Takayasu's arteritis is a vasculitis of the great-sized arteries which usually affects the subclavian arteries and carotid system [4]. According to the involvement of vessels, angiographic classification was proposed at the Takayasu conference in 1994 as follows [5]:
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Type 1: Branches from the aortic arch
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Type 2a: Ascending aorta, aortic arch, and its branches
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Type 2b: Ascending aorta, aortic arch, and its branches, thoracic descending aorta
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Type 3: Thoracic descending aorta, abdominal aorta, and/or renal arteries
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Type 4: Abdominal aorta and/or renal arteries
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Type 5: Combined features of types 2b and 4
According to this classification system, involvement of the coronary or pulmonary arteries should be designated as C (+) or P (+), respectively. We classified our patients as type 2a Takayasu's arteritis angiographically, due to involvement of the aortic arch, subclavian arteries, and carotid arteries.
Collateral circulation was well-developed in the patient with critical stenosis in the involved great arteries. Most of the collateral circulation usually comes from the abdominal vessels, either through internal thoracic arteries or new collaterals from the superior and inferior mesenteric arteries, similar to our case. Direct collateral vessel from coronary circulation was not reported. Thus, our case is probably the first reported case of coronary-carotid artery collateral formation associated with Takayasu's arteritis.
Conflict of interest
None.
Footnotes
Supplementary material related to this article can be found, in the online version, at http://dx.doi.org/10.1016/j.jccase.2013.12.010.
Appendix A. Supplementary data
The following are Supplementary data to this article:
References
- 1.Hayashi T., Deguchi K., Nagotani S., Zhang H., Sehara Y., Tsuchiya A., Abe K. Cerebral ischemia and angiogenesis. Curr Neurovasc Res. 2006;3:119–129. doi: 10.2174/156720206776875902. [DOI] [PubMed] [Google Scholar]
- 2.Hardman R.L., Lepora J.E., Cardan R.A., Trimmer C.K., Josephs S.C. Common and rare collateral pathways in aortoiliac occlusive disease: a pictorial assay. AJR Am J Roentgenol. 2011;197:W519–W524. doi: 10.2214/AJR.10.5896. [DOI] [PubMed] [Google Scholar]
- 3.Tokgözoğlu L., Yorgun H., Gürses K.M., Canpolat U., Ateş A.H., Tülümen E., Kaya E.B., Aytemir K., Kabakçı G., Tuncer M., Oto A. The association between circulating endothelial progenitor cells and coronary collateral formation. Atherosclerosis. 2011;219:851–854. doi: 10.1016/j.atherosclerosis.2011.08.045. [DOI] [PubMed] [Google Scholar]
- 4.Karabulut A., Teskin O. Treatment strategies for coronary lesions in Takayasu arteritis patients – case report and review of the literature. Kardiol Pol. 2010;68:1176–1180. [PubMed] [Google Scholar]
- 5.Moriwaki R., Noda M., Yajima M., Sharma B.K., Numano F. Clinical manifestations of Takayasu arteritis in India and Japan – new classification of angiographic findings. Angiology. 1997;48:369–379. doi: 10.1177/000331979704800501. [DOI] [PubMed] [Google Scholar]
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