Coronary arterial involvement in Takayasu arteritis (TA) is not uncommon. Herein, we describe a case of TA with celiac trunk and superior mesenteric artery occlusion combined with coronary artery disease. Bilateral huge internal thoracic arteries (ITAs) and the inferior mesenteric artery provided the major visceral collateral circulation. After percutaneous intervention to the right coronary artery, off-pump coronary artery bypass grafting for the left coronary territory was done using a right ITA graft and its large side branch because of its relatively minor contribution to the visceral collateral circulation.
A 49-year-old man presented with exertional chest pain. He had hypertension that was well controlled with medication. He did not show any constitutional symptoms such as fever, malaise, or fatigue. Inflammatory markers were suggestive of mild disease; the erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were 13 mm/hr (normal range, 0 to 10 mm/hr) and 1.1 mg/L (normal range, 0 to 5 mg/L), respectively. Coronary angiography (CAG) showed 80% concentric stenosis at the left main coronary artery, chronic total occlusion of the left anterior descending (LAD) artery, and 95% stenosis of the proximal right coronary artery (Fig. 1A, B). Transthoracic echocardiography showed normal left ventricular systolic function with severe hypokinesia at the mid-inferior and inferolateral wall. Flow acceleration at the abdominal aorta was also suspected. Computed tomography (CT) of the aorta revealed a diffuse severe tapered narrowing of the descending thoracic artery through the abdominal aorta with the narrowest dimension of 6 mm at the level of the renal arteries. The arch vessels were intact with mild stenosis at the left common carotid artery. Total occlusion of the celiac trunk and the superior mesenteric artery (SMA) was identified with major visceral collateral circulation from both the inferior mesenteric artery (IMA) and the bilateral internal thoracic arteries (ITAs) (Fig. 1C, D). The ankle-brachial index had decreased to 0.7 on both sides. In order to enlarge the narrowing aortic lumen and to increase the forward flow to the IMA and the lower extremities, a vascular stent for the abdominal aorta (12 mm×100 mm, Hercules Vascular; S&G Biotech Inc., Seongnam, Korea) was first deployed. After this procedure, the patient received steroid therapy under the impression of Takayasu arteritis (TA). During a 5-month follow-up period, the angina class deteriorated from Canadian Cardiovascular Society II to III. Follow-up CT angiography showed slightly improved abdominal aortic dimensions (Fig. 2B). The ankle-brachial index also recovered to the normal range, and inflammatory markers such as ESR and CRP likewise dropped to the normal range. Considering the patient’s young age and the absence of possible arterial grafts, we adopted a hybrid approach for complete revascularization. First, drug-eluting balloon angioplasty (SeQuent Please; B. Braun, Melsungen, Germany) for the proximal right coronary artery (RCA) lesion was done during the follow-up CAG (Fig. 2A). Then, he received dual antiplatelet therapy (aspirin and clopidogrel). Two weeks later, off-pump coronary artery bypass grafting (OPCAB) for the LAD and the large ramus intermedius (RI) was carried out using the right ITA
TA is characterized as pan-arteritis causing ischemic symptoms related to stenotic lesions . TA can be classified according to the involved vessels as follows: type I (branches of the aortic arch), type IIa (ascending aorta and aortic arch), type IIb (ascending aorta, aortic arch, and descending thoracic aorta), type III (descending thoracic aorta and abdominal aorta), type IV (abdominal aorta and/or renal arteries), and type V (combined features of types IIb and IV) . Our patient showed type V TA. The distribution of the types varies among countries, but a recent study reported that type V (54.5%) and type II (22.3%) were the most common types of TA in Korea . Coronary arterial involvement is not uncommon in TA, and occurs in 10% to 30% of cases. Typical lesions involve stenosis at the coronary ostium or proximal segments of the coronary arteries . This patient had proximal coronary artery involvement without ostial lesions.
This patient was relatively old, considering that TA is typically seen in young patients with an age of onset of less than 40 years . Other possible large vessel vasculitis conditions can occur at this age, such as infectious aortitis, giant cell arteritis (GCA), or Behcet disease. This patient did not have any sign of infection or history of syphilis. Symptoms of cranial aortitis, which is characteristic of GCA, such as new-onset headache, jaw claudication, or visual problems, were also absent. A neurysms involving large branches of the pulmonary artery, which are typically seen in Behcet disease, were not present either .
As this patient was considered to be in the active stage of TA with elevated inflammatory markers and a thickened aortic wall at the first presentation, he underwent OPCAB after stabilization of the disease activity using oral steroid treatment following aortic stenting. Surgery is strongly recommended during the inactive phase of vasculitis because subsequent steroid treatment can lead to a significant regression of the coronary artery stenosis, resulting in the occlusion of bypass grafts from flow competition [2,4]. We performed total arterial revascularization considering the patient’s young age. According to the American College of Cardiology Foundation/American Heart Association guidelines for coronary artery bypass surgery, complete arterial revascularization may be reasonable in patients less than 60 years of age . In this patient, although the IMA provided most of the collateral circulation in the SMA territory, the left ITA provided a significant amount of the collateral circulation in the celiac trunk territory. Thus, we used the right ITA as a blood source for coronary artery bypass grafting. Fortunately, there was a large side branch of the right ITA that was used for lengthening the
We adopted an I-composite graft considering the location of the target coronary artery and the length of the free side branch. This graft made the total graft longer than if a Y-composite graft, which anastomoses the second graft in an end-to-side fashion, were used.
Some controversy exists regarding the