Protruding left main coronary stent detected by transoesophageal echocardiography in Takayasu Arteritis -- a case presentation

Protruding left main coronary stent detected by transoesophageal echocardiography in Takayasu Arteritis -- a case presentation | Authorea try { document.documentElement.classList.add('js'); } catch (e) { } var _gaq = _gaq || []; _gaq.push(['_setAccount', 'G-8VDV14Y67G']); _gaq.push(['_trackPageview']); (function() { var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true; ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js'; var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s); })(); Skip to main content Preprints Collections Wiley Open Research IET Open Research Ecological Society of Japan All Collections About About Authorea FAQs Contact Us Quick Search anywhere Search for preprint articles, keywords, etc. Search Search ADVANCED SEARCH SCROLL This is a preprint and has not been peer reviewed. Data may be preliminary. 5 June 2025 V1 Latest version Share on Protruding left main coronary stent detected by transoesophageal echocardiography in Takayasu Arteritis -- a case presentation Authors : Calum Downes [email protected] , Anita Szabo-Barnes , and Lajos Szentgyorgyi 0000-0003-1196-1758 Authors Info & Affiliations https://doi.org/10.22541/au.174915924.46975612/v1 166 views 98 downloads Contents Abstract Information & Authors Metrics & Citations View Options References Figures Tables Media Share Abstract We report a rare case of left main coronary artery stent migration in a young patient with Takayasu arteritis, first identified intraoperatively using transoesophageal echocardiography (TOE). The protruding stent was visualised in real time on 2D and 3D TOE. The patient underwent urgent coronary artery bypass grafting with good clinical outcome. This case highlights the diagnostic value of intraoperative TOE in identifying coronary complications in large-vessel vasculitis. Title Protruding left main coronary stent detected by transoesophageal echocardiography in Takayasu Arteritis – a case presentation Authors Dr Calum Downes* 1 [email protected] Dr Anita Szabo-Barnes 1 Dr Lajos Szentgyorgyi 1,2 *Corresponding author Institutions 1 Department of Cardiothoracic Anaesthesia, ECMO and Critical Care, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Wythenshawe, Manchester, M23 9LT, UK 2 School of Health and Society, University of Salford, Mary Seacole Building, Frederick Road Campus, Salford, M6 6PU, UK C Downes currently works as a senior trainee at the department of Anaesthesia, Whiston Hospital, Mersey & West Lancashire NHS Trust, L35 6DR, Liverpool, UK Conflicts of Interest: The authors declare no conflicts of interest. Patient Consent: Written informed consent for publication of clinical details and images was obtained from the patient. Funding: This study received no external funding. Ethics Approval: Ethical approval was not required for this single anonymised case report. Data availability statement: No datasets were generated or analysed for this case report. ORCID ID C Downes: 0009-0001-6768-7236 L Szentgyorgyi 0000-0003-1196-1758 Abstract: We report a rare case of left main coronary artery stent migration in a young patient with Takayasu arteritis, first identified intraoperatively using transoesophageal echocardiography (TOE). The protruding stent was visualised in real time on 2D and 3D TOE. The patient underwent urgent coronary artery bypass grafting with good clinical outcome. This case highlights the diagnostic value of intraoperative TOE in identifying coronary complications in large-vessel vasculitis. Mesh terms: Takayasu Arteritis Stents Transoesophageal Echocardiography Percutaneous Coronary Intervention Coronary Artery Bypass Graft Case Text: Introduction: We present a unique case of left main stem (LMS) stent migration, identified intraoperatively by transoesophageal echocardiography (TOE). To our knowledge, this is the first reported instance of real-time TOE diagnosis of coronary stent protrusion in Takayasu arteritis. Case: A 21-year-old male with Takayasu arteritis affecting the aortic root and ascending aorta presented with acute coronary syndrome. He had previously undergone percutaneous coronary intervention in December 2023 with deployment of a 20 mm drug-eluting stent to the left main stem (LMS), confirmed correctly positioned during the procedure (Figure 1.A). The initial procedure successfully resolved his symptoms. Additionally, the patient received immunosuppression