Incidence and predictors of large-artery complication (aortic aneurysm, aortic dissection, and/or large-artery stenosis) in patients with giant cell arteritis: A population-based study over 50 years

Peripheral arterial disease in polymyalgia rheumatica

Patients with polymyalgia rheumatica have been shown to have an increased risk of peripheral arterial disease on longitudinal follow-up. Possible explanations for this include premature atherosclerosis related to chronic inflammation, as with other inflammatory rheumatological conditions. Alternatively, polymyalgia rheumatica can be associated with vasculitis, even in the absence of clinical giant cell arteritis, and peripheral vascular disease may represent subclinical vasculitis. Further work is required to elucidate the reasons for this increased risk. Currently, it would remain reasonable to aggressively control modifiable atherosclerotic risk factors.

Long-term follow-up of aortic involvement in giant cell arteritis: a series of 48 patients

To date, only a few series have analyzed the long-term outcome of giant cell arteritis (GCA) patients with aortic involvement, which prompted us to conduct the current retrospective study. Our aims were to 1) determine the prevalence of GCA in patients exhibiting nonatherosclerotic aortic involvement (that is, aortitis, aortic ectasia, and/or aneurysm); and 2) evaluate clinical features and long-term outcome of GCA patients exhibiting aortitis, aortic ectasia, and/or aortic aneurysm.From January 1997 to March 2008, 66 consecutive patients in the Department of Internal Medicine at the University of Rouen medical center received a diagnosis of nonatheromatous aortic complications (aortitis, aortic ectasia, and/or aneurysm). In these 66 patients, aortic involvement was related to GCA (n = 48), Takayasu arteritis (n = 6), relapsing polychondritis (n = 1), and infection (n = 11).Of the 48 patients with GCA, aortic involvement preceded the initial GCA diagnosis in 1 patient. Aortic involvement was identified in association with GCA in 40 patients (83.3%), and developed after the onset of GCA in the 7 remaining patients (14.6%). Aortic involvement was more often asymptomatic (77.1%). The aortic helical computed tomography (CT)-scan procedure principally showed isolated aortitis (circumferential thickening of the aortic wall >3 mm) in 41 patients (85.4%). In the remaining 7 patients with GCA (14.6%), aortic helical CT scan demonstrated aortic thoracic ectasia and aortitis (n = 3), aortic thoracic aneurysm and both thoracic and abdominal aortitis (n = 3), and both aortic abdominal aneurysm and aortitis (n = 1). All patients were given steroid therapy at a median daily dose of 1 mg/kg initially.At 6-month follow-up, 34 of 48 patients systematically underwent both thoracic and abdominal CT scan. Aortic helical CT scan demonstrated complete disappearance of aortitis in 8.8% of patients, improvement of aortitis in 47.1%, unchanged pattern of aortitis and/or aortic thoracic ectasia/aneurysm in 41.2%, and deterioration of aortic thoracic aneurysm in 1 patient (2.9%). At 18-month follow-up, 11 patients systematically underwent both thoracic and abdominal CT scan. Aortic helical CT scan showed complete disappearance of aortitis (n = 1), improvement of aortitis (n = 1), unchanged pattern of aortic thoracic ectasia/aneurysm (n = 2), and deterioration of aortic thoracic aneurysm (n = 1). At patients' last follow-up, the median daily dose of prednisone was 7 mg. Steroid therapy could be discontinued in 17 patients (35.4%).The current retrospective study suggests that aortic impairment may be more prevalent than previously reported. Our findings suggest that specific inflammatory thickening of the aortic wall is common at the time of GCA diagnosis, and that aortitis may be the first manifestation of GCA-associated aortic complications. Whether isolated aortitis leads to vascular wall injury responsible for late-onset aneurysmal disease remains to be determined. At this time, we recommend long-term monitoring for aortic aneurysms, especially in high-risk subjects, although the optimal frequency and imaging modality have not yet been determined. A yearly screening strategy for thoracic/abdominal aortic aneurysms has been proposed for patients with GCA, including physical examination, 2-view chest radiograph, and abdominal ultrasound.

[Large-vessel vasculitis. Imaging and interventional therapy]

Giant cell arteritis and Takayasu's arteritis are classified as primary large-vessel vasculitides. Inflammatory cell infiltrates and cytokines induce destruction and hyperplasia of the vessel wall, leading to stenoses or aneurysms. When extracranial large arteries are involved, there is often a similar clinical and radiologic disease pattern of an inflammatory aortic arch syndrome. Rare causes of large-vessel vasculitis include Behçet's disease, association with other autoimmune diseases, and infection. Depending on the localization, imaging is usually performed by means of duplex ultrasound, magnetic resonance imaging, computed tomography, or positron emission tomography. These imaging modalities are used not only to establish the diagnosis but also to determine the disease extent and activity and to perform follow-up in the course of medical therapy. Angiography offers the option to perform interventional therapy for vascular stenoses and occlusions.

Epidemiological and clinical features of giant cell arteritis in Tunisia

BACKGROUND

Giant cell arteritis (GCA) is a systemic vasculitis of the elderly that could result in vision loss or even be life threatening. Unlike western countries, this disease is considered exceptional in Tunisia.

OBJECTIVE

The aims of this study were to determine epidemiological and clinical features of GCA in Tunisian population and to identify management difficulties.

PATIENTS AND METHODS

A multicentric study of 96 patients in whom GCA was diagnosed between 1986 and 2003. All patients fulfilled the ACR criteria for classification of GCA.

