Excimer LASER in Middle Aorta Syndrome in Takayasu Aortoarteritis : a case report by Professor Dr Smit Shrivastava

By Professor Dr Smit Shrivastava

https://doi.org/10.1016/j.ihjcvr.2024.10.002

First in world

Keywords Excimer LASER atherectomyBalloon non-treatable lesions : Middle aortic aortic syndromeTakayasu aortoarteritis

Introduction

Takayasu Aortoarteritis is a large vessel giant cell vasculitis primarily affecting the aorta and its large branches in females between the ages of 10 to 40 years of Asian origin, presenting with constitutional symptoms and vaso-occlusive symptoms.[1]. The underlying pathogenic mechanism may involve specific yet unidentified target receptors in the aorta for T cell activation and Giant Cell arteritis. [2] The vascular involvement begins from the left middle or proximal subclavian artery to involve other thoracic branches of the aorta and to involve abdominal aorta and pulmonary arteries in half cases. [3]

Raipur chhattisgarh VISHESH Takayasu arteritis has a vacillating chronic course with self-limited disease in less than a fifth of the patients. The preferred treatment remains undefined with varied presentations and success and often include endovascular surgery and percutaneous transluminal angioplasty and/or stent graft placement.

The excimer LASER coronary angioplasty was introduced in the early 1980s, mainly to manage balloon-untreatable lesions, chronic total occlusion and thrombus in coronary arteries. 4, 5 This case report describes the first in world use of Excimer LASER atherectomy in middle aortic syndrome in a Takayasu arteritis patient.

Case Description

This 46-year-old female was referred for anterior wall myocardial infarction with barely palpable pulses without congestive cardiac failure. The catheter coronary angiography through the radial and femoral access was unsuccessful due to severe fibrotic occlusion in the right axillary artery and a cut off at the infrarenal aorta respectively [Figure 1]. She was then subjected to CT coronary angiography and an aortogram that showed non critical 50% stenosis in the left anterior descending artery and narrowed lumen of left common carotid artery, left subclavian artery and left axillary artery. There was diffuse long segment concentric mural thickening of the wall of abdominal aorta noted with irregular narrow lumen for a segment of approximate 17 cm starting from T7 to L3 vertebral level. Within the narrowed segment there was very tight stenosis of aorta noted for a segment of 4 cm from the level of L1 to L3 vertebra (infrarenal segment) with lumen appearing thread-like. The abdominal aorta lumen diameter above T7 vertebrae was 20 mm and below L3 vertebrae was 12 mm.

She was taken up for a planned revascularization for the infrarenal near total occlusion. The femoral access was through a fluoroscopic guided puncture of a barely palpable right femoral artery. Utilizing the Judkins 6 Fr right coronary guiding catheter to track Asahi Rinato PTCA guidewire across the occluded abdominal aorta. The thread like abdominal aorta lumen was not crossable with 1.2mm x 10 mm PTCA balloon, so 1.4mm excimer Laser catheter atherectomy at initially 45 mJ/mm2 fluence and pulse repetition rate of 25 Hz and later at 60 mJ/mm2 fluence and pulse repetition rate of 30 Hz was performed with slow incursion over the guidewire across the 17 cm length. [Figure 2] The guide catheter recorded an initial blood pressure gradient of over 96 mmHg across the abdominal aorta stenosis. The channel facilitated passage of the 3.5 mm X 12 mm Quantum Apex PTCA balloon catheter across the lesion. The multiple dilatations at 10 to 13 psi by PTCA balloon catheter enlarged the channel to accommodate the guiding catheter and thoracic aorta placement of Amplatz support guidewire. The angioplasty of abdominal aorta was then carried out with slow and guarded inflation of Balloon in Balloon (40 mm x 10 mm at 5 psi for four times & 50 mm X 20 mm at 3 and 4 psi for two times each) under conscious sedation. Successful recanalization of the occluded abdominal aorta by balloon angioplasty was evidenced by the femoral artery pressures equalizing to the suprarenal aortic pressures at 196/100 mmHg on a pull back. [Figure 3] The renal arteries could be opacified with clarity and totality.

Conclusion

This is the first ever use of Excimer Laser Atherectomy to facilitate passage of angioplasty balloon catheter across a middle aortic syndrome in a Takayasu Aortoarteritis patient. More experience will be needed before defining its place in treatment; however, this case illustration offers an important bail out strategy in patients with near total balloon non-crossable occlusion in Takayasu aortoarteritis patients.

Declaration of Competing Interest

☒ The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

☐ The authors declare the following financial interests/personal relationships which may be considered as potential competing interests:

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