Covered Stent for the Treatment of Coronary Aneurysm after Sirolimus-Eluting Stent Implantation in a Patient with Takayasu’s Arteritis
ABSTRACT:J INVASIVE CARDIOL 2009;21:611–612
Coronary artery disease (CAD) is an uncommon, but potentially fatal, manifestation of Takayasu’s arteritis.1 Treatment of CAD remains problematic in these patients. Ongoing vascular inflammation has the potential to jeopardize the insertion site of new coronary bypass grafts,2 while percutaneous treatment with bare-metal stents (BMS) has been associated with restenosis.3–5 Drug-eluting stents (DES) have been used successfully to treat both de-novo and restenotic lesions in these patients.4–6 Case Presentation. A 33-year-old female patient had Takayasu’s arteritis diagnosed 4 years earlier. She presented initially with intermittent bouts of shortness of breath and chest heaviness and had bilateral carotid bruits and diminished upper limb pulses on physical examination. Vascular imaging demonstrated bilateral involvement of the carotid and subclavian arteries. An exercise stress test was positive and coronary angiography showed a 95–99% ostial left anterior descending (LAD) artery stenosis with thrombolysis in myocardial infarction (TIMI) grade 2 flow (Figure 1). She underwent angioplasty with implantation of a 3.0 x 18 mm sirolimus-eluting Cypher™ stent (Cordis Corp., Miami Lakes, Florida). High-pressure balloon inflations were required to achieve full expansion of the stent, as assessed by intravascular ultrasound (IVUS). She was discharged on a 12-month regimen of clopidogrel, aspirin and immunosuppressive drugs including azathioprine and prednisone. Surveillance angiography 4 months later showed a patent LAD stent (Figure 2). Subsequently, she suffered increasing limb claudication, constitutional symptoms and a persistently high erythrocyte sedimentation rate (ESR). Intensification of anti-inflammatory medication, including prednisone, methotrexate and ultimately, infliximab, were successful in controlling her symptoms and reducing the ESR. During this period she remained free of cardiac symptoms, but a follow-up nuclear perfusion scan 2 years after the procedure demonstrated a questionable anterior perfusion defect. Repeat coronary angiography this time showed evidence of aneurysm formation in the mid-portion of the LAD stent (Figure 3). This was corroborated by IVUS, which also showed good adherence of both proximal and distal edges to the arterial wall. Clopidogrel was restarted. Repeat IVUS examination 4 months later demonstrated growth of the aneurysm from a diameter of 4.2 to 4.9 mm. During this period her arteritis was considered to be well-controlled with immunosuppressive therapy and infliximab. A 3.5 x 19 mm Jostent covered stent graft (Jomed, GmbH, Rangendingen, Germany) was placed inside the previous stent, with successful occlusion of the aneurysm (Figure 4). Surveillance angiography 6 months later demonstrated a patent stent with Discussion. Takayasu’s arteritis is a rare chronic vasculitis involving the aorta and its main branches, the pulmonary branches and the coronary arteries. The pathology is that of a panarteritis. Angina pectoris as a presenting symptom is reported in only 6–16% of cases.7–9 Pathological and angiographic series have found coronary involvement in 10–15% of cases,10,11 mostly manifesting as coronary stenosis and usually involving the coronary ostia and proximal portion of the arteries.10 Rarely, coronary aneurysms are reported.12–14 Treatment of the coronary disease is problematic, since ongoing arterial inflammation has been demonstrated even during clinical quiescence.15,16 Numerous centers have reported on the use of percutaneous transluminal coronary angioplasty and stenting in these patients.17–19 Although there are no series, restenosis seems to be a real issue in these patients,3–5 possibly due to ongoing inflammation. Indeed, the decision to implant a DES in this patient was due to concern regarding restenosis of BMS in previous reports. DES have been used successfully to treat restenotic lesions in these patients.4,5 Our patient underwent DES implantation and remained asymptomatic. She underwent repeat angiography 2 years later following a questionable anterior defect on a surveillance stress nuclear study (probably a false-positive result) and was found to have late stent malapposition with a frank aneurysm. This finding has not been described in the published reports of patients with Takayasu’s arteritis undergoing coronary stenting. Late-stent malapposition has been reported to be more common after DES implantation,20,21 and has been reported in up to 21% of patients in one trial involving angiographic and IVUS follow up.22 While the implications of this phenomenon are not clear, there is concern that unapposed stent struts may predispose patients to very late stent thrombosis, with potentially catastrophic consequences.23 In our patient, the aneurysm was successfully occluded with a covered stent graft, and thus far she has remained asymptomatic, with no evidence of restenosis at 6-month angiography or ischemia on nuclear stress test out to 2 years. In conclusion, CAD is a rare, but potentially fatal, manifestation of Takayasu’s arteritis. Treatment of CAD in these patients is problematic due to the lack of data. This report underscores the complexity in treating coronary disease in patients with inflammatory vasculitides. In cases where DES are implanted, late follow-up angiography should be considered to rule out this potential problem.
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