RESULTS

The majority of cases (77%) were diagnosed since 1994. The male/female ratio was 0.88 and the mean age at the time of diagnosis was 70.8+/-7.7 years. Clinical features were characterized by gradual onset in 64.4% of cases. The most frequent clinical manifestations were headache (91.7%), abnormalities in temporal arteries (85.4%), severe ischemic manifestations (80.2%), constitutional symptoms (75%), and polymyalgia rheumatica (56.3%). Biological inflammatory syndrome was noted in all patients. Temporal artery biopsy established histological diagnosis in 73% of cases. All patients were treated by corticosteroids. Remission was obtained in 45.6%. Relapses occurred in 40.4% of cases and 30 patients were still receiving corticosteroids at the time of study. Four patients died and irreversible ischemic complications were noted in 15.6% of cases. Steroid adverse effects occurred in 56 patients.

CONCLUSION

GCA is not exceptional to Tunisia. It occurs amongst elderly patients with no female predominance noticed. Clinical features are similar to those reported in other series.

Cardiovascular risk factors and acute-phase response in idiopathic ascending aortitis: a case control study

Introduction

Idiopathic aortitis is a rare condition characterized by giant cell or lymphoplasmacytic inflammation of the aorta. The purpose of this study was to describe risk factors for the development of idiopathic aortitis.

Methods

We conducted a case control study of 50 patients who were age-matched with two control subjects with non-inflammatory ascending aortic aneurysms. We examined whether the prevalences of gender, hypertension, hyperlipidemia, diabetes mellitus, smoking, family history of any aortic aneurysms, and elevated inflammatory markers differed between cases and controls.

Results

The mean age of cases was 71.6 ± 8.9 years and that of controls was 71.1 ± 8.9 years. We found female gender (odds ratio [OR] 2.41, 95% confidence interval [CI] 1.20 to 4.85; P = 0.014) and active smoking (OR 3.37, 95% CI 1.12 to 10.08; P = 0.03) to be associated with idiopathic aortitis. The association with smoking persisted after adjustment for gender (OR 3.24, 95% CI 1.05 to 9.96; P = 0.04). There was a trend toward lower prevalence of diabetes mellitus in cases (OR 0.39, 95% CI 0.11 to 1.43; P = 0.16) but no difference in prevalences of other risk factors. The median pre-operative erythrocyte sedimentation rate (ESR) was 20 mm/hour in cases (n = 13) and 9 mm/hour in controls (n = 22). The median pre-operative C-reactive protein (CRP) levels were 12 mg/L in cases (n = 8) and 3 mg/L in controls (n = 6) (normal: <8 mg/L). A higher proportion of cases versus controls had elevations in ESR (38% versus 9%; P = 0.075) and CRP (62% versus 0%; P = 0.031).

Conclusions

Gender and smoking may interact in complex mechanisms with immune and proteolytic pathways in older, less distensible thoracic aortas. Elevated acute-phase reactants as a marker of systemic inflammation may be present in some patients.

Giant cell arteritis: an updated review

Giant cell arteritis (GCA) is the most common primary vasculitis of adults. The incidence of this disease is practically nil in the population under the age of 50 years, then rises dramatically with each passing decade. The median age of onset of the disease is about 75 years. As the ageing population expands, it is increasingly important for ophthalmologists to be familiar with GCA and its various manifestations, ophthalmic and non-ophthalmic. A heightened awareness of this condition can avoid delays in diagnosis and treatment. It is well known that prompt initiation of steroids remains the most effective means for preventing potentially devastating ischaemic complications. This review summarizes the current concepts regarding the immunopathogenetic pathways that lead to arteritis and the major phenotypic subtypes of GCA with emphasis on large vessel vasculitis, novel modalities for disease detection and investigative trials using alternative, non-steroid therapies.

Thromboembolic disease in vasculitis

PURPOSE OF REVIEW

To give an overview of recent clinical findings of thromboembolic disease in vasculitis and provide insight into possible explanations of the association between thrombosis and inflammation.

RECENT FINDINGS

A high incidence of venous thrombotic events has recently been described in four distinct cohorts of patients with antineutrophil cytoplasmic antibody-associated vasculitis (AAV), especially during periods of active disease. No factors other than the vasculitis itself have been identified that explain this high occurrence of thrombosis. Several studies have shown an increased rate of thrombosis in Behçet's disease, with a different clinical presentation from that observed in AAV. Recent laboratory findings provide exciting insights into a bidirectional feedback loop between coagulation and inflammation that may be applicable to vasculitis.

SUMMARY

Thrombosis is an important clinical manifestation of some types of vasculitis. Better understanding of the association of thrombosis with inflammation in vasculitis might lead to development of clinically useful biomarkers and new approaches to therapy. Additionally, study of the specific factors involved in thrombosis in systemic vasculitis could help explain the role of inflammation in more common settings of venous thrombotic events.

Comparison of duplex sonography and high-resolution magnetic resonance imaging in the diagnosis of giant cell (temporal) arteritis

OBJECTIVE

To compare the diagnostic performance of high-resolution magnetic resonance imaging (MRI) and color-coded duplex sonography (CCDS) in patients with giant cell (temporal) arteritis (GCA).

METHODS

Results of high-resolution MRI and CCDS in 59 patients with suspected GCA were compared with the final clinical diagnosis (based on the American College of Rheumatology GCA criteria and a 6-month followup study). Sensitivity, specificity, and positive and negative predictive values (PPV, NPV) were calculated for each method. In 41 of the patients, imaging results were also compared with the findings of a temporal artery (TA) biopsy.

