Coronary Involvement in Takayasu’s Arteritis

Saori Kobayashi

University of Tokyo Hospital

clinics

clinical lab OR

wards

Takayasu’s Arteritis(TA)

Vasculitis of aorta and its primary branch →stenosis and aneurysm

Japan, Southeast Asia, India, and Mexico Male:Female=1:9, Most common in their 20’s~30’s

May involve coronary artery

→dyspnea, palpitations, angina, MI, CHF

TA and Atherosclerosis chronic inflammatio

n cause atherosclerosis

Higher incidence than the other collagen disease

↑sensitivity of platelets to collagen, ↑thromboxane B2

　 cause thrombosis

0

5

10

15

20

25

30

TA SLE normal

Incidence of arteriosclerosis in carotid artery(Seyahi et al.)

Coronary involvement in TA

Occurs in 10 ～ 30% Often fatal Classified into 3 pathorogic types

Type1:stenosis or occlusion of coronary ostia

Type2:diffuse or focal coronary arteritis

Type3:coronary aneurism

2/3!

Treatment of TA

　・　　

Steroids(>6mo remission:28%)

immunosuppressant ：Cyclosporin,Cyclophosphamide,Methotrexate,etc..

Anti-platelet therapy（ low-dose Aspirin）

angioplasty/surgery

If uncontrolled

Control of vasculitis

Symptomatic occulusion

thrombosis

Treatment for coronary artery occulusion in TAsurgery （ CABG,MIDCAB) ・・ often not indicated

・ because internal thoracic artery can’t be used due to occulusion of braciocepharic a./sabclavian a.

・ because of calcification of aorta

High incidence of restenosis:36 ％angioplasty(PTCA)

・ alternative to surgery

Often lead to unsatisfactory results

Very high incidence of restenosis:78 ％

Recent stent ： DES

DES(drug-eluting stent):

・ elute drug such as Paclitaxel or Siloromus

・ expected to inhibit proliferation of vascular endotherium and prevent restenosis and thrombosis

・ Actually 、 has dramatic effect to prevent restenosis.

Applying DES to TA Case:53yo female Diagnosed with TA when Pt is 42yo, had been treate

d with Prednisone Angina of effort at the age of 53 、 90 ％ stenosis at

LCA ostia was detected. Refused surgery and PTCA was performed (bare-m

etal stent)→0%stenosis 、 asymptomatic Angina relapsed ３ mo after 、 90 ％ restenosis wa

s detected　→ PTCA(Sirolimus-Eluting Stent)６ mo after 、 asymptomatic and no stenosis was dete

cted

Applying DES to TA

There are many cases reported that DES is effective in patients who had bare-metal PTCA and had recurrent restenosis

There is no evidence that DES improve the prognosis of TA more than bare-metal stent

How do DES work in ordinary atherosclerosis ?

DES in ordinary atherosclerosis：BASKET-LATE Trial 746 patients randomly assigned to DES group or BMS gr

oup(n=499, 244, respectively) Taking clopidogrel for 6mo→without clopidogel for 12mo

DES BMSRestenosis-related target vascular revascularization

4.5% 6.7%

Primary endpoint （ cardiac death, non-fatal MI after discontinuation of clopidogrel ）

4.9% 1.3%

Thrombosis-rerated events 2.6% 1.3%

DES in normal arteriosclerosis

DES

Prevention of restenosis(8.7%→4.9%)

↑incidence of cardiac event by thrombosis→need to take anti-platelet agent

Do we really need to use DES?

BMS in TA

Extremely high incidence of restenosis;78%

（ 5%/18mo in usual arteriosclerosis) Recurrent in several months:↓QOL, ADL Surgical therapy is often not indicated Progression of atherosclerois/restenosis h

as correlation with inflammation activity

DES in TA

DES may contribute as a “bridge” until inflammation control is obtained

DES

Suppress neointimal hyperplasia ＋attenuate arteritis

→lower risk of restenosis→QOL improvement

↑cardiac event？

Conclusion Coronary lesion in TA occurs most often in o

stia High incidence of restenosis If bare-metal ste

nt is applied Given unique character of atherosclerosis in

TA, selective use of DES limited to patients with an uncontrolled inflammation may contribute to improve patency rates of future definite interventions v(^_^)v

References

Moche Rav-Acha et al. Coronary involvement in Takayasu’s arteritis Autoimmunity Reviews 6 2007;566-571

Furukawa Y et al, Sirolimus-Eluting Stent for In-Stent Restenosis of Left Main Coronary Artery in Takayasu Arteritis Circ J 2005;69:752-755

Matthias Pfistereer et al. Late Clinical events After Clopidogrel Discintinuation May Limit the Benefit of Drug –Eruting Stents. The 　 Lancet 2007; 370:1552-1559

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