Recurrent restenosis following stent and rotational atherectomy of coronary artery stenosis in Takayasu's arteritis

doi:10.1016/S0167-5273(98)00126-0

International Journal of Cardiology

Volume 65, Issue 3, 1 August 1998, Pages 295-300

https://doi.org/10.1016/S0167-5273(98)00126-0 Get rights and content

Abstract

We report a patient with Takayasu's arteritis who had recurrent restenosis following intracoronary bifurcation stenting of proximal left anterior descending and first diagonal arteries, and rotational atherectomy for in-stent restenosis. After all, the patient underwent coronary artery bypass grafts (CABG) and has remained asymptomatic during 3 months without damaging myocardium. We suggest that endoluminal stenting or rotational atherectomy may be an alternative treatment for the patients with coronary artery stenosis due to active Takayasu's arteritis as a therapy to postpone CABG.

Introduction

Takayasu's arteritis, is a chronic inflammatory disease involving the aorta, its major branches, and the pulmonary arteries, and it occurs most frequently in females in their reproductive years 1, 2. Previous studies have shown an increased risk of failure of surgical revascularization [3]. Recently, percutaneous transluminal coronary angioplasty (PTCA) and elective endoluminal stenting of the native coronary arteries in Takayasu's disease have been reported 4, 5. But the follow-up result has not yet determined.

We report a patient with Takayasu's arteritis who had recurrent restenosis following intracoronary bifurcation stenting of proximal left anterior descending (LAD) and first diagonal (D1) arteries, and rotational atherectomy for in-stent restenosis.

Section snippets

Case report

A 33 year-old woman had suffered from exertional chest pain for 3 weeks. Chest pain was relieved by sublingual nitroglycerin. She complained of fatigability, malaise, and dizziness. Bruit was heard at base of both sides of neck and periumblicular region. Upper extremity pulse was faint on the left side. An erythrocyte sedimentation rate was 43 mm/hr and quantitation of C-reactive protein was 2+. Angiography revealed stenosis of left subclavian, both carotid, both vertebral, and left renal

Discussion

Involvement of the coronary arteries in Takayasu's arteritis has been described 4, 6. Treatment strategies to improve clinical outcomes have ranged from medical therapy with steroid and immunosuppressive agents 2, 7to PTCA [4]or stenting [5]. Antelmi et al. [4]reported that PTCA for Takayasu's arteritis was limited by high grade residual stenosis presumably due to recoil. Percutaneous angioplasty has been attempted in coronary and renal arteries with Takayasu's arteritis, and also associated

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Natural history of aortoarteritis (Takayasu's disease)
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Rescue PTCA in a 16 year old boy with Takayasu's disease and evolving myocardial infarction
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Endoluminal stenting for unprotected left main stenosis in Takayasu's arteritis
Catheter Cardiovasc Diagn
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There are more references available in the full text version of this article.

Cited by (22)