RESULTS

Thirty-six of the 59 patients (61%) were ultimately diagnosed as having GCA. Sensitivity of high-resolution MRI and CCDS was 69% and 67%, respectively, specificity was 91% and 91%, PPV was 93% and 92%, and NPV was 66% and 64%, respectively. TA biopsy findings were positive in 24 of the 41 biopsied patients (59%). Sensitivity of high-resolution MRI and CCDS compared with TA biopsy was 83% and 79%, respectively, specificity was 71% and 59%, PPV was 80% and 73%, and NPV was 75% and 67%, respectively. The differences between high-resolution MRI and CCDS were not significant.

CONCLUSION

The diagnostic power of high-resolution MRI and CCDS in detecting GCA was comparable. Either of these noninvasive techniques may have value in the evaluation of patients with suspected GCA, and decisions regarding which technique to use may depend on the clinical setting.

Neuro-ophthalmic complications in giant cell arteritis

Giant cell arteritis (GCA) is a medical emergency characterized by systemic inflammation and critical ischemia. Neuro-ophthalmic complications occur early, with permanent vision loss in up to one fifth of patients. This mainly results from failure of prompt recognition and treatment. Diagnosis of GCA is often preceded by unrecognized symptoms, including constitutional upset and jaw claudication. Features predictive of permanent visual loss include jaw claudication and temporal artery abnormalities on physical examination. These patients often do not mount high inflammatory responses. Modern imaging techniques show diagnostic promise, and have led to an increased recognition of major artery involvement in GCA. However, temporal artery biopsy remains the gold standard for investigation. Intimal hyperplasia on histologic examination is associated with neuro-ophthalmic complications. The mainstay of therapy remains corticosteroids. Experience using conventional disease-modifying drugs has been mixed, and biologic therapies require further evaluation for their steroid-sparing potential.

[Mesenteric artery involvement in giant cell arteritis: two cases and literature review]

INTRODUCTION

Mesenteric involvement has been rarely reported in giant cell arteritis (GCA). Our literature search using the Medline database (1966-2008), reviewing all articles in English and French languages identified only 31 cases of mesenteric ischemia related to GCA. We report two additional cases.

CASE REPORTS

We report two men with GCA. At diagnosis of GCA-associated mesenteric involvement, patients exhibited: fever/fatigue (n=2), abdominal complaints (n=1), clinical signs of GCA (n=1). In both patients, abdominal CT-scan showed circumferential halo around the superior mesenteric artery. At systematic follow-up, CT-scan revealed improvement of mesenteric damage in both patients.

CONCLUSION

Our study indicates that CT-scan is a useful technique in diagnosis of GCA-associated mesenteric involvement. Furthermore, we suggest that CT-scan may also be helpful in both the monitoring and the medical management of GCA-related mesenteric artery involvement.

Giant cell arteritis: heterogeneity in clinical presentation and imaging results

OBJECTIVE

Giant cell arteritis (GCA) is commonly known for its clinical presentation of temporal arteritis. However, GCA affects large arteries, predominantly the aorta and its proximal branches, in up to 75% of cases. We describe the clinical presentation and diagnostic test results of patients with large-vessel GCA.

METHODS

Case description of 11 patients with large-vessel GCA diagnosed consecutively in our hospital.

RESULTS

The clinical presentation of large-vessel GCA is highly variable, from systemic inflammation to aortic rupture. Imaging shows variable abnormalities, but 18-fluorodeoxyglucose positron-emission-tomography (18-FDG PET) seems to be a sensitive and reasonably specific diagnostic test for large-vessel GCA.

CONCLUSION

Large-vessel GCA is a clinically heterogeneous condition. 18-FDG PET should be considered in the diagnostic work-up of suspected cases. Since this disorder has a high complication rate, and is responsive to treatment with corticosteroids, a high level of clinical suspicion is warranted.

Prognosis of large-vessel giant cell arteritis

OBJECTIVE

The prognosis of large-vessel GCA (LV-GCA) has not yet been investigated. How does it compare to GCA without arm vasculitis (GCA controls)?

METHODS

Charts of 53 LV-GCA patients and 53 GCA controls were reviewed following a predetermined protocol. Telephone interviews of patients or their primary care physicians were conducted. Forty LV-GCA patients underwent follow-up duplex ultrasound examinations of proximal arm arteries.

RESULTS

The mean observation time was 50 (s.d. +/- 31) months. None of the LV-GCA patients developed ischaemic arm complications. In 30%, proximal arm artery wall swelling disappeared completely. It decreased in 53%. In 8% it remained unchanged, in 5% it increased and in 5% arteries occluded with collateral flow. After the start of treatment, anterior ischaemic optic neuropathy developed neither in LV-GCA patients nor in GCA controls, amaurosis fugax occurred in 4 and 6%, arterial hypertension in 53 and 66%, strokes in 9 and 9%, myocardial infarction in 2 and 2%, diabetes mellitus in 30 and 25%, osteoporosis in 38 and 23%, and osteoporotic fractures in 15 and 4%, respectively. Mean corticosteroid dose was 3.7 mg/day. Mean duration of therapy was 42 months. All differences were insignificant. Four LV-GCA patients developed vasculitic popliteal artery stenoses.

CONCLUSIONS

The prognosis of LV-GCA is benign with regard to ischaemic complications. Proximal artery wall swelling decreases in most cases. Its course is similar to GCA without proximal arm arteritis.

