Comparing the effects of different management strategies on long-term outcomes for significant coronary stenosis in patients with Takayasu arteritis

Refractory Takayasu's Arteritis with Severe Coronary Involvement-Case Report and Literature Review

This report presents the case of a female patient diagnosed with Takayasu arteritis from childhood, with severe, refractory coronary involvement, leading to two acute coronary syndromes and multiple anginous episodes. Consequently, the patient suffered aorto-bicarotid bypass two times, multiple interventional procedures with stent implantation, balloon angioplasty, and up to ten repeated in-stent restenosis that required reinterventions, despite being on maximal immunosuppressive treatment. In recent years, various studies have been reported that aim to best characterize this particular type of vascular damage and to indicate optimal therapeutic options for treatment. The latter should be based on the activity of the underlying disease; however, no reliable markers are available in TA. The management of TA patients with coronary involvement continues to be a challenge and requires both drug and interventional techniques to avoid life-threatening events.

Monocyte-to-high-density lipoprotein ratio as a predictor for patients with Takayasu arteritis and coronary involvement: a double-center, observational study

Background

The implication of the monocyte-to-high-density lipoprotein ratio (MHR) in Takayasu arteritis (TAK) remains unclear.

Objective

We aimed to assess the predictive value of the MHR to identify coronary involvement with TAK and determine the patient prognosis.

Methods

In this retrospective study, 1,184 consecutive patients with TAK were collected and assessed, and those who were initially treated and with coronary angiography were enrolled and classified according to coronary involvement or no involvement. Binary logistic analysis was performed to assess coronary involvement risk factors. Receiver-operating characteristic analysis was used to determine the MHR value to predict coronary involvement in TAK. Major adverse cardiovascular events (MACEs) were recorded in patients with TAK and coronary involvement within a 1-year follow-up, and Kaplan-Meier survival curve analysis was conducted to compare MACEs between them stratified by the MHR.

Results

A total of 115 patients with TAK were included in this study, and 41 of them had coronary involvement. A higher MHR was found for TAK with coronary involvement than for TAK without coronary involvement (P = 0.014). Multivariate analysis showed that the MHR is an independent risk factor for coronary involvement in TAK (odds ratio: 92.718, 95% confidence interval (CI): 2.813-3056.291, P = 0.011). With the best cut-off value of 0.35, the MHR identified coronary involvement with 53.7% sensitivity and 68.9% specificity [area under the curve (AUC): 0.639, 95% CI: 0.544-0.726, P=0.010] and identified left main disease and/or three-vessel disease (LMD/3VD) with 70.6% sensitivity and 66.3% specificity (AUC: 0.704, 95% CI: 0.612-0.786, P = 0.003) in TAK. Combined with other variables, the MHR identified coronary involvement with 63.4% sensitivity and 90.5% specificity (AUC: 0.852, 95% CI: 0.773-0.911, P < 0.001), and identified LMD/3VD with 82.4% sensitivity and 78.6% specificity (AUC: 0.827, 95% CI: 0.720-0.934, P < 0.001) in TAK. A total of 39 patients with TAK and coronary involvement were followed up for 1 year, and 5 patients suffered a MACE. Those with an MHR >0.35 had a higher MACE incidence than their counterparts with an MHR ≤0.35 (χ² = 4.757, P = 0.029).

Conclusions

The MHR could be a simple, practical biomarker for identifying coronary involvement and LMD/3VD in TAK and predicting a long-term prognosis.

Coronary ostial angioplasty for juvenile Takayasu arteritis involving the coronary artery using external iliac artery grafts

Takayasu arteritis can affect the coronary ostia, leading to myocardial ischemia. Coronary ostial angioplasty effectively treats coronary artery ostial lesions associated with Takayasu arteritis. We present a case of juvenile Takayasu arteritis with bilateral subclavian artery occlusions treated with a novel coronary artery ostial angioplasty using the external iliac artery.

Retrograde Percutaneous Coronary Intervention in a Case of Takayasu Arteritis with Left Main Coronary Artery Chronic Total Occlusion

Background

Takayasu arteritis (TA) frequently involves the coronary arteries, and restenosis is common after initial percutaneous coronary intervention (PCI). However, PCI remains a good option for patients who develop graft failure after coronary artery bypass graft surgery (CABG). Drug-coated balloons help in repeat revascularization after stent failure in TA. Case Presentation. A 31-year-old female with previous history of Takayasu arteritis (TA) and CABG with left internal mammary artery (LIMA) to left anterior descending artery (LAD) grafting in 2012, presented to us with exertional angina of 6-month duration. Her coronary angiogram showed total occlusion of the left main coronary artery (LMCA) ostium and atretic LIMA graft. Since the guiding catheter could not engage the LMCA, a retrograde approach was planned. After lesion crossing, the retrograde guidewire could not be externalized even after multiple attempts. Hence, a repeat antegrade approach was tried, and antegrade wire crossed through the channel created by the retrograde microcatheter. Then, intravascular ultrasound (IVUS) guided LMCA-LAD stenting was done. The patient was started on dual antiplatelets and prednisolone and was on regular follow-up. Three months later, the patient presented to us with non-ST elevation MI. Coronary angiogram showed critical in-stent restenosis of the LMCA stent, and optical coherence tomography (OCT) showed diffuse neointimal hyperplasia. OCT-guided PCI using sirolimus-coated balloon was done. On 8 months of follow-up, the patient remains symptom free.

