Recurrent Coronary Restenosis in Takayasu Arteritis

BACKGROUND: Coronary involvement in Takayasu arteritis is uncommon but associated with high rates of in-stent restenosis and challenging revascularization. CASE SUMMARY: A 22-year-old woman with Takayasu arteritis and congenital antithrombin III deficiency presented with non-ST-segment elevation myocardial infarction due to severe ostial right coronary artery in-stent restenosis after multiple prior percutaneous interventions. Intravascular ultrasound confirmed significant neointimal hyperplasia. A stent-sparing strategy using excimer laser coronary atherectomy, cutting balloon angioplasty, and paclitaxel drug-coated balloon under intravascular ultrasound guidance was performed with bivalirudin anticoagulation. Final angiography demonstrated TIMI 3 flow with significant luminal gain. DISCUSSION: Recurrent restenosis in Takayasu arteritis represents a major therapeutic challenge. This case highlights the role of multimodal, stent-avoidant strategies and individualized anticoagulation in complex inflammatory vasculopathy with concomitant thrombophilia. TAKE-HOME MESSAGES: Recurrent in-stent restenosis in Takayasu arteritis reflects ongoing vascular inflammation and requires strategies beyond repeat stenting. A stent-sparing, intravascular imaging-guided approach using laser atherectomy and drug-coated balloon can effectively treat refractory restenosis while minimizing additional stent burden.