Implantation of a Drug-Eluting Stent for the Coronary Artery Stenosis of Takayasu Arteritis
De Novo and In-Stent Restenosis
A 35-year-old woman with a history of hypertension presented with shortness of breath and atypical chest discomfort. Although a vascular bruit was not heard at any site of the body, the upper extremity pulses were very faint on both sides. The erythrocyte sedimentation rate (ESR) was 39 mm/h, and measurement of C-reactive protein (CRP) yielded a value of 1.94 mg/dL. Although the ECG was not suggestive of ischemia, an echocardiogram revealed severe hypokinesia of the anterior wall from the middle left ventricle to the apex. Angiography revealed total occlusions of both subclavian arteries (Figure 1A and 1B). Coronary angiography revealed a tight ostial stenosis of the left main coronary artery and right coronary artery (RCA) without any distal disease (Figure 2A and 2B). A clinical diagnosis of Takayasu arteritis was made because the patient had faint pulses with mild claudication of both arms and ostial coronary disease. A percutaneous coronary intervention (PCI) with a paclitaxel-eluting stent (3.5-mm diameter, 12 mm long; TAXUS, Boston Scientific, Natick, Mass; Figure 2C) was performed successfully on the ostial lesion of the left main coronary artery. Several days after the PCI on the left main coronary lesion, we performed a PCI with a bare-metal stent on the ostial lesion of the RCA. The large diameter of the RCA ostium precluded implantation of a drug-eluting stent (DES) because a large-diameter (>3.5 mm) DES was not available. The final angiographic results were good (Figure 2D). The patient remained free of symptoms after the PCI, and 2 days after the second stenting, she was discharged from the hospital. She was also treated with oral steroids for 3 months after the PCI, and her ESR and CRP concentrations returned to normal. There were no clinical events during follow-up, and follow-up angiography was performed 6 months after the PCI. A follow-up angiography and intravascular ultrasound (IVUS) examination demonstrated good patency of the paclitaxel-eluting stent, with minimal neointimal hyperplasia at the left main coronary ostial lesion (Figure 3A), whereas a tight in-stent restenosis was noted in the bare-metal stent of the RCA ostial lesion with severe neointimal hyperplasia (Figure 3B). Because the inflammatory marker (ESR and CRP) values were normal, we repeated the PCI with a sirolimus-eluting stent (3.5-mm diameter, 23 mm long; Cypher, Cordis, Miami Lakes, Fla) without any additional immunosuppressive therapy. Angiography after the repeated PCI showed good results (Figure 3C). Two days after the repeated PCI, the patient was discharged without immunosuppressive agent therapy. During the second follow-up, there were no clinical events, and the inflammatory marker values were also normal. Fourteen months after the first PCI and 8 months after the second PCI, follow-up angiography was performed. Compared with the results from the 6-month follow-up angiography, the second follow-up angiography and IVUS examination revealed no significant interval changes of the paclitaxel-eluting stent, with minimal neointimal hyperplasia of the left main coronary ostial lesion (Figure 4A). In the in-stent restenotic lesion of the RCA, although small amounts of neointimal hyperplasia were noted at 2 sites, the patency of the sirolimus-eluting stent was also good (Figure 4B). The ESR was 6 mm/h and the CRP value was 1.94 mg/dL. On the day after the coronary angiography, the patient was discharged without immunosuppressive agent therapy.
We have previously reported the 6-month results of this case. With the exception of the current case, to our knowledge there is no published literature on the use of DES for the treatment of stenotic coronary lesions associated with Takayasu arteritis. This case indicates that a DES maintained good patency for a long time (>1 year) and that it was also effective for the treatment of an in-stent restenotic lesion of a stenosed coronary artery associated with Takayasu arteritis. Although more data and a longer follow-up will be required to better understand the role of DES for the treatment of Takayasu arteritis, we suggest that whenever suitable, implantation of a DES be considered instead of a bare-metal stent in Takayasu arteritis.