The Vulnerable vessel: When Inflammation Primes, Thrombosis Strikes-takayasu Arteritis with Antiphospholipid Syndrome Overlap

Abstract

Background: Takayasu arteritis (TA) and antiphospholipid syndrome (APS) are distinct vascular disorders with complementary mechanisms of arterial injury. Their coexistence may create an inflammatory-thrombotic “double-hit” phenotype characterised by premature atherosclerotic-appearing disease, recurrent thrombosis, restenosis, and multiterritorial arterial involvement. Case Summary: A 48-year-old woman with hypertension and recurrent pregnancy loss presented with accelerated hypertension and unstable angina. Coronary angiography demonstrated premature diffuse multivessel coronary disease with chronic total occlusion of the left anterior descending artery (LAD) and critical left circumflex (LCX) and right coronary artery (RCA) disease. Severe left renal artery stenosis was simultaneously identified. Following coronary and renal revascularisation, she developed inferior myocardial infarction with LCX stent thrombosis, coronary in-stent restenosis (ISR), and progressive right renal artery disease. CT aortography was consistent with Type IV TA. Persistent lupus anticoagulant and anticardiolipin IgG positivity, together with recurrent pregnancy morbidity and arterial thrombosis, supported APS. During follow-up, she developed ischaemic stroke. Following immunosuppressive and antithrombotic therapy with repeated coronary and renal revascularisation, LV systolic function improved from 30 to 45%, with durable coronary and renal stent patency at follow-up. Conclusion: Recurrent coronary thrombosis or restenosis in a relatively young patient with premature coronary disease should prompt consideration of systemic vasculitis and autoimmune thrombophilia. Recognition of TA–APS overlap may influence the timing of revascularisation, immunosuppression, and long-term antithrombotic therapy.