Diagnosis and treatment of giant cell arteritis

Giant cell arteritis (GCA) is a chronic granulomatous vasculitis of unknown aetiology occurring in the elderly. It affects the cranial branches of the arteries originating from the aortic arch and is usually associated with markedly elevated acute-phase reactants. In 10-15% of cases the extra-cranial branches of the aortic arch are involved. GCA is closely related to polymyalgia rheumatica (PMR), although the relationship between the two disorders is still unclear. New-onset headache, scalp tenderness, jaw claudication, temporal artery abnormalities on physical examination, visual symptoms and associated PMR represent the most typical and frequent features of the disease. Systemic manifestations, including fever, anorexia and weight loss, are observed in 50% of cases. Less frequent manifestations are related to the central or peripheral nervous systems, the respiratory tract and extra-cranial large-vessel involvement. As GCA is characterized by a wide spectrum of clinical manifestations, it is important to recognize the different onset patterns of the disease and related diagnostic steps. The diagnosis is relatively straightforward in the presence of typical cranial manifestations, but it may be challenging in the case of a normal erythrocyte sedimentation rate, occult GCA or in patients with isolated extra-cranial features. Temporal artery biopsy still represents the gold standard for diagnosis, while the role of ultrasonography, high-resolution magnetic resonance imaging and positron emission tomography should be better addressed. Corticosteroids remain the therapy of choice. Data supporting the usefulness of antiplatelet agents and anticoagulants combined with corticosteroids to prevent ischaemic complications as well as the corticosteroid-sparing effect of methotrexate and anti-tumour necrosis factor-alpha drugs are limited and non-conclusive.

Aortic involvement in recent-onset giant cell (temporal) arteritis: a case-control prospective study using helical aortic computed tomodensitometric scan

OBJECTIVE

The prevalence of the involvement of large vessels in giant cell arteritis (GCA) is 3-13%. Aortitis is the most serious complication of GCA. Computed tomodensitometric (CT) scan allows analysis of both the aortic wall and endoluminal part of the aorta. Therefore, we conducted a study using CT scan to analyze aortic abnormalities in patients with recent-onset GCA.

METHODS

This prospective controlled study compared patients with biopsy-proven GCA with a matched control group based on sex, age, and cardiovascular risk factors. During the 4-week period following diagnosis of GCA, patients underwent an aortic CT scan. The aortic imaging results were blindly compared between both groups.

RESULTS

From January 5, 1998 to January 11, 1999, 22 patients and 22 controls were screened by CT scan for aortic involvement. Thickening of the aortic wall was more frequent among patients than controls (45.4% versus 13.6%; P = 0.02). Aortic thickening (mean 3.3 mm) was located on the ascending part of the thoracic aorta in 22.7% of the patients, with no evidence of thickening in the controls (P = 0.05). Thickening of the abdominal aortic wall was noted in 27.3% of the patients and none of the controls (P = 0.02).

CONCLUSION

This study suggests that inflammatory aortic thickening, detected by CT scan, occurs frequently at the time of diagnosis of GCA, and that this condition predominantly occurs on the ascending part of the aorta.

Horton's aortitis

Giant cell arteritis is the most common systemic vasculitis in people over the age of 50 years. Ischaemic manifestations are well known. 'Occult' manifestations as aortic aneurysmal disease need consideration. The incidence of aortic aneurysm and/or dissection is about 18.5 per 1000 person-years at risk (18.9 in Lugo(4) and 18.7 in Olmsted County(3)). Predictive factors are hypertension, polymyalgia rheumatica, coronaropathy, and hyperlipaemia. Another factor is the apparition of an aortic regurgitation murmur as in this case. So, these patients should be monitored by echocardiography.

Giant cell arteritis: a systemic vascular disease

Abstract

Giant cell arterits (GCA) is increasingly being recognized as a systemic vascular disease, not confined to the cranial arteries. Epidemiological studies have shown that almost one-third of the patients with GCA develop serious peripheral vascular complications during long-term follow up, and there is growing evidence that unrecognized extracranial involvement may be even more common. GCA of large- and medium-sized peripheral arteries typically leads to long tapering and occlusion of the arterial lumen due to concentric intimal thickening, sometimes accompanied by spontaneous dissection. Depending on the extent of the arterial obliteration and on the anatomy of the involved arterial segment, this may result in severe ischemia of the limbs during the acute phase of the disease. GCA of the aorta usually remains asymptomatic for many years, and leads to a markedly increased risk of aneurysms and dissections, particularly of the thoracic aorta. Evolving vascular imaging techniques such as duplex ultrasound, computer tomography (CT), magnetic resonance imaging (MRI), and fluorine-18-desoxyglucose positron emission tomography (18F-FDG-PET) have greatly improved our ability to detect and study arterial changes in large-artery vasculitis. Boosted by these advances in vascular imaging, vascular specialists are increasingly involved in the early diagnosis, follow-up and treatment of patients with large-vessel vasculitis.

Development of aortic aneurysm/dilatation during the followup of patients with giant cell arteritis: a cross-sectional screening of fifty-four prospectively followed patients

OBJECTIVE

Giant cell arteritis (GCA) may involve the aorta. Retrospective studies have demonstrated a higher prevalence of aortic aneurysm among patients with GCA compared with the general population. We investigated the prevalence of aortic aneurysm in a cohort of patients with biopsy-proven GCA using a defined protocol and assessed whether persisting low-grade disease activity is associated with higher risk of developing aortic aneurysm.

METHODS

Fifty-four patients with GCA (14 men and 40 women) were cross-sectionally evaluated after a median followup of 5.4 years (range 4.0-10.5 years). The screening protocol included a chest radiograph, abdominal ultrasonography scan, and computed tomography scan when aortic aneurysm was suspected or changes with respect to the baseline chest radiograph were observed. Clinical and laboratory data, corticosteroid requirements, and relapses were prospectively recorded.

