To stent or not to stent - a challenging decision in a rare condition

Abstract

Introduction: In this case we discuss the management of a patient with recurrent acute coronary syndrome due to Takayasu arteritis (TA). Case report description: In 2007, a 13-year-old Caucasian male with angina, electrocardiographic and troponin abnormalities consistent with an acute coronary syndrome, and widespread bruits, was found to have multiple arterial stenoses involving the aorta, renal and carotid arteries. The erythrocyte sedimentation rate was 32mm (0-7), C reactive protein 36 mg/L (0-7) with a mild normocytic anaemia. Coronary angiography showed triple vessel disease and he was diagnosed with TA with coronary artery involvement. Coronary artery bypass graft surgery (free left internal mammary graft to the left anterior descending artery and sequential saphenous vein graft to the intermediate and left posterolateral vessels) was performed. The patient received intensive medical therapy and angioplasty for hypertension due to bilateral renal artery stenosis. His condition continued to progress and angina recurred in 2012 with coronary angiography demonstrating occlusion of the vein graft segment to the posterolateral artery. The patient was managed medically but was diagnosed with a non-ST elevation myocardial infarction in 2013 due to occlusion of the vein graft to the intermediate. He suffered ongoing symptoms of cardiac ischaemia and after discussion with the Cardiosurgical team a decision was made to treat the diseased native right coronary artery by percutaneous coronary artery intervention (PCI) with drug eluting stents. Despite this measure the patient has experienced ongoing angina and further PCI to the ungrafted left coronary artery territories is under consideration. Discussion: TA most commonly presents in 20-30 year-old females of East Asian descent and coronary artery involvement in children is very rare. From a cardiac perspective this case highlights the challenge of managing coronary artery disease in the setting of active large vessel vasculitis. Limited data exist to guide clinicians in this setting. Whether redo cardiac surgery at age 18 would be superior to a percutaneous approach is unclear. Implications to clinical practice: 1. Our case highlights the importance of considering vasculitis in the differential diagnosis of a young patient presenting with chest pain. 2. Rare clinical scenarios can pose a management dilemma for the treating physician due to the paucity of supporting research available to direct the decision making process. Treatment strategies should be decided on a case-by-case basis and consensus opinion from the multidisciplinary team is recommended.