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A 41-year-old female with previous diagnosisof Takayasu arteritis was hospitalized with recurrent chest pain at rest forlast 4 months. She was on immune modulators like corticosteroid andMycophenolate mofetil. Physical examination revealed weak bilateral upper limbpulsation.Bilateral lower limb blood pressures were equal and158/90 mmHg each.

A 12-lead had baselineST depression and T inversion in the chestand limb leads.The ejection fraction was50%. Routine bloodtests were normal.Contrast enhanced Computed tomography ofthoracic and abdominal aorta showedocclusion of innominate artery and leftsubclavian artery. Renal arteries and carotid arteries were normal.

Coronary angiogram from right femoral accessrevealed critical left main and right coronary ostial stenosis. LMCA wasectatic after its ostial stenosis. Left main prior to the ectasia was 5.2mm in diameter.The proximal RCA was 4.8mm in diameter.
LMCA stenosis.mp4
RCA angiogram.mp4

The right coronary artery was hooked using 6 Fr JR guide. The vessel was wired using a Fielder FC .The critical ostial stenosis was predilated using 4x10mm NC balloon. Then lesion was stented using 4.5x15mm Resolute Integrity with cuspal wire support. The ostium was flared using a 5mmx12 mm NC balloon with good result. Left main coronary artery was hooked using 7Frx3.5 XB guide from Cordis. Three fielder FC wires were used for left side. Two were used to wire LAD and LCX and the third one was used as a cuspal wire for precise ostial stenting. The left main critical stenosis was predilated using a4mmx12mm NC balloon. Then the lesion was stented using Ultimaster 4.5x15mm stent, Terumo at 22 ATM.As there was significant under expansion of the stent, it was post dilated using 5mmx6mm NC balloon followed by ostial flaring using a 12x5mm NC balloon with good result. The procedure was supported two stand-by femoral sheaths i.e., right femoral sheath vein for temporary pacemaker support and left femoral artery sheath for IABP support.
RCA with cuspal wire_x264.mp4
LMCA optimisation after stenting_x264.mp4
LMCA flaring_x264.mp4

This case of Takayasu arteritis is quite interesting because of several reasons. There was critical stenosis of the left main coronary artery and right coronary artery. Both the  lesions were treated by angioplasty using  standard procedural technique with acceptable immediate result. LMCA ostial stenting has similar long-term result to CABG in cases of atheromatous disease, but this case needs close follow up because the stenosis was  due to Takayasu arteritis involving both the ostia. The use of Intra coronary Imaging would have been more informative in this case.