RESULTS

Twelve patients (22.2%) had significant aortic structural damage (aneurysm/dilatation), 5 of them candidates for surgical repair. Aortic aneurysm/dilatation was more frequent among men (50%) than women (12.5%; relative risk 3.5, 95% confidence interval 1.53-8.01, P = 0.007). At the time of screening, patients with aneurysm/dilatation had lower serum acute-phase reactants, lower relapse rate, and needed shorter periods to withdraw prednisone than patients without aortic structural damage.

CONCLUSION

There is a substantial risk of developing aortic aneurysm/dilatation among patients with GCA. Our data do not support that aneurysm formation mainly results from persistent detectable disease activity. Additional factors including characteristics of the initial injury or the target tissue may also determine susceptibility to aortic aneurysm/dilatation.

Five clinical conundrums in the management of giant cell arteritis

Clinicians who treat patients with giant cell arteritis (GCA) face many unresolved challenges. Visual loss still occurs in 15% to 20% of patients despite the availability of therapy for the disease that is generally effective. Aneurysm formation and large vessel stenosis are increasingly recognized complications. Substantial iatrogenic morbidity stems from glucocorticoid therapy, and recent trials have failed to identify an efficient steroid sparing agent. In this review, the authors address five major clinical conundrums in the management of GCA.

Atherosclerosis in patients with biopsy-proven giant cell arteritis

OBJECTIVE

To examine the presence of atherosclerosis in a series of giant cell arteritis (GCA) patients attended to in a community hospital and to determine whether clinical features or steroid therapy might be associated with the development of atherosclerotic disease.

METHODS

Forty consecutive patients diagnosed with biopsy-proven GCA, periodically followed at the rheumatology outpatient clinic of Hospital Xeral-Calde, Lugo (Spain), who had ended steroid therapy and had at least 3 years of followup were assessed for the presence of atherosclerosis by determination of the carotid intima-media thickness (IMT) and carotid plaques using high-resolution B-mode ultrasound. Forty matched controls were also studied.

RESULTS

GCA patients exhibited less carotid artery IMT than did matched controls (mean +/- SD 1.01 +/- 0.16 mm versus 1.13 +/- 0.20 mm; P = 0.005; difference in means 0.12, 95% confidence interval 0.04-0.20). Patients who required steroid therapy for >2 years had greater mean +/- SD carotid IMT (1.04 +/- 0.17 mm versus 0.95 +/- 0.15 mm) but the difference was not statistically significant (P = 0.10). A positive correlation between age at the time of the study and the carotid artery IMT in GCA patients was observed (r = 0.673, P < 0.001). However, adjusting for age, sex, and classic atherosclerosis risk factors, no significant correlation between carotid IMT and the routine laboratory markers of inflammation assessed at the time of disease diagnosis, disease duration, or cumulative prednisone dose was found.

CONCLUSION

The present study demonstrates that atherosclerotic macrovascular disease is not increased in patients with GCA.

Vasculitides

Despite the spatial closeness of blood vessels and inflammatory cells, blood vessel walls are infrequently targeted by inflammation. Giant cell arteritis (GCA) and Takayasu’s arteritis (TA) are characterized by inflammation directed against the vessel wall. GCA and TA display stringent tissue tropism and affect defined vascular territories in a preferential manner. GCA predominantly affects the second- to fifth-order aortic branches, often in the extracranial arteries of the head. The aorta itself may also be affected in GCA, albeit less often than other regions. In contrast, in TA, the aorta and its major branches are the prime disease targets.

Diagnostic value of high-resolution MR imaging in giant cell arteritis

BACKGROUND AND PURPOSE

Clinical indications of giant cell arteritis may be unspecific, and noninvasive diagnosis is often difficult. This study investigated the hypothesis that high-resolution MR imaging of the superficial cranial arteries is a noninvasive imaging technique that can detect the occurrence of giant cell arteritis.

MATERIALS AND METHODS

Contrast-enhanced, high-resolution MR imaging was performed on 64 consecutive patients with suspected giant cell arteritis. Mural thickness, lumen diameter, and a mural contrast enhancement score were assessed with T1-weighted spin-echo images with submillimeter in-plane spatial resolution. The final rheumatologist's diagnosis according to the clinical criteria of the American College of Rheumatology including laboratory tests and results of temporal artery biopsies from 32 patients was used as a "gold standard" for the evaluation of the MR imaging findings.

RESULTS

All of the examinations provided diagnostic image quality. Evaluation of the mural inflammatory MR imaging signs for diagnosing vasculitis resulted in a sensitivity of 80.6% and a specificity of 97.0%. In comparison, histology results alone showed a sensitivity of 77.8% and specificity of 100%. The mean wall thickness increased significantly from 0.39 mm (+/-0.18 mm) to 0.74 mm (+/-0.32 mm; P < .001), and the lumen diameter decreased significantly from 0.84 mm (+/-0.29 mm) to 0.65 mm (+/-0.38 mm; P < .05) for patients with giant cell arteritis.

CONCLUSION

Contrast-enhanced, high-resolution MR imaging allows noninvasive assessment of mural inflammation in giant cell arteritis with good diagnostic certainty. Measures of mural thickening and contrast enhancement can be obtained in these small vessels and provide valuable vasculitic MR imaging findings.

