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Coronary Involvement in Takayasu’s Arteritis

Coronary Involvement in Takayasu’s Arteritis. Saori Kobayashi. University of Tokyo Hospital. wards. clinical lab OR. clinics. Takayasu’s Arteritis(TA). Vasculitis of aorta and its primary branch →stenosis and aneurysm Japan, Southeast Asia, India, and Mexico Male:Female=1:9,

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Coronary Involvement in Takayasu’s Arteritis

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  1. Coronary Involvement in Takayasu’s Arteritis Saori Kobayashi

  2. University of Tokyo Hospital wards clinical lab OR clinics

  3. 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

  4. TA and Atherosclerosis • chronic inflammation cause atherosclerosis • Higher incidence than the other collagen disease • ↑sensitivity of platelets to collagen, ↑thromboxane B2 cause thrombosis Incidence of arteriosclerosis in carotid artery(Seyahi et al.)

  5. 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!

  6. Treatment of TA Control of vasculitis ・ Steroids(>6mo remission:28%) If uncontrolled immunosuppressant： Cyclosporin,Cyclophosphamide, Methotrexate,etc.. Symptomatic occulusion angioplasty/surgery thrombosis Anti-platelet therapy（low-dose Aspirin）

  7. Treatment for coronary artery occulusion in TA surgery（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％

  8. 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.

  9. Applying DES to TA • Case:53yo female • Diagnosed with TA when Pt is 42yo, had been treated with Prednisone • Angina of effort at the age of 53、90％ stenosis at LCA ostia was detected. • Refused surgery and PTCA was performed (bare-metal stent)→0%stenosis、asymptomatic • Angina relapsed ３mo after、90％ restenosis was detected 　→PTCA(Sirolimus-Eluting Stent) ６mo after、asymptomatic and no stenosis was detected

  10. 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 ?

  11. DES in ordinary atherosclerosis：BASKET-LATE Trial • 746 patients randomly assigned to DES group or BMS group(n=499, 244, respectively) • Taking clopidogrel for 6mo→without clopidogel for 12mo

  12. DES in normal arteriosclerosis ↑incidence of cardiac event by thrombosis→need to take anti-platelet agent Prevention of restenosis(8.7%→4.9%) DES Do we really need to use DES?

  13. 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 has correlation with inflammation activity

  14. DES in TA • DES may contribute as a “bridge” until inflammation control is obtained Suppress neointimal hyperplasia＋attenuate arteritis →lower risk of restenosis ↑cardiac event？ →QOL improvement DES

  15. Conclusion • Coronary lesion in TA occurs most often in ostia • High incidence of restenosis If bare-metal stent 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

  16. 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. TheLancet 2007; 370:1552-1559

  17. Spring is coming soon…

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