Download Coronary Involvement in Takayasu`s Arteritis

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
30
chronic
inflammation cause 25
atherosclerosis
20
 Higher incidence
15
than the other
10
collagen disease
5
 ↑sensitivity of
0
TA
SLE
normal
platelets to collagen,
↑thromboxane B2
Incidence of arteriosclerosis in
cause thrombosis
carotid artery(Seyahi et al.)

Coronary involvement in TA
Occurs in 10～30%
 Often fatal
 Classified into 3 pathorogic types
2/3!
Type1:stenosis or occlusion of coronary ostia
Type2:diffuse or focal coronary arteritis
Type3:coronary aneurism

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）
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％
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
treated with Prednisone
 Angina of effort at the age of 53、90％ stenosis at
LCA ostia was detected.
 Refused surgery and PTCA was performed (baremetal stent)→0%stenosis、asymptomatic
 Angina relapsed ３mo after、90％ restenosis was
detected
→PTCA(Sirolimus-Eluting Stent)
６mo after、asymptomatic and no stenosis was
detected

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：BASKETLATE Trial


746 patients randomly assigned to DES group or BMS
group(n=499, 244, respectively)
Taking clopidogrel for 6mo→without clopidogel for 12mo
DES
BMS
Restenosis-related target vascular
revascularization
4.5%
6.7%
Primary endpoint（cardiac death, nonfatal MI after discontinuation of
clopidogrel）
Thrombosis-rerated events
4.9%
1.3%
2.6%
1.3%
DES in normal arteriosclerosis
↑incidence of cardiac event
Prevention of
restenosis(8.7%→4.9%) by thrombosis→need to
take anti-platelet agent
DES
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
has correlation with inflammation activity

DES in TA
Suppress neointimal hyperplasia＋
↑cardiac event？
attenuate arteritis
→lower risk of restenosis
→QOL improvement
DES

DES may contribute as a “bridge” until
inflammation control is obtained
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

References

Moche Rav-Acha et al. Coronary involvement in
Takayasu’s arteritis Autoimmunity Reviews 6 2007;566571

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
Spring is coming soon…