Case Report: Coronary artery involvement and nonvisualization of pulmonary artery branches first detected during follow-up of Takayasu arteritis

Takayasu arteritis (TA) is a chronic granulomatous large-vessel vasculitis of unknown etiology that can involve the coronary and pulmonary arteries. A 30-year-old woman presented with crushing chest pain and was found to have 95% stenosis at the ostium of the left main coronary artery. Approximately 3.5 months after coronary stent implantation, severe in-stent restenosis occurred, requiring balloon angioplasty. Positron emission tomography/computed tomography (PET/CT) showed thickening of the ascending aorta and aortic arch wall with increased fluorodeoxyglucose uptake, supporting the clinical diagnosis of TA. She received glucocorticoids and methotrexate and, because of persistent coronary disease, underwent off-pump coronary artery bypass grafting, followed by tocilizumab. During follow-up, C-reactive protein and erythrocyte sedimentation rate remained within reference ranges. In September 2025, echocardiography estimated a mean pulmonary artery pressure of 21 mmHg, whereas an October examination did not report pulmonary hypertension. On October 15, 2025, right heart catheterization measured a pulmonary artery pressure of 39/10 mmHg (mean 20 mmHg), which did not meet the current hemodynamic threshold for pulmonary hypertension. Pulmonary angiography showed nonvisualization of the right upper and middle lobar pulmonary artery branches. Because of the lack of baseline pulmonary vascular imaging or a complete evaluation of alternative causes, the onset and etiology of this finding remain uncertain. Normal acute-phase reactants during tocilizumab therapy should not be regarded as evidence of the absence of vascular disease, and angiographic nonvisualization alone cannot establish active vasculitic occlusion.