Retrograde Percutaneous Coronary Intervention in a Case of Takayasu Arteritis with Left Main Coronary Artery Chronic Total Occlusion

BACKGROUND: Takayasu arteritis (TA) frequently involves the coronary arteries, and restenosis is common after initial percutaneous coronary intervention (PCI). However, PCI remains a good option for patients who develop graft failure after coronary artery bypass graft surgery (CABG). Drug-coated balloons help in repeat revascularization after stent failure in TA. Case Presentation. A 31-year-old female with previous history of Takayasu arteritis (TA) and CABG with left internal mammary artery (LIMA) to left anterior descending artery (LAD) grafting in 2012, presented to us with exertional angina of 6-month duration. Her coronary angiogram showed total occlusion of the left main coronary artery (LMCA) ostium and atretic LIMA graft. Since the guiding catheter could not engage the LMCA, a retrograde approach was planned. After lesion crossing, the retrograde guidewire could not be externalized even after multiple attempts. Hence, a repeat antegrade approach was tried, and antegrade wire crossed through the channel created by the retrograde microcatheter. Then, intravascular ultrasound (IVUS) guided LMCA-LAD stenting was done. The patient was started on dual antiplatelets and prednisolone and was on regular follow-up. Three months later, the patient presented to us with non-ST elevation MI. Coronary angiogram showed critical in-stent restenosis of the LMCA stent, and optical coherence tomography (OCT) showed diffuse neointimal hyperplasia. OCT-guided PCI using sirolimus-coated balloon was done. On 8 months of follow-up, the patient remains symptom free. CONCLUSION: Coronary artery disease in TA may require repeated interventions due to stent/graft failure. Drug-coated balloons play a crucial role in repeat revascularization for stent failure in TA. Retrograde approach increases the technical success rate of PCI in LMCA-CTO.