Catheter-Based Revascularization and Antithrombotic Strategies for Post-Kawasaki Disease Coronary Artery Lesions: A Narrative Review of Guideline-Aligned Management

Coronary artery aneurysms, stenosis, and thrombosis following Kawasaki disease (KD) remain clinically significant from childhood through adulthood, producing ischemia driven by complex vascular remodeling rather than atherosclerosis. As survivors age, revascularization decisions become frequent and complex, demanding consideration of unique features like ectasia, intimal hyperplasia, and calcification. This narrative review synthesizes contemporary evidence and guideline frameworks [American Heart Association (AHA) 2017/2024; Japanese Circulation Society (JCS) 2020] to clarify appropriate catheter-based revascularization strategies. We summarize risk stratification guided by lesion morphology and long-term prognosis. Pre-procedural evaluation integrates coronary computed tomography angiography for anatomic mapping with adjunctive intravascular ultrasound or optical coherence tomography to characterize calcium and aneurysm-neck geometry. In anatomically complex or aneurysmal vessels where traditional physiology may be misleading, PET-derived myocardial flow reserve can provide complementary insight. For focal, technically approachable stenosis, percutaneous coronary intervention (PCI) is feasible when performed with imaging guidance and tailored lesion preparation. Conservative rotational atherectomy may be required for heavy calcification, and stent selection must accommodate abrupt caliber transitions around aneurysms. Covered stents, such as PK Papyrus, are reserved strictly for acute perforation. In contrast, diffuse multivessel disease, left-main involvement, or aneurysm-complex anatomy generally favors coronary artery bypass grafting (CABG), supported by favorable long-term outcomes in contemporary Japanese series. In these settings, CABG—typically with an internal thoracic artery–first strategy—provides durable graft patency and remains the preferred revascularization approach. Antithrombotic therapy requires individualized balancing of thrombosis and bleeding risk. Aspirin and dual antiplatelet therapy are applied in usual PCI contexts, while giant aneurysms or prior thrombosis often warrant warfarin-based anticoagulation, with limited but emerging adult data on selective direct oral anticoagulants (DOACs) use. Ultimately, KD-related coronary disease requires imaging-guided, physiology-informed, and anatomy-specific strategies. A heart-team approach and structured longitudinal follow-up remain essential for optimizing outcomes as these patients transition into adulthood.