The emergency room in systemic rheumatic diseases

Complications of systemic rheumatic diseases frequently have protean manifestations and may present a diagnostic problem. Patients with connective tissue diseases and vasculitides may have dangerous or life threatening conditions, which must be recognised and treated promptly to prevent rapidly evolving morbidity and mortality. Knowledge of possible emergencies in the context of a defined rheumatic disease may aid in promoting a high index of suspicion and contribute significantly to the timely diagnosis of many potentially dangerous conditions. This review is written for the emergency room physician and discusses the early recognition of selected emergencies in the context of a defined rheumatic disease.

High-risk repair of ascending aortic aneurysm due to giant cell aortitis

Giant cell arteritis increases the risk of developing a thoracic aortic aneurysm. Thoracic aortic aneurysm repair in octogenarians carries a profound increase in postoperative morbidity and mortality. We report the successful repair of an ascending aortic aneurysm in an 83-year-old woman with a history of treatment for temporal arteritis and pathologic evidence of giant cell aortitis.

Giant cell arteritis in northwestern Spain: a 25-year epidemiologic study

To continue our investigation of the epidemiology of giant cell arteritis (GCA) in southern Europe, we assessed the potential presence of trends, peaks, and fluctuations in the incidence of this vasculitis over a 25-year period in the Lugo region of northwestern Spain. We also sought to determine whether changes in the clinical spectrum of the disease existed. From 1981 to 2005, biopsy-proven GCA was diagnosed in 255 Lugo residents. The age- and sex-adjusted annual incidence rate was 10.13 (95% confidence interval [CI], 8.93-11.46) per 100,000 population aged 50 years and older. The mean age +/- SD at the time of diagnosis was 75.0 +/- 6.9 years. The annual incidence rate in women (10.23; 95% CI, 8.60-12.08) was slightly greater than that in men (9.92; 95% CI, 8.19-11.89) (p = 0.15). The annual incidence rate increased with advancing age up to a maximum of 23.16 (95% CI, 19.52-27.28) in the 70-79 year age-group. A progressive increase in the incidence was observed from 1981 through 2000 (p = 0.001). However, the age- and sex-adjusted incidence rate for biopsy-proven GCA in the Lugo region did not show peaks in the annual incidence of GCA. Likewise, we observed no seasonal pattern for the diagnosis of the disease. Visual ischemic manifestations and irreversible visual loss were observed in 57 (22.4%) and 32 (12.5%) of the 255 patients, respectively. A negative trend manifested by a progressive decline in the number of patients with visual ischemic manifestations (p = 0.021) or permanent visual loss (p = 0.018) was found over the 25-year period of study. The decline in the frequency of visual manifestations of GCA could not be attributed to a shorter delay to diagnosis, as no significant differences were observed when the delays to diagnosis in the 5 consecutive 5-year periods were compared. In conclusion, the current study confirms a progressive increase in the incidence of biopsy-proven GCA in northwestern Spain, and suggests that there has been a change in the clinical spectrum of the disease.

[Screening of abdominal aortic involvement using Doppler sonography in active giant cell (temporal) arteritis at the time of diagnosis. A prospective study of 30 patients]

BACKGROUND

Inflammatory involvement of extracranial large-sized arteries occurs in 10-20% of patients with giant cell (temporal) arteritis. Aortic involvement may reveal giant cell arteritis or occur as a late-onset complication, and represents one of the most serious manifestation of the disease with the risk of aortic dissection and/or aneurysm rupture. The thoracic aorta is more frequently involved but abdominal aortitis may also occur in giant cell arteritis. To date, few data are available about abdominal aorta changes at the initial stage of giant cell arteritis.

PATIENTS AND METHODS

This prospective monocentric study was conducted between May 1998 and May 2002, and included 30 consecutive patients with biopsy-proven giant cell arteritis. Standard clinical and biological data were collected. Each patient underwent an abdominal aortic Doppler-sonography that looked for aneurysm, ectasia, thickening of the vascular wall, and hypoechoic halo around the aorta.

RESULTS

Among the 30 patients of this study (25 women, 5 men, mean age 68.5 years), 4 (13%) had an abdominal aortic aneurysm, with a low diameter (23 to 27 mm), measuring 2 to 5.5 cm in length. A vascular wall thickening superior or equal to 3 mm was noted in 17 patients (68%). A 4 to 8 mm periaortic hypoechoic halo was found in 10 patients (33%). This halo was present in 3 out of the 4 patients with aneurysm.

CONCLUSION

Aortic involvement is a potentially serious complication of giant cell arteritis. The question of a systematic screening of this complication remains open to discussion. Our study shows that Doppler sonography may detect morphological abnormalities on the abdominal aorta at the initial stage of giant cell arteritis. These abnormalities comprise mild aneurysms, thickening of the vascular wall and periaortic halo, which could correspond to inflammatory locations of the disease. Complementary studies are needed to assess their specificity and their seriousness.

Statin therapy does not seem to benefit giant cell arteritis

OBJECTIVE

Since statins interfere with a variety of immune-inflammatory pathways shared by atherosclerosis and giant cell arteritis (GCA), they might be potentially useful as adjunctive therapy to glucocorticosteroids in GCA. Our aim was to examine whether concomitant use of statins had any potential benefit in GCA.

METHODS

Retrospective follow-up study of an unselected population of 121 patients with GCA. A comparative analysis between patients with and without statin therapy was performed.

RESULTS

At the time of the GCA diagnosis, 30 patients (25%) had already been receiving statins and continued taking them during the corticosteroid treatment. No statistically significant reduction in the incidence of severe ischemic complications (including visual manifestations, jaw claudication, cerebrovascular accidents, ischemic heart disease, and limb claudication due to large artery stenosis) was observed in this group compared with the remaining patients. When we analyzed follow-up data, we found no significant differences between groups in terms of frequency of relapses, incidence of aortitis, and percentage of patients recovered from GCA. The duration of therapy and corticosteroids requirements among patients in permanent remission was similar in both groups.