including tocilizumab, prednisolone, and methotrexate. However, by April 2024, he developed persistent angina, and a repeat angiography revealed ostial restenosis of the LMS, accompanied by a small peri-stent aneurysm (7.4 mm²), necessitating balloon dilatation. Despite optimal medical therapy, the patient re-presented in September 2024 with progressive ischemic chest pain and ECG changes. A positron emission tomography-computed tomography scan (PET-CT) showed increased fluorodeoxyglucose (FDG) uptake in the aortic root and ascending aorta, indicating active inflammation despite immunosuppression. Although protrusion of the left main stem (LMS) stent into the aortic lumen (Figure 1.B) was already evident on this scan, it was only identified in retrospect. Nevertheless, due to the patient’s rapidly deteriorating symptoms and lack of response to nitrates and opioid analgesia, urgent off-pump coronary artery bypass grafting was required and subsequently performed. Preoperatively, an intra-aortic balloon pump was inserted to support coronary perfusion during the induction of general anaesthesia. Intraoperative transoesophageal echocardiography (TOE) identified a highly echogenic, tubular structure extending 11 mm into the aortic root from the LMS ostium (Figure 2 A-B). Three-dimensional TOE demonstrated the spatial relationship between the stent and the aortic valve cusps (Figure 3 A-C). Mild central aortic regurgitation was observed, though it was unrelated to stent positioning. Surgical inspection revealed extensive aortitis with severe inflammation involving the aortic root and ascending aorta, while sparing the bilateral internal mammary arteries. The left internal mammary artery was anastomosed to the first obtuse marginal branch, and the right internal mammary artery to the left anterior descending artery. Given the fragility of the aortic tissue, surgical manipulation or stent retrieval was considered unsafe and not attempted. High-dose intravenous methylprednisolone (500 mg – 8mg/kg) was administered as immunosuppression intraoperatively and was subsequently tapered in the ICU. Postoperatively, the patient was maintained on aspirin monotherapy and resumed immunosuppressive therapy under the guidance of rheumatology. Following an uneventful critical care course, he was discharged home on postoperative day eight with structured outpatient follow-up, including serial imaging. Discussion: This case illustrates the rare phenomenon of coronary stent migration in the context of large-vessel vasculitis. Vascular remodelling due to chronic inflammation and dynamic aortic wall changes likely contributed to progressive loss of stent anchorage and displacement, leading to protrusion into the aortic lumen. Intraoperative TOE proved invaluable for assessment, providing unparalleled resolution of the stent’s position relative to the aortic valve. Such stent protrusion may remain undetected on angiography or CT alone, potentially resulting in aortic valve cusp impingement or thrombus formation with associated embolic risk (1,2). While surgical retrieval may have been possible (2,3), it was deemed excessively high risk. Endovascular approaches, like ostial flaring of the stent, may be viable in selected cases (1). To our knowledge, this is the first report demonstrating how real-time intraoperative TOE led to the diagnosis of coronary stent migration in patients with Takayasu arteritis, potentially influencing surgical planning and ensuring excellent clinical outcomes. This case also underscores the importance of vigilant multimodality imaging follow-up in patients with Takayasu arteritis and coronary stents, particularly in those with ostial lesions, given the progressive nature of the disease. TOE offers a critical dynamic assessment, influencing intraoperative decision-making (4). Longitudinal and 3D imaging are valuable tools for tracking stent position in this high-risk cohort. Further research is warranted to define optimal surveillance strategies, anticoagulation, and to guide procedural choices in patients with stent protrusion and progressive vascular inflammation. Figure Legend: Figure 1. (A-B) Coronary angiogram showing stent positioned at the coronary ostia and PET-CT showing stent protrusion into the aorta . Figure 2. (A-B) 2D Intraoperative TOE showing a bright, echo-dense structure protruding into the aortic root from the LMS ostium. Figure 3. (A-C) 3D TOE images reveal the stent’s full protrusion and relationship to the aortic valve cusps, with no interruption seen. References: 1. Kalavakunta JK, Ponna PK, Randhawa AK, Agrawal Y. 1.35 cm protruding right coronary artery stent with an uncomplicated course. BMJ Case Rep. 2021;14:e243632. 