akayasu arteritis is a form of large vessel vasculitis with an unclear pathogenesis, although autoimmune mechanisms as well as a genetic etiology are possibly involved in its evolution and progression. Because Takayasu arteritis affects the entire aorta and its major branches, it occasionally complicates coronary artery stenoses. Although revascularization therapy is recommended for such patients, obstructive lesions in the subclavian arteries, active inflammation or severe calcification of the aorta often render coronary bypass grafting impossible. In addition, the long-term outcome of percutaneous coronary intervention (PCI) in patients with Takayasu arteritis is largely unknown. We describe a case of Takayasu arteritis with left main coronary artery (LMCA) stenosis that was successfully treated by sirolimus-eluting stent (SES) deployment after repeated in-stent restenosis following bare metal stenting.
Case ReportA 53-year-old woman was admitted to hospital because of worsening exertional angina. At the age of 42 years, she had been diagnosed as having Takayasu arteritis. Magnetic resonance angiography and 99m technetium pulmonary perfusion scintigraphy revealed an occlusion of the left pulmonary artery and multiple mild stenoses in both of the common carotid and subclavian arteries. She had been treated with oral glucocorticoids (prednisolone) and was generally in good condition for the past 11 years until she presented with exertional angina. Angiography in August 2003 revealed severe (90%) ostial stenosis in a short LMCA with involvement of the distal bifurcation (Fig 1A), an intact right coronary artery ( Fig 1B) and total occlusion of the left pulmonary artery (Fig 1C). Collateral circulation via the intercostal arteries had developed between the left internal thoracic artery and left pulmonary circulation. Although coronary bypass surgery was recommended as the first therapeutic option, the patient refused open-chest surgery and PCI was then considered as another option. Because the patient developed unstable angina, a bare metal stent (3.0×15 mm ACS RX Multi-Link™, Guidant) was urgently implanted in her LMCA in September 2003; at that time, SES were not available in Japan. The kissing balloon technique was used for stenosis of the bifurcation of the left anterior descending artery (LAD) (4.0×15 mm POWERSAIL, Guidant) and left circumflex artery (LCX) (2.5×20 mm Maverick2, Boston Scientific). The 90% LMCA stenosis was successfully dilated to 0% (Fig 1D) and the angina completely disappeared. The daily dose of oral prednisolone was increased from 12.5 mg to 20 mg because the blood test suggested enhanced activity of the Takayasu arteritis, showing positive C-reactive protein (CRP: 3.6 mg/dl) and an augmented erythrocyte sedimentation rate (48 mm/h). These inflammatory parameters normalized within 1 month. However, 3 months later, the patient was readmitted for recurrence of the angina. She underwent balloon angioplasty using a 4.0×18 mm POWERSAIL (Guidant) for the LMCA and LAD, and 2.5×15 mm Stormer (Medt...