Comparing the effects of different management strategies on long-term outcomes for significant coronary stenosis in patients with Takayasu arteritis
2020, International Journal of Cardiology
Citation Excerpt :
Recently with advances in revascularization, CABG and PCI have also emerged as important treatment modalities for coronary stenosis secondary to TA [19]. However, outcomes are still unsatisfactory in TA patients undergoing revascularization, with restenosis being the major problem [11,12,20,21]. For now, few studies have addressed question of the effects of treatment including medical and revascularization therapy for patients with TA and significant coronary stenosis.
The long-term outcomes and optimal treatment strategy for patients with Takayasu arteritis (TA) and significant coronary stenosis remain unclear. We aim to investigate the prognosis of these patients according to the initial management strategy.
A total of 57 consecutive patients with TA and significant coronary stenosis were included between 2002 and 2018. The cohort was divided into the percutaneous coronary intervention (PCI) group (n = 18), coronary artery bypass graft (CABG) group (n = 10), and medical-therapy group (n = 29). The primary outcome was major adverse cardiac events (MACEs) defined as a composite of cardiac death, myocardial infarction, and coronary revascularization.
Over a median follow-up of 4.5 (IQR 3.5–8.0) years, 24 (42.1%) patients experienced at least one MACE. The long-term rates of MACEs and re-revascularization were significantly higher in the PCI group than in the other 2 groups (HR 5.306, 95% CI 2.160–13.036, p < 0.001; HR 12.286, 95% CI 3.257–46.343, p < 0.001, respectively). The cumulative incidences of MACEs and subsequent revascularization were similar between the CABG and medical-therapy group. Active disease at baseline and PCI were independent predictors of MACEs (HR, 7.039, 95% CI 2.031–24.396; p = 0.002; HR, 4.400; 95% CI 1.804–10.727; p = 0.001, respectively) and revascularization (HR 4.632, 95% CI 1.010–21.235, p = 0.048; HR 9.820, 95% CI 2.641–36.514, p = 0.001, respectively).
The initial baseline active disease is an important predictor of long-term outcome and subsequent revascularization in patients with TA and significant coronary artery stenosis. Also, PCI is independently associated with higher risk of MACEs and re-revascularization.
Long-term outcomes of coronary artery bypass grafting versus percutaneous coronary intervention for Takayasu arteritis patients with coronary artery involvement
2017, Seminars in Arthritis and Rheumatism
Citation Excerpt :
Recently with advances in endovascular treatment, PCI has emerged as an alternative choice for coronary artery lesions secondary to Takayasu arteritis [11]. However, the long-term outcomes is still unsatisfactory, in-stent restenosis is a major problem of PCI [9,12,13]. There is no information available on the comparison of long-term outcomes between PCI and CABG in TA patients with coronary artery involvement.
Coronary artery involvement significantly increases mortality of patients with Takayasu arteritis (TA); however, the optimal revascularization strategy for this condition has not been established. We aimed to compare the long-term outcomes of TA patients with coronary artery involvement treated with coronary artery bypass grafting (CABG) and percutaneous coronary intervention with stenting (PCI).
Data from 46 TA patients with coronary artery involvement were analyzed according to their revascularization strategies. The resulting events included myocardial infarction, repeated revascularization, cardiac death, and the major adverse cardiac events (MACE), which is a combination of the former events.
The risk of MACE was significantly higher in the PCI group than in the CABG group during a median of 41.0 months follow-up (P < 0.001), especially in those who underwent revascularization at the active stage of TA (P = 0.001), whereas no difference was found between PCI and CABG groups in patients who underwent revascularization at the stable stage of TA (P = 0.138). The incidence of MACE was higher in TA patients at the active stage than those at the stable stage in all patients (P < 0.001). For patients at the active stage, the risk of MACE was significantly lower in patients with than those without usage of prednisone (P = 0.028); while no difference was found between patients who were stable not requiring prednisone and patients who were stable on prednisone (P = 0.525).
With regard to MACE, CABG is superior to PCI despite medical therapy in TA patients with coronary artery involvement. In TA patients at the stable stage, PCI is similar with CABG in prognosis. For patients at the active stage, if emergency revascularization is necessary, CABG is ideal; if not, receiving medical therapy until disease remission and then undergoing PCI may be an alternative choice of CABG.
Ventricular assistance and cardiac transplant in a patient with Takayasu disease: First reported case
2015, Cirugia Cardiovascular
La enfermedad de Takayasu es una patología muy poco frecuente, de etiología desconocida, que en niños puede constituir una entidad agresiva y potencialmente letal. Comunicamos el primer caso de asistencia ventricular y trasplante cardíaco en un paciente con enfermedad de Takayasu.
