1. Coronary Involvement in Takayasu’s Arteritis Saori Kobayashi

2. University of Tokyo Hospital clinics clinical lab OR wards

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 ・ 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

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 ３ mo after 、 90 ％ restenosis was detected →PTCA(Sirolimus-Eluting Stent) ６ mo 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 DESBMS Restenosis-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 events2.6%1.3%

12. 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?

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 DES Suppress neointimal hyperplasia ＋ attenuate arteritis →lower risk of restenosis →QOL improvement ↑cardiac event ？

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. The Lancet 2007; 370:1552-1559

17. Spring is coming soon…