Aortitis-Associated Left Main Obstruction Requiring Urgent CABG: When Youth Is Not Low Risk

Acute coronary syndrome in young adults is rare and should trigger evaluation for nonatherosclerotic causes.

A 19-year-old woman presented with exertional chest pain and dyspnea with rising troponin. Chest computed tomography angiography ruled out pulmonary embolism. Coronary computed tomography angiography showed circumferential proximal left main coronary artery (LM) thickening with >90% stenosis and aortic wall thickening. Coronary angiography confirmed diffuse LM disease involving the left anterior descending artery (LAD)/left circumflex ostia with TIMI grade II LAD flow and right coronary artery collaterals. Refractory ischemia despite aspirin, heparin, high-dose steroids, nitroglycerin, and intra-aortic balloon pump support prompted urgent coronary artery bypass grafting (left internal mammary artery to LAD; radial artery to obtuse marginal). Aortic/periaortic biopsy showed chronic adventitial inflammation with medial degeneration.

Large-vessel vasculitis (eg, Takayasu arteritis) can cause ostial/proximal coronary stenosis presenting as acute coronary syndrome. Diagnosis often relies on multimodality vascular imaging and histopathology when available, because systemic features may be limited.

Young age does not exclude critical coronary artery disease. LM wall thickening with aortic changes should raise suspicion for inflammatory aortopathy.