Invisible Aortic Arch Vessels

From the Department of Medicine, Advocate Christ Medical Center/University of Illinois at Chicago, Oak Lawn, Illinois, and the ^§Division of Cardiology, Department of Medicine, Advocate Christ Medical Center/ University of Illinois at Chicago, Oak Lawn, Illinois. The authors report no conflicts of interest regarding the content herein. Manuscript submitted September 8, 2008, provisional acceptance given October 13, 2008, manuscript accepted November 14, 2008. Address for correspondence: Tanyanan Tanawuttiwat, MD, 4440 West 95th Street, Oak Lawn, IL 60453. E-mail: ttanawuttiwat@gmail.com

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J INVASIVE CARDIOL 2009;21:69
Case Presentation. A 62-year-old white female was admitted to our hospital for non-ST-elevation myocardial infarction (NSTEMI). She had been diagnosed with Takayasu’s arteritis 28 years previously, but had not been followed up and had never been on immunosuppressants. Her upper extremities and carotid pulses were not palpable. She underwent cardiac catheterization and was found to have a heavily calcified aorta, with total occlusions of the brachiocephalic, left common carotid and left subclavian arteries (Figure 1). The left main coronary artery and the left circumflex coronary artery were patent. The left anterior descending artery was large, tortuous and had a 30–40% occlusion in the mid segment. The diagonal branches had a 50% occlusion distally (Figure 2). The right coronary artery (RCA) was significantly calcified and was severely diseased in the mid segment, with multiple segments of beaded appearance and a bridging collateral to the distal RCA (Figure 3). The patient was treated medically for NSTEMI and was started on prednisone for Takayasu’s arteritis. Takayasu’s arteritis is a rare vasculitis that mainly affects women at childbearing age and primarily involves the aorta, its branches and the pulmonary arteries, to various degrees. The pathogenesis of the disease has not been defined, however, there is active inflammation in the media level of the arteries. In the course of the disease, as a result of destruction at the elastic lamina and muscular media, and as a result of the inflammation leading to intimal proliferation, stenosis and occlusions occur. Various treatments, including steroids, vascular surgery and balloon angioplasty, have been used in the management of these patients. The first choice of treatment in patients who have Takayasu’s arteritis and noncritical vascular involvement is immunosuppression, primarily with corticosteroids. When steroids are administered, a 40–60% rate of remission is seen. Approximately 40% of steroid-resistant patients respond to the steroids with the addition of cytotoxic agents. Methotrexate, an alternative to cyclophosphamide as an immunosuppressive agent, may induce remission when other treatments have failed. Approximately 20% of all patients are resistant to any kind of treatment.