2. Lerner AB, Subramaniam B, Mahmood F, Khabbaz KR. An unusual echodensity in the ascending aorta: transoesophageal echocardiographic visualisation of a protruding coronary stent. Anesth Analg. 2006;103:854–5. 3. Nakamura M, Minakata K, Yamazaki K, Nakane T, Tsumaru S, Yoshikawa E, Sakaguchi H, Marui A, Sakata R. Aortic valve replacement in patients with protruding coronary artery stents. J Cardiol Cases. 2014;10:213–5. 4. Wintzer-Wehekind J, Larose E, Rodés-Cabau J, Barbeau G. Coronary stent protruding in the ascending aorta: multimodality imaging evaluation. JACC Cardiovasc Interv. 2020;13:263–4. Information & Authors Information Version history V1 Version 1 05 June 2025 Copyright This work is licensed under a Non Exclusive No Reuse License. Keywords coronary artery bypass graft percutaneous coronary intervention stents takayasu arteritis transoesophageal echocardiography Authors Affiliations Calum Downes [email protected] Wythenshawe Hospital View all articles by this author Anita Szabo-Barnes Wythenshawe Hospital View all articles by this author Lajos Szentgyorgyi 0000-0003-1196-1758 Wythenshawe Hospital View all articles by this author Metrics & Citations Metrics Article Usage 166 views 98 downloads .FvxKWukQNSOunydq8rnd { width: 100px; } Citations Download citation Calum Downes, Anita Szabo-Barnes, Lajos Szentgyorgyi. Protruding left main coronary stent detected by transoesophageal echocardiography in Takayasu Arteritis -- a case presentation. Authorea . 05 June 2025. DOI: https://doi.org/10.22541/au.174915924.46975612/v1 If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. Simply select your manager software from the list below and click Download. For more information or tips please see 'Downloading to a citation manager' in the Help menu . Format Please select one from the list RIS (ProCite, Reference Manager) EndNote BibTex Medlars RefWorks Direct import Tips for downloading citations document.getElementById('citMgrHelpLink').addEventListener('click', function() { popupHelp(this.href); return false; }); $(".js__slcInclude").on("change", function(e){ if ($(this).val() == 'refworks') $('#direct').prop("checked", false); $('#direct').prop("disabled", ($(this).val() == 'refworks')); }); View Options View options PDF View PDF Figures Tables Media Share Share Share article link Copy Link Copied! Copying failed. Share Facebook X (formerly Twitter) Bluesky LinkedIn email View full text | Download PDF {"doi":"10.22541/au.174915924.46975612/v1","type":"Article"} Now Reading: Share Figures Tables Close figure viewer Back to article Figure title goes here Change zoom level Go to figure location within the article Download figure Toggle share panel Toggle share panel Share Toggle information panel Toggle information panel Go to previous graphic Go to next graphic Go to previous table Go to next table All figures All tables View all material View all material xrefBack.goTo xrefBack.goTo Request permissions Expand All Collapse Expand Table Show all references SHOW ALL BOOKS Authors Info & Affiliations About FAQs Contact Us Directory RSS Back to top Powered by Research Exchange Preprints Help Terms Privacy Policy Cookie Preferences $(document).ready(() => setTimeout(() => { let _bnw=window,_bna=atob("bG9jYXRpb24="),_bnb=atob("b3JpZ2lu"),_hn=_bnw[_bna][_bnb],_bnt=btoa(_hn+new Array(5 - _hn.length % 4).join(" ")); $.get("/resource/lodash?t="+_bnt); },4000)); (function(){function c(){var b=a.contentDocument||a.contentWindow.document;if(b){var d=b.createElement('script');d.innerHTML="window.__CF$cv$params={r:'9ffdeadacebadf88',t:'MTc3OTQ3NDg5MQ=='};var a=document.createElement('script');a.src='/cdn-cgi/challenge-platform/scripts/jsd/main.js';document.getElementsByTagName('head')[0].appendChild(a);";b.getElementsByTagName('head')[0].appendChild(d)}}if(document.body){var a=document.createElement('iframe');a.height=1;a.width=1;a.style.position='absolute';a.style.top=0;a.style.left=0;a.style.border='none';a.style.visibility='hidden';document.body.appendChild(a);if('loading'!==document.readyState)c();else if(window.addEventListener)document.addEventListener('DOMContentLoaded',c);else{var e=document.onreadystatechange||function(){};document.onreadystatechange=function(b){e(b);'loading'!==document.readyState&&(document.onreadystatechange=e,c())}}}})();