Conclusion

Coronary artery disease in TA may require repeated interventions due to stent/graft failure. Drug-coated balloons play a crucial role in repeat revascularization for stent failure in TA. Retrograde approach increases the technical success rate of PCI in LMCA-CTO.

A Case Report: An Elderly Male Patient With Takayasu Arteritis After Coronary Artery Bypass Grafting

Background: Takayasu arteritis is a rare chronic granulomatous inflammation involving the aorta and its main branches. In this report, we describe an extremely rare elderly male patient with Takayasu arteritis (TA) after coronary artery bypass grafting (CABG). Case Summary: A 61-year-old male patient with persistent precordial pain underwent angiography. Vascular murmurs could be heard in carotid artery and bilateral renal artery by auscultation. Laboratory parameters showed high Erythrocyte Sedimentation Rate (ESR) and C-reactive protein (CRP). CT coronary angiography showed multiple stenoses of aorta and its main branches, such as carotid and renal artery involvement. Coronary angiography showed that the coronary artery had multiple branch stenoses, the left anterior descending artery (LAD) had severe stenosis, the distal end of which was reversed to the right coronary artery (RCA), and the RCA was completely occluded. Because of the high level of markers of inflammatory activity, the patient began to take glucocorticoid. Although the patient still had multibranch stenosis of coronary artery, considering the previous CABG operation history, surgery, and interventional therapy of the patient were not feasible, the patient was given conservative drug for further treatment. After treatment, the inflammatory index was significantly descended, and N terminal-pro Brain natriuretic peptide (NT-pro BNP) was decreased. Discussion: A rare case of an elderly male patient with Takayasu arteritis after coronary artery bypass grafting was reported. In addition to hypertension, hyperlipidemia, and other risk factors, coronary artery involvement caused by TA may be a major cause of aggravation of symptoms in patients with acute myocardial infarction (AMI), especially after CABG.

Aortitis: an update

PURPOSE OF REVIEW

Aortitis is the inflammation of the aorta due to various causes. Clinical presentations vary as well as the imaging findings. Exact pathogenetic mechanisms or triggering factors, as well as the best diagnostic and monitoring modalities and treatment strategies, are yet to be elucidated. We reviewed recent studies in aortitis and associated diseases.

RECENT FINDINGS

Multiple cohort studies reporting long-term outcomes in patients with noninfectious aortitis were recently published. Comparative features of isolated aortitis were described. Six angiographic clusters for giant cell arteritis and Takayasu have been identified. New classification criteria have been proposed for IgG4-related disease by a data-driven method. The ultrasonographic slope sign and a halo score were described as specific imaging parameters in giant cell arteritis. The promising role of PET-computed tomography, not only in the diagnosis of aortitis but also in monitoring disease activity, has been noted. Results of in-vitro studies on Janus kinase (JAK)/signal transducers and activators of transcription and mammalian target of rapamycin (mTOR) pathways, comparative studies with leflunomide as an induction therapy, and a long-term follow-up study with tocilizumab may contribute to the management of Takayasu arteritis.

SUMMARY

An impressive number of studies have addressed aortitis in recent years. However, there still is a lack of robust data on causes, monitoring disease activity by imaging and biomarkers, and drugs providing steroid-free remission in noninfectious aortitis.

Male Patients with Takayasu Arteritis and Coronary Artery Involvement are Prone to have Serious Coronary Stenosis and High Mortality

BACKGROUND

Takayasu arteritis (TAK) is a rare autoimmune vasculitis that predominantly affects the aorta and its major branches, including the coronary arteries. Limited information is available regarding sex-specific differences in coronary artery involvement among TAK patients.

OBJECTIVE

To assess the differences in coronary angiographic findings and the long-term outcomes between male and female TAK patients having coronary artery involvement.

METHODS

This retrospective cohort study included 87 TAK patients, grouped by sex, who underwent coronary angiography. General characteristics, clinical features, coronary angiographic findings, and therapeutic strategies were obtained from medical records. Major Adverse Cardiac Events (MACE), including death from any cause; myocardial infarction; repeated coronary artery revascularization; and rehospitalization due to unstable or progressive angina, or heart failure occurring during follow-up, were also recorded.

RESULTS

A total of 207 coronary lesions with stenosis were found in 87 TAK patients. The prevalence of ostial coronary lesions was lower in men than in women (9.1 vs. 23.9%, p=0.031). We observed less moderate stenosis (6.8 vs 22.7%, p=0.018) and more severe stenosis or occlusion (70.5 vs 46.0%, p=0.004) in the coronary lesions of male TAK patients. During the up to 7-year follow-up, death from any cause was greater in men than in women (21.4 vs. 1.5%, p=0.003); no other significant differences in MACE occurrence were observed between sexes.

CONCLUSIONS

Among TAK patients with coronary artery involvement, males tend to have more severe coronary stenosis and a higher risk for long-term mortality than females.