CONCLUSION

We did not observe a significant benefit derived from the use of statins at low to moderate doses in the incidence of severe ischemia or the disease outcome.

Inflammatory rheumatic disease and smoking are predictors of aortic inflammation: A controlled study of biopsy specimens obtained at coronary artery surgery

OBJECTIVE

Several inflammatory rheumatic diseases are associated with accelerated atherosclerosis. Atherosclerosis may result from systemic and/or local vascular inflammation. The aim of this study was to evaluate the occurrence of chronic inflammatory infiltrates in the aortas of patients with and those without inflammatory rheumatic disease who had undergone coronary artery bypass graft (CABG) surgery, and to assess the relationship between the infiltrates and other factors thought to play a role in atherosclerosis, such as smoking.

METHODS

Aortic specimens routinely removed during CABG surgery in 66 consecutive patients with inflammatory rheumatic disease and 51 control patients without inflammatory rheumatic disease were examined by light microscopy for the occurrence, location, and severity of chronic inflammatory infiltrates and atherosclerotic lesions.

RESULTS

Mononuclear cell infiltrates in the inner adventitia (apart from those localized along the epicardium) were more frequent in the group of patients with inflammatory rheumatic disease (47% versus 20%; P = 0.002, odds ratio [OR] OR 3.6, 95% confidence interval [95% CI] 1.6-8.5), and the extent of these infiltrates was greater. Multivariate analyses revealed that the occurrence of mononuclear cell infiltrates was associated with inflammatory rheumatic disease (OR 2.99, P = 0.020) and current smoking (OR 3.93, P = 0.012), and they were observed in 6 of 7 patients with a history of aortic aneurysm. Inflammatory infiltrates in the media were seen only in patients with inflammatory rheumatic disease. The frequency of atherosclerotic lesions, inflammation within the plaques, and epicardial inflammatory infiltrates in the 2 groups was equal.

CONCLUSION

Among aortic samples collected during CABG surgery, those obtained from patients with inflammatory rheumatic disease had more pronounced chronic inflammatory infiltration in the media and inner adventitia than those obtained from control patients. Current smoking was an independent predictor of chronic inner adventitial infiltrates. The infiltrates may represent an inflammatory process that promotes atherosclerosis and formation of aneurysms.

Giant cell arteritis

Giant cell, or temporal, arteritis is a vasculitis of the medium and large arteries that preferentially involves vessels originating from the arch of the aorta. Classically, this disease manifests in an older individual with new-onset persistent headache, an abnormal temporal artery on examination, and increased serum inflammatory markers. The level of clinical suspicion for giant cell arteritis should be based upon patient age, clinical symptoms, and laboratory evaluation. However, the diagnostic gold standard is achieved by histologic confirmation by temporal artery biopsy. Prompt treatment with corticosteroids is essential in order to minimize the frequency of permanent sequelae such as visual loss and stroke.

Treatment of giant cell arteritis using induction therapy with high-dose glucocorticoids: A double-blind, placebo-controlled, randomized prospective clinical trial

OBJECTIVE

Glucocorticoid (GC) therapy for giant cell arteritis (GCA) is effective but requires prolonged administration, resulting in adverse side effects. The goal of the current study was to test the hypothesis that induction treatment with high-dose pulse intravenous (IV) methylprednisolone permits a shorter course of therapy.

METHODS

Twenty-seven patients with biopsy-proven GCA were enrolled in a randomized, double-blind, placebo-controlled study to receive IV methylprednisolone (15 mg/kg of ideal body weight/day) or IV saline for 3 consecutive days. All patients were started on 40 mg/day prednisone and followed the same tapering schedule as long as disease activity was controlled. The numbers of patients with disease in remission after 36, 52, and 78 weeks of treatment and taking <or=5 mg/day prednisone were compared. Cumulative prednisone dose, number of relapses, and development of adverse GC effects were assessed.

RESULTS

Ten of the 14 IV GC-treated patients, but only 2 of 13 control patients, were taking <or=5 mg/day prednisone at 36 weeks (P = 0.003). This difference was maintained; there was a higher number of sustained remissions after discontinuation of treatment in the IV GC-treated group and a lower median daily dose of prednisone at 78 weeks (P = 0.0004). The median cumulative dose of oral prednisone, excluding the IV GC dose, was 5,636 mg in the IV GC-treated group compared with 7,860 mg in the IV saline-treated group (P = 0.001).

CONCLUSION

Initial treatment of GCA with IV GC pulses allowed for more rapid tapering of oral GCs and had long-term benefits, with a higher frequency of patients experiencing sustained remission of their disease after discontinuation of treatment.

Myocardial thievery: the coronary-subclavian steal syndrome

Coronary-subclavian steal syndrome entails the reversal of blood flow in a previously constructed internal mammary artery coronary conduit, which produces myocardial ischemia. The most frequent cause of the syndrome is atherosclerotic disease in the ipsilateral, proximal subclavian artery. Although coronary-subclavian steal was initially reported to be rare, the increasing documentation of this phenomenon and its potentially catastrophic consequences in recent series suggests that the incidence of the problem has been underreported and that its clinical impact has been underestimated. We review the causes and background of coronary-subclavian steal; methods of preventing, diagnosing, and treating it; and the potential influence of various treatment regimens on long-term survival and the likelihood of late adverse events in patients with coronary-subclavian steal syndrome.

