Shifting perspectives in coronary involvement of polyarteritis nodosa: case of 3-vessel occlusion treated with 4-vessel CABG and review of literature

Background Polyarteritis Nodosa (PAN) is a systemic vasculitis (SV) historically thought to spare the coronary arteries. Coronary angiography and contemporary imaging reveal coronary stenosis and dilation, which are associated with significant morbidity and mortality. Coronary arteries in PAN are burdened with accelerated atherosclerosis from generalized inflammation adding to an inherent arteritic process. Traditional atherosclerotic risk factors fail to approximate risk. Few reports document coronary pathology and optimal therapy has been guarded.Methods Database publication query of English literature from 1990-2022.Results Severity of coronary involvement eludes laboratory monitoring, but coronary disease associates with several clinical symptoms. Framingham risk factors inadequately approximate disease burden. Separating atherosclerosis from arteritis requires advanced angiographic methods. Therapy includes anticoagulation, immunosuppression and revascularization. PCI has been the mainstay, though stenting is confounded by vagarious alteration in luminal diameter and reports of neointimization soon after placement.Conclusions When graft selection avoids the vascular territory of SV's, CABG offers definitive therapy. We have contributed report of a novel CABG configuration in addition to reviewing, updating and discussing the literature. Accumulating evidence suggests discrete clinical symptoms warrant suspicion for coronary involvement. - Polyarteritis Nodosa causes coronary arteritis, commonly in asymptomatic patients- Angiography with Optical Coherence Tomography or ultrasound differentiates the disease- Laboratory monitoring does not correlate with coronary severity- Coronary involvement is associated with abdominal pain, new hypertension and young age- Standard atherosclerotic risk factors do not associate with coronary involvement- PCI is complicated by arterial stenosis adjacent to dilation and rapid neo-intimal expansion- CABG offers definitive therapy, though selection of graft material is complex