Regression of the Left Main Trunk Lesion by Steroid Administration in Takayasu's Aortitis

doi:10.1378/chest.99.2.508

Chest

Volume 99, Issue 2, February 1991, Pages 508-510

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A 62-year-old man with unstable angina due to severe narrowing of the left main trunk (LMT) was examined. Emergency bypass surgery was performed with an internal mammary artery graft, instead of a saphenous vein graft, because of the thickened, edematous ascending aorta. Postoperative coronary angiography showed the lesion of the LMT markedly regressing. Presumably, this stenotic lesion of the LMT was caused by active aortitis and was partially reversible by steroid administration both during and after surgery. Steroid therapy can be added to the list of treatments for cases of LMT disease associated with Takayasu's aortitis, if signs of active inflammation are present.

Section snippets

CASE REPORT

A 62-year-old man had noticed an oppressive sensation in his chest upon exertion since March 1989. On May 23, 1989, the sensation had lasted for ten hours, and he was transferred to this hospital. The peak creatine phosphokinase level was 796 IU, but no new abnormal Q waves developed on electrocardiography. After admission, he remained free from angina pectoris with nitrates, calcium antagonists, and β-adrenergic blockers. The level of CRP was 5.5 mg/dl, and normocytic and normochromic anemia

DISCUSSION

A severe LMT lesion, persistently abnormal CRP levels, and the thickened, edematous ascending aorta, as seen during surgery in this case, are characteristic of Takayasu's aortitis. Surgical therapy for Takayasu's aortitis during the active phase carries great risk. Generally, aortic valve replacement is postponed until inflammation has subsided with steroid therapy.¹ Cherin et al² reported a case of reversible coronary stenosis after steroid administration. The regression was suspected by

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Inflammatory arteritis with reversible coronary localization in a 70-year old woman
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There are more references available in the full text version of this article.

Cited by (19)