Polymyalgia rheumatica and giant cell arteritis

Polymyalgia rheumatica and giant cell arteritis are the commonest inflammatory rheumatic conditions seen in the elderly. This review focuses on the diagnostic processes and complications of disease and treatment; and the safe management of these conditions with careful consideration of balance between benefits and long-term risks of glucocorticosteroid therapy.

Review of isolated ascending aortitis: differential diagnosis, including syphilitic, Takayasu’s and giant cell aortitis

The image of tree-barking and proximal aortic root dilatation is firmly entrenched in the minds of practising pathologists as representing syphilis until proven otherwise. We discuss the differential diagnosis of syphilitic aortitis, Takayasu's disease, and giant cell aortitis, with a review of the literature and brief overview of other types of aortitis. As a starting point, we report a case of non-specific, or idiopathic, aortitis with aneurysm that was initially misdiagnosed as syphilitic aortitis. We then review the literature and emphasise the lack of histological data and histopathological criteria for the diagnosis of non-infectious aortitis and the implications for treatment in cases of isolated aortitis. Tree-barking is a non-specific finding in aortitis of any aetiology, and syphilitic aortitis in developed countries is rare. It is still unclear if there are histological features that separate Takayasu's disease and giant cell arteritis. In the majority of patients presenting with aortic root aneurysms, aortitis is an isolated finding not associated with autoimmune disease. Despite a plethora of literature, a histological classification of aortitis has yet to be attempted.

Endovascular Treatment of Complicated Aortic Aneurysms in Patients with Underlying Arteriopathies

Patients with arteriopathies including giant cell arteritis, Marfan syndrome, and Takayasu's disease are at risk for aneurysmal degeneration of the aorta. Aortic repair has been recommended for these patients to prevent rupture. The purpose of this study was to examine outcomes following endovascular stent graft (EVSG) repair of aortic aneurysms in this patient population. Over an 8-year period, 11 patients (six men, five women) with arteriopathies underwent endovascular aortic repair. The mean age was 50 (range 15-81). Diseases included Marfan syndrome (n = 6), Takayasu's disease (n = 3), and giant cell arteritis (n = 2). Success of EVSG repair was evaluated per the reporting standards of the Society for Vascular Surgery/American Association for Vascular Surgery. Follow-up was a mean of 28.9 months (range 3-68). Six patients underwent EVSG repair of the thoracic aorta, four underwent EVSG repair of the abdominal aorta, and one underwent a staged repair of the thoracic and subsequently the abdominal aorta. Six true aneurysms and six pseudoaneurysms were repaired. Eight patients had previous aortic surgery, including four with multiple aortic operations. For the 12 aneurysms treated, technical success was achieved in 11 (91.7%). One technical failure occurred due to a small iliac access vessel, requiring an eventual iliac conduit for insertion. Early complications (<30 days) occurred in three patients. Type I or III endoleak developed following two repairs (16.7%). Aneurysm expansion occurred following one repair (8.3%). No aneurysm-related deaths occurred during follow-up. EVSG repair of aortic aneurysms is feasible and can be safely performed in patients with arteriopathies. Long-term durability in this younger group of patients who carry an ongoing risk of arterial degeneration remains to be determined.

Abdominal aortic aneurysms: an underestimated type of immune-mediated large vessel arteritis?

PURPOSE OF REVIEW

To review recent studies on the immune-mediated pathogenesis of abdominal aortic aneurysms, opening a wide field for possible new therapeutic approaches.

RECENT FINDINGS

Immune-mediated processes including involvement of neutrophils, interferon-gamma producing T cells and proinflammatory cytokines play an important role especially in the initiation of abdominal aortic aneurysm disease. C-reactive protein was associated with aneurysm size and is possibly produced by the aneurysmal tissue itself. From the clinical perspective, both inflammatory and noninflammatory abdominal aortic aneurysms are associated with various autoimmune diseases. Preliminary data of F-FDG positron emission tomography imaging of abdominal aortic aneurysms suggest focal uptake of F-FDG within the aneurysm wall in patients with either large, rapidly expanding or symptomatic aneurysms that are prone to rupture. Thus basic research findings and clinical research focusing on the underlying immune-mediated mechanisms of abdominal aortic aneurysms will likely pave the way for new medical therapies in the future. In animal models the effects of rapamycin as an immunosuppressive agent, modulation of estrogen receptors by tamoxifen as well as gene therapy using decoy oligonucleotides binding to the transcription factor ets has already proved helpful in decreasing aneurysm expansion rates.

SUMMARY

Pathophysiological, immunogenetical and interventional studies support the concept of abdominal aortic aneurysm as an immune-mediated process, which will help to identify more laboratory and imaging signs of development in the future. Further research will now assess the possible benefit of antiinflammatory therapeutic approaches, especially in patients with small abdominal aortic aneurysms.

Bildgebende Verfahren bei Riesenzellarteriitis (M. Horton)

This review article highlights several diagnostic imaging modalities in giant cell arteritis. Color-coded Duplex sonography is a relatively cost-efficient but strongly observer-dependent imaging modality. It may be difficult to distinguish inflammatory from atherosclerotic mural changes. Positron emission tomography with (18)F-fluoro-2-deoxy-D-glucose is very sensitive in detecting extracranial involvement of large vessel vasculitis. However, it provides no information on inflammatory changes of the superficial cranial arteries. High-resolution MRI is a new observer-independent method that allows visualizing and assessing the superficial cranial arteries in high detail. Extracranial large artery involvement can be evaluated during the same investigation. At present, only single-center experiences with this promising but rather complex procedure exist. A comparative multicenter trial is about to be initiated.