Balloon angioplasty of the aorta in Takayasu's arteritis: Initial and long-term results

Challenges with Takayasu's arteritis: a case study

Takayasu's arteritis (TA) is a systemic vasculitis that involves an autoimmune-mediated transmural degeneration of the aorta and its major branches, leading to severe arterial stenoses or occlusions with subsequent cerebral, cardiopulmonary, mesenteric, renal, or limb ischemia. Patient history and physical examination, arteriography, magnetic resonance imaging, and specific laboratory tests facilitate the diagnosis of TA. Major treatments for the condition include the use of corticosteroids, cytotoxic agents, antiplatelet drugs, percutaneous transluminal angioplasty (PTA), and surgical revascularization. Major nursing interventions for TA include teaching the patient and family about the progression and treatments of TA and performing periodic patient assessments for manifestations of systemic vasculitis, alterations in tissue perfusion, and alterations in coping.

Long-term immunosuppressive treatment of a child with Takayasu's arteritis and high IgE immunoglobulins

A 7-year-old child presented with a severe form of Takayasu's arteritis, with two consecutive episodes involving the right testis and then the left kidney 6 months later. The renal artery obstruction was accompanied by severe hypertension. An aortography showed a complete obstruction of the left renal artery and a narrowing of the right subclavian artery. Plasma renin activity was high. Serum immunoglobulins were within the normal range, except for an increase in IgE (880 mu/l). Despite 4 months', treatment with antihypertensive drugs, prednisone, cyclophosphamide, and anticoagulant, the blood pressure never returned to normal and the left renal function remained completely absent. A nephrectomy was performed which immediately normalized plasma renin activity and blood pressure. The child was subsequently treated with alternate-day prednisone for 3 months, alternating with 3 months of cyclophosphamide or, later, azathioprine. Persantine (dipyridamole) and acetylsalicylic acid were administered continuously. The right radial pulse returned to normal within 2 years. An 8-year follow-up failed to detect any new episode of arteritis. The right kidney showed signs of compensatory hypertrophy. Finally, a recent arteriography demonstrated not only a normal right renal artery blood flow but almost total disappearance of the right subclavian artery obstruction. However, the IgE remained abnormally high (2,023 micrograms/l).

Fatal aortic rupture following balloon angioplasty of aortic restenosis in aortoarteritis

We report a case of fatal aortic rupture following balloon dilation in a young female with aortoarteritis in whom restenosis of the aorta was observed 16 years after a patch aortoplasty operation. To the best of our knowledge, this complication has not been reported in aortoarteritis, although such instances have been reported in recoarctation. This unfortunate experience leads us believe that aortic segment in operated cases may be resistant to balloon dilation and vulnerable to rupture. In such cases, balloon angioplasty should either be avoided or performed with extreme caution. A sequential balloon dilation technique starting with a smaller balloon may be helpful in avoiding this complication.

Influence of angiographic morphology on the acute and longer-term outcome of percutaneous transluminal angioplasty in patients with aortic stenosis due to nonspecific aortitis

PURPOSE

We studied the relationship of initial angiographic morphology in patients with aortic stenosis due to nonspecific aortitis and its relationship to immediate and later outcome following percutaneous transluminal angioplasty (PTA).

METHODS

Correlation was performed in 10 successive patients by retrospective analysis. All had clinically inactive nonspecific aortitis and hemodynamically significant aortic stenosis resulting in hypertension or lower limb claudication. Five patients had discrete concentric stenosis; the other five had eccentric stenosis with diseased aortic segments adjacent to the stenosis.

RESULTS

The five patients with concentric stenosis (Group I) had primarily successful and uncomplicated PTA with sustained improvement. The five patients (Group II) with eccentric stenosis had initial success in three patients and two initial treatment failures with one patient showing late improvement. Four of these patients developed large intimal flaps. One of these had an aneurysm during follow-up. Follow-up angiograms in five patients showed remodelling with further angiographic and clinical improvement.

CONCLUSION

Eccentricity of the stenosis and diffuse aortic disease correlate unfavorably with immediate outcome of PTA but late improvement may still be seen.

Balloon angioplasty for renovascular hypertension in Takayasu's arteritis

Percutaneous transluminal renal angioplasty was performed in 54 consecutive patients with hypertension and renal artery stenosis caused by Takayasu's arteritis. Angioplasty was technically successful in 67 (89.3%) of 75 lesions attempted. In these 67 lesions, the degree of stenosis decreased from 88.3 +/- 4.8% to 23.5% +/- 13.6% (p < 0.001) after angioplasty. Following successful angioplasty there was significant improvement in hypertension (p < 0.001) within 48 hours. Patients with bilateral renal artery stenosis had higher systolic blood pressure both before balloon dilatation (p < 0.05) and after balloon dilatation before discharge (p < 0.001), compared with patients with unilateral renal artery stenosis. Three to 70 months (mean 26.4 +/- 10.3 months) after successful angioplasty, blood pressure was reduced to normal or was improved in 93% of patients. Angiographic restudy an average of 14.2 +/- 7.8 months after angioplasty showed restenosis at the same site in 7 of 52 (13.5%) lesions and fresh stenosis in one artery. All these eight lesions were successfully dilated. Further improvement in the luminal diameter was observed in 11 (21.2%) lesions. Late angiographic restudy in seven patients an average of 56.1 +/- 6.3 months after angioplasty showed no restenosis. Our results suggest that balloon angioplasty is safe and highly effective in relieving renal artery stenosis caused by Takayasu's arteritis and should be the treatment of choice for renovascular hypertension in this disease.

Percutaneous transluminal angioplasty in Takayasu arteritis

Percutaneous transluminal balloon angioplasty (PTBA) was performed in 87 patients for 111 stenotic lesions due to Takayasu arteritis. Of the lesions attempted for dilatation, 35 were in the aorta, 64 in renal arteries, 9 in subclavian, and 3 in common iliac arteries. The stenosis of aorta could be successfully dilated in 33 of 35 (94.3%) patients with fall in peak systolic pressure gradient (PSG) from 77.7 +/- 28.4 mmHg to 26.4 +/- 20.6 mmHg (P < 0.001) and increase in luminal diameter from 4.7 +/- 2.4 mm to 10.1 +/- 4.1 mm (P < 0.001). On hemodynamic and angiographic restudy in 20 patients at 3-24 months (mean 7.7 +/- 4.1 months) further fall in PSG (> or = 15 mmHg) was observed in 7 patients, no significant change in 12 patients and restenosis with increase in PSG in one patient which could be successfully redilated. Late restudy at 36-60 months (mean 43 +/- 9.4) in six patients showed continued relief of stenosis (mean PSG 8.8 +/- 7.8 mmHg). Of the 64 stenotic lesions of the renal arteries, 58 (90.6%) could be successfully dilated with decrease in stenosis from 89.1 +/- 10.1% to 29.9 +/- 14.9% (P < 0.001). Follow-up intra-arterial digital subtraction angiography in 25 patients at a mean follow-up period of 13.1 months (range 3-29 months) showed restenosis in 5/36 (13.9%) lesions which could be successfully redilated. Angioplasty was also successful in dilating 8/9 (88.9%) subclavian and all 3 common iliac artery stenosis.(ABSTRACT TRUNCATED AT 250 WORDS)