Se describe el caso clínico de un varón de 15 años que presenta dolor torácico y signos clínicos de insuficiencia cardíaca secundarios a un síndrome coronario agudo con elevación del ST en V1-V4. En la coronariografía se objetiva tronco de la arteria coronaria izquierda de escaso calibre con imagen obstructiva en el tercio medio, arteria descendente anterior con oclusión trombótica aguda a nivel ostial proximal y circunfleja con lesión ostial crítica. En la aortografía se observa interrupción de la aorta abdominal infrarrenal y las arterias iliacas comunes y externas. Dada la situación de inestabilidad del paciente, se opta por el traslado a quirófano de forma urgente. Se le realiza un doble pontaje coronario, sin observar mejoría en la función cardíaca, por lo que se implanta una asistencia ventricular izquierda paracorpórea. A las 72 h se lleva a cabo el trasplante cardíaco ortotópico. La evolución posterior es favorable, siendo dado de alta a los 39 días. El estudio histopatológico del corazón revela una arteritis crónica a nivel coronario y de aorta ascendente, con infarto masivo de ventrículo izquierdo.
Se trata de una extraña presentación de enfermedad de Takayasu, que exige una alta sospecha clínica y plantea una estrategia interdisciplinar perfectamente coordinada para la resolución satisfactoria.
Takayasu disease is a rare form of chronic non-specific large vessel vasculitis of unknown etiology. It usually affects young adults, and can be fatal in children. The first reported case is presented of ventricular assistance followed by heart transplant in a patient with Takayasu disease.
The case is presented of 15 year old child who presented with chest pain and clinical signs of cardiac failure. His electrocardiogram showed ST-segment elevation in V1-V4, and he was referred for coronariography due to suspicion of acute coronary artery disease. The left main coronary artery was of small caliber and exhibited stenosis in the middle segment. The anterior descendent artery showed a thrombotic occlusion at the proximal segment, and there was a critical lesion in the circumflex branch. There was an interruption of the infrarenal abdominal aorta and common and external iliac arteries. Due to the critical situation of the patient, he was referred to urgent surgical intervention and a double bypass graft was performed without noticing any improvement in the cardiac function. A left ventricular assistance device was therefore implanted. Seventy-two hours later an orthotopic heart transplant was performed. The progress was excellent and the patient was discharged 39 days later. Histopathology studies revealed a chronic arteritis in the coronary arteries and ascending aorta, and a massive left ventricular infarction.
In a rare disease like Takayasu disease, a clear multidisciplinary and coordinated strategy is needed in order to achieve a successful therapeutic outcome.
Takayasu arteritis revisited: Current diagnosis and treatment
2013, International Journal of Cardiology
Citation Excerpt :
Several case reports have demonstrated the utility of drug-eluting stents for TA patients. However, the observation period of these reports was quite short, less than 1 year [84–86]. Indeed, one report showed an unfavorable long-term outcome after drug-eluting stent for TA [87].
Takayasu arteritis (TA) is a rare nonspecific inflammatory disease of unknown cause, predominantly affecting the aorta and its main branches, coronary arteries, and pulmonary arteries of young females. It induces a variety of nonspecific inflammatory symptoms and ischemic symptoms due to stenotic lesions. Further progression of TA causes destruction of the arterial wall media, leading to aortic regurgitation and aneurysms or rupture of the involved arteries. Although serological tests specific for TA are not available, new better biomarkers are emerging such as pentraxin3 and matrix metalloproteinases. Recent advances in imaging modalities including magnetic resonance angiography, computed tomography (CT), sonography, and fluorodeoxy glucose positron emission tomography/CT (FDG-PET/CT) allow earlier and accurate diagnosis of TA. Duration between onset of the disease and diagnosis has become much shorter during the last decade. Medical treatment for TA is also changing. In addition to the traditional glucocorticoids and immunosuppressants, many new biological agents are being applied to patients with TA refractory to conventional treatment with favorable results. As for treatment for vascular complications, efficacy of endovascular treatment is still a matter of controversy because of the high rate of restenosis at an early stage after the procedure. Based on these advances, the prognosis and quality of life of TA patients have improved to a great deal. However, there are many issues that remain to be solved in the management of TA.
Long-term outcome of drug-eluting stent for coronary artery stenosis in Takayasu's arteritis
2010, International Journal of Cardiology
Sirolimus-eluting stent implantation for ostial stenosis of left main coronary artery after Bentall operation in aortitis syndrome
2010, Journal of Cardiology
We describe a 66-year-old woman with aortitis syndrome, successfully treated with percutaneous coronary intervention using sirolimus-eluting stent (SES) for ostial stenosis of left main coronary artery after Bentall operation. At one-year follow-up, she had no evidence of restenosis and no clinical events. Stent implantation with SES may be useful for ostial left main coronary stenosis after Bentall operation in selected patients with aortitis syndrome.

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Recurrent restenosis following stent and rotational atherectomy of coronary artery stenosis in Takayasu's arteritis

Abstract

Introduction

Section snippets

Case report

Discussion

Natural history of aortoarteritis (Takayasu's disease)

Circulation

Takayasu's arteritis and its therapy

Ann Intern Med

Treatment of Takayasu's arteritis: An analysis of 29 operated patients

Thorac Cardiovase Surg

Rescue PTCA in a 16 year old boy with Takayasu's disease and evolving myocardial infarction

Arq Bras Cardiol

Endoluminal stenting for unprotected left main stenosis in Takayasu's arteritis

Catheter Cardiovasc Diagn