a b s t r a c t

Takayasu arteritis is a form of vasculitis that involves the aorta, its major branches, and the pulmonary arteries. Coronary artery involvement is not uncommon, and most frequently includes the ostia and proximal segments. Early diagnosis of Takayasu arteritis is difficult since it is a rare disease and is accompanied by various nonspecific clinical symptoms. However, recent advances in imaging modalities-including magnetic resonance angiogra- phy, computed tomography (CT), sonography, and fluoro-deoxyglucose positron emission tomography (FDG- PET)/CT Isobe (2013) [2]-have facilitated earlier and more accurate diagnoses of this condition. Here we report a case in which imaging revealed stenosis in the ostia of the coronary artery.

(C) 2016

A 29-year-old man presented with stable angina pectoris that had lasted three months. The patient had no relevant medical history, did not drink alcohol or smoke, and had no family history of coronary artery disease. His blood pressure was 101/60 and 130/82 mmHg in his right and left arms, respectively. His heart rate was 70 beats/min. Cardiac ex- amination was unremarkable, his lungs were clear to auscultation, his abdomen was benign, and there was no Pitting edema of his extremi- ties. Electrocardiogram and echocardiogram findings were normal. Tro- ponin I levels, and renal and liver function test results were also normal. Laboratory test results showed Total leukocytes, 7.5 x 10⁹/L; hemoglo- bin, 13.2 g/dL; platelet count, 180 x 10⁹/L; and negative findings for syphilis antibodies.

Coronary angiography revealed Significant stenosis (95%) of the ostia of the left main coronary artery (Fig. 1A), and occlusion of the right coronary arteries (Fig. 1B). The patient refused coronary artery by- pass grafting, and agreed to drug-eluting stent treatment for the left main coronary artery stenosis. He received aspirin (100 mg/day) and clopidogrel (75 mg/day).

Laboratory tests showed an erythrocyte sedimentation rate of 9 mm/h, and a C-reactive protein concentration of 2.77 mg/L. Tests were negative for other inflammatory markers, including Rheumatoid factor, venereal disease, complement activity, antiphospholipid anti- bodies, antinuclear antibodies, extractable nuclear antigens, and antineutrophil cytoplasmic antibodies. CT revealed significant stenosis of the right subclavian artery (Fig. 2A) and celiac axis (Fig. 2B). It was suspected that the patient had Takayasu arteritis (TA) in an inactive state. The patient was treated with oral prednisone (1 mg/kg/day) and

* Corresponding author at: 15 Yuquan Road, Beijing 100049, People’s Republic of China.

E-mail address: [email protected] (Y.-T. Zhao).

cyclophosphamide (100 mg/day). During a one-month follow-up, the patient experienced no chest pain or Cardiovascular complications.

This case illustrates the presence of stenosis of the ostia of the coro- nary artery in a patient with no Traditional risk factors, and without an- giographic evidence of atherosclerosis. The etiology was unclear. Although coronary atherosclerosis is detected in 80% of young patients, this population is less likely to have severe coronary vessel obstruction compared to older adults. Young individuals more commonly present nonobstructive or single-vessel coronary artery disease. Several unusual conditions can lead to coronary artery stenosis among young patients-including coronary arteritis in Vasculitic disorders (such as TA), systemic lupus erythematosus, Kawasaki’s disease, congenital cor- onary disease (such as fibromuscular dysplasia), or blunt chest trauma that causes a coronary lesion.

TA is the most common large-vessel vasculitis in childhood, but its etiology is unknown. Multiple biomarkers for diagnosing and evaluating TA activity are currently under development, but more specific markers are desirable. In the present case, angiographic images of the coronary artery, subclavian artery, and celiac axis supported a TA diagnosis. The American College of Rheumatology criteria for TA diagnosis include age, symptoms, signs, and angiographic findings revealing involvement of the aorta and its major branches, with the presence of more than three criteria suggesting a high probability of TA [1]. Our presently de- scribed patient met three out of six criteria.

Approximately 10% of TA cases include coronary artery involvement, most commonly the ostia and proximal segments [3]. Such involvement is classified into three distinct morphological types: stenosis or occlu- sion of the coronary ostia, diffuse or focal coronary arteritis, and coro- nary aneurysm formation. The present case illustrates the presence of stenosis of the ostia of the coronary artery in a patient with no tradition- al risk factors, and without angiographic evidence of atherosclerosis.

http://dx.doi.org/10.1016/j.ajem.2016.10.071

0735-6757/(C) 2016

Fig. 1. Coronary angiography showed significant stenoses, including 95% stenosis of the ostia of the left main coronary artery (A, arrow), and total occlusion of the right coronary arteries (B, arrow).

Angiographic images of the coronary artery, subclavian artery, and celi- ac axis supported the diagnosis of Takayasu arteritis.

TA treatment involves high-dose corticosteroid and immunosup- pressive drugs. Significant coronary artery stenoses are treated with stent implantation or Coronary artery bypass grafting. Our patient re- fused a coronary artery bypass graft, but accepted a drug-eluting stent to treat the significant stenosis in the left main coronary artery. Previous case reports have demonstrated the efficacy of drug-eluting stents for TA treatment; however, such reports have included only short observa- tion periods. Long-term follow-up data are required to evaluate the role of drug-eluting stent implantation for treating coronary arterial lesions in patients with TA. The patient in the present case also requires a longer follow-up period.

Funding sources

There were no sources of funding for this work.

Disclosures

Conflicts of interest: none.

Acknowledgements

None.

References

1. Arend WP, Michel BA, Bloch DA, et al. The American College of Rheumatology 1990 criteria for the classification of Takayasu arteritis. Arthritis Rheum 1990;33(8): 1129-34.
2. Isobe M. Takayasu arteritis revisited: current diagnosis and treatment. Int J Cardiol 2013;168(1):3-10.
3. Sun T, Zhang H, Ma W, et al. Coronary artery involvement in takayasu arteritis in 45 Chinese patients. J Rheumatol 2013;40(4):493-7.

   

   Fig. 2. Computed tomography images showed significant stenoses of the right subclavian artery (A, arrow) and the celiac axis (B, arrow).