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 :
Immunosuppressive therapy as first-line treatment for TA has been reported to be effective in controlling disease activity and halting angiographic progression [18]. Nonetheless, current knowledge regarding the effect of medical therapy including anti-inflammation and anti-atherosclerosis in patients with TA and coronary involvement stems mainly from case reports [15]. The optimal medical therapy in these patients remains unclear.
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.
Outcomes of percutaneous coronary intervention and coronary artery bypass grafting in patients with Takayasu arteritis
2017, International Journal of Cardiology
Citation Excerpt :
In addition, the timing of the operation is important, and surgical treatment should be avoided during the active stage of inflammation in TA. What's more, the involved narrowing coronary artery lesions may regress after steroid therapy [26]. However, inflammation may be persistent in a rather portion (40%) of patients even after treatment [27] and this would jeopardize the insertion sites of new grafts.
Coronary artery involvement is not a rare presentation of Takayasu arteritis (TA) and the treatment is challenging. The optimal methods of revascularization, and prognosis of treatment have not been established.
To assess the long-term outcomes of percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) in TA patients.
Patients with coronary artery involved in TA who underwent either PCI or CABG were identified between February 2003 and December 2015. The primary outcome was long-term all-cause mortality. Secondary outcomes were myocardial infarction (MI), stroke, and repeat revascularization.
Thirty-one patients were enrolled (PCI = 19 vs. CABG = 12). Most of them were female (25, 80.6%) and the mean age was 42.6 ± 13.8 years (16–64 years). Angina pectoris was the most common initial symptom (26 cases, 83.9%) and concomitant aortic regurgitation was present in 8 (25.8%) patients. Both groups had a low rate of corticosteroids use [4/19 (21.1%) vs. 2/12 (16.7%)]. During the median follow-up of 101 months (10–384 months), PCI group had a significantly higher incidence of restenosis [12/19(63.2%) vs. 3/12(25%)]. Two patients with severe aortic regurgitation in PCI group suffered from cardiac death during follow-up.
Coronary artery involvement should be suspected in TA patients with angina pectoris, especially young women. PCI had a very high rate of in-stent restenosis in patients without corticosteroids and CABG may be a preferred treatment option.
Coronary involvement in Takayasu's arteritis
2007, Autoimmunity Reviews
Citation Excerpt :
Interestingly, in this study the long-term outcome for patients with TA was best predicted either by the existence of a complication that developed along the past clinical course or by an elevated erythrocyte sedimentation rate. Indeed, there are multiple studies demonstrating the major influence of effective steroid therapy on the angiographic features of the involved vessels in TA [38,39]. The crucial importance of attenuating the inflammatory process before any revascularization procedure is attempted, whatever it may be, is well established [5,39,40].
Coronary involvement may appear in up to a third of patients with Takayasu's arteritis. This affliction may have a dominant impact on the clinical manifestations of the patient. Occlusion of the ostia of the left main coronary artery and of proximal segments of the coronary arteries is the most frequent finding of the coronary vasculature in patients with Takayasu's arteritis. Beyond the vasculitic process enhanced atherosclerosis has a significant and detrimental impact on the disease development. Revascularizations are often unsuccessful particularly when the inflammatory disease is not under satisfactory control. New techniques have been developed in order to use vessels that have not been damaged by the disease as grafts.
Left Main Coronary Artery Stenosis: State-of-the-Art
2007, Current Problems in Cardiology
Citation Excerpt :
The few studies that have involved histologic examination of coronary vessels have reported atherosclerosis as the primary cause of LMCA stenosis. Nonatherosclerotic causes of ostial stenosis reported in literature20-25 include syphilitic aortitis, giant cell arteritis, Takayasu disease, calcific diseases of the aortic valve and aortic valve replacement, trauma from coronary angiography, mediastinal irradiation, and a high angulated takeoff of the left main artery. Several case reports in literature have described severe intimal thickening consisting predominantly of fibrous tissue without extracellular deposits.26,27
Patients with stenosis of the left main coronary artery present difficult challenges. The risks associated with this lesion have been known since the early days of angiography when patients were found to have increased mortality during follow-up. This information led to the general guidelines that surgical revascularization should be considered the treatment of choice in patients with significant left main coronary artery stenosis.
Current advances in invasive cardiology have brought important information to the field. Intravascular ultrasound is now used routinely to evaluate angiographically indeterminate lesions with criteria now set forward as to what constitutes an indication for revascularization. Stents have even further dramatically changed the landscape. There are substantial issues, however, that need to addressed. These include the following: (1) the effect of specific lesion location on outcome—it is known that patients with distal bifurcation left main disease have worse outcome; (2) the potential for subacute thrombosis of the left main coronary artery; (3) the impact of left ventricular function and patient comorbidities irrespective of the degree and location of left main coronary artery stenosis; and (4) the risk–benefit ratio of stenting versus coronary artery bypass graft surgery.
These issues are currently being addressed in two seminally important trials including the SYNTAX trial, which randomizes patients with left main and/or three-vessel disease to either coronary artery bypass graft surgery or a TAXUS drug-eluting stent. This trial is in the final stages of patient recruitment and will have important implications for the field. The other trial is the COMBAT trial, which is focused exclusively on left main coronary artery stenosis and randomizes patients with left main coronary artery disease either to a Sirolimus-eluting stent (Cypher, Johnson and Johnson Cordis, USA) or to coronary artery bypass graft surgery.
The field of left main coronary artery disease continues to expand in terms of the evidence available for optimal patient evaluation and selection of treatment modalities.
Angiographic findings and surgical treatments of coronary artery involvement in Takayasu arteritis
2003, Journal of Thoracic and Cardiovascular Surgery
Citation Excerpt :
Radial pulse became palpable, and the erythrocyte sedimentation rate and C-reactive protein levels tended to normalize in almost all patients in 2 reported series.27,28 Iga and associates29 reported a patient with Takayasu arteritis who had CABG as a result of unstable angina because of narrowing of the left main artery, and regression of ostial stenosis was observed after steroid therapy. Patients with Takayasu arteritis show 3 types of abnormal coronary findings: coronary aneurysm, coronary steal phenomenon, and coronary ostial stenosis.
Background: Takayasu arteritis is associated with a low incidence of coronary artery involvement, such as stenosis, obstruction, aneurysm, and coronary steal syndrome, but coronary ischemia can be fatal. Methods: Between 1972 and April 2001, 81 of 130 patients given a diagnosis of Takayasu arteritis underwent selective coronary angiography, and among them, 31 patients (4 male and 27 female patients; mean age, 41.1 ± 13.2 years) had abnormal coronary angiographic findings and were recruited for this study. Results: Abnormal coronary findings consisted of 24 coronary artery stenoses of greater than 75%, 3 coronary artery-bronchial artery anastomoses, 3 aneurysmal coronary ectasias, and 1 combined coronary ectasia and anastomosis. Among 24 patients with coronary stenosis, the ostium was most frequently involved (87.5%). Twenty-three of 24 patients with coronary artery stenoses were treated surgically. The mean follow-up duration was 9.65 ± 6.9 years, with a 100% follow-up rate. Four fistulas and 4 aneurysms in 7 patients were not treated surgically. Coronary steal phenomenon was always associated with occluded pulmonary arteries and pulmonary hypertension. Aneurysmal coronary ectasia was related to severe aortic hypertension with or without aortic regurgitation and atypical coarctation. There were 2 (8.7%) in-hospital deaths and 3 (13%) late deaths. The actuarial survival rate, including in-hospital deaths, was 86.5% ± 7.3% at 5 years and 81.4% ± 8.4% at 10 years. Conclusion: The incidence of coronary abnormalities is relatively low in patients with Takayasu arteritis; however, surgical treatment is recommended for patients with coronary ostial stenoses because coronary ischemia can be one of the major causes of death.
J Thorac Cardiovasc Surg 2003;125:570-7
Left main coronary artery disease
1999, American Journal of the Medical Sciences
A 50-year-old male smoker with hypertension was brought to the emergency room by EMS. He reported several months of exertional chest pain. Over the previous week, the pain had increased in frequency; on the day of admission, it occurred while the patient was at rest. The last episode was accompanied by diaphoresis and shortness of breath. The patient was given nitrates in the ambulance and was pain free by the time of arrival at the emergency room. Physical examination was unremarkable. Electrocardiogram (ECG) showed nonspecific changes (Figure 1).

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Chest

Selected ReportsRegression of the Left Main Trunk Lesion by Steroid Administration in Takayasu's Aortitis

Section snippets

CASE REPORT

DISCUSSION

Ann Thorac Surg

Inflammatory arteritis with reversible coronary localization in a 70-year old woman

Eur Heart J

Selected Reports
Regression of the Left Main Trunk Lesion by Steroid Administration in Takayasu's Aortitis