Stentless left main revascularisation for takayasu arteritis using directional coronary atherectomy and a drug-coated balloon: a case report.

Background: Coronary involvement in Takayasu arteritis is characterized by chronic fibrotic thickening of the arterial intima and is associated with a high risk of restenosis after coronary intervention. In young women, coronary artery bypass grafting and coronary stenting are often undesirable, owing to long-term procedural implications and considerations regarding future pregnancy. Case summary: A 21-year-old woman presented with severe left main coronary artery stenosis caused by Takayasu arteritis. After inflammation had been adequately controlled with glucocorticoid therapy and a monoclonal antibody directed against the interleukin-6 receptor, stentless revascularization was undertaken. Directional removal of fibrotic tissue was followed by inflation of a drug-coated coronary balloon. This approach led to a complete relief of the patient's symptoms, and imaging over 5 years demonstrated sustained patency of the left main coronary artery without restenosis. The patient gave birth to two healthy children without experiencing cardiovascular complications. Discussion: This case illustrates the potential value of a stentless strategy that integrates systemic control of vascular inflammation with targeted removal of fibrotic coronary tissue. The favourable long-term outcome emphasizes the importance of deferring coronary intervention until inflammatory activity has been adequately suppressed. It further suggests that a personalized revascularization approach without stent implantation may be a viable alternative in patients for whom conventional bypass surgery or coronary stenting is undesirable.