The American College of Rheumatology 1990 criteria for the classification of Takayasu arteritis

Efficacy of Tofacitinib in Takayasu Arteritis Refractory to Biologic DMARDs-A Multicentre Study in Indian Patients

BACKGROUND

The management of patients with Takayasu arteritis (TAK), especially those who are refractory to biologic disease-modifying anti-rheumatic drugs (DMARDs), is challenging.

OBJECTIVE

We determined the efficacy of tofacitinib in patients with TAK who could not achieve or maintain stable disease despite biologic DMARDs (bDMARD-NR).

METHODS

Details of consecutive patients with TAK treated with originator/generic tofacitinib at 5 centres in India were recorded retrospectively from the medical records. The activity of the disease was assessed using multiple domains including Indian Takayasu arteritis score (ITAS), C-reactive protein (CRP) and imaging. Active disease was defined by either (i) ITAS-A(CRP) ≥ 3 wherein both ITAS and CRP each contributed at least 1 point to the final score; or (ii) clinical ITAS score > 1 in the presence of imaging activity even without raised CRP. The parameters between patients with good response and no response to treatment were compared.

RESULTS

Altogether, 33 patients (30 females) with a mean age of 28.9 ± 7.6 years and a disease duration of 39.0 (15.8-72.0) months who received tofacitinib were included. Sixteen patients (54.5%) who failed anti-TNF agents [n = 14, (42.4%)] or tocilizumab [n = 14, (42.4%)] were classified as bDMARD-NR. During a follow-up of 15.0 (6.5-20.0) months, 23 (69.7%) satisfied the above composite criteria for inactive disease using clinical, laboratory, and imaging parameters. Among bDMARD-NR, 14 (77.8%) achieved inactive disease. Four patients discontinued tofacitinib due to adverse drug events. No predictors of response were identified.

CONCLUSION

Tofacitinib may be an effective option in a subset of patients who fail to attain stable disease state despite use of csDMARDs and bDMARDs.

Long-term successfully endovascular treatment of a complicated Takayasu's arteritis with thrombectomy and stenting: a case report

BACKGROUND

Takayasu arteritis is a rare form of large-vessel vasculitis primarily affecting the aorta and its major branches, with a higher prevalence in young women. This inflammatory disease can lead to significant complications, including ischemic stroke and transient ischemic attacks, though large-vessel occlusion stroke is an uncommon initial manifestation. Diagnosis relies heavily on vascular imaging, and treatment typically involves high-dose glucocorticoids, revascularization procedures, and close monitoring for restenosis, which occurs frequently after interventions.

CASE PRESENTATION

This case report describes a 38-year-old North African woman who presented with acute left-sided hemiparesis and visual disturbances due to large-vessel occlusion involving the common carotid artery and middle cerebral artery. Mechanical thrombectomy and stenting were performed successfully, resulting in complete recanalization without complications. The patient was later diagnosed with Takayasu arteritis, and this was managed with high-dose corticosteroids. During a 2-year follow-up, no complications such as restenosis or re-occlusion were observed, and the patient remained in good health.

CONCLUSION

This case is notable for the successful use of dual mechanical thrombectomy and stenting in the acute management of stroke in Takayasu arteritis without short- or long-term complications, a rare outcome not commonly reported in the literature. It highlights the potential efficacy of this approach in carefully selected patients, suggesting that postoperative immunosuppressive therapy may reduce the incidence of restenosis.

The Prospective Registry of MyositIS (PROMIS): I. Next-generation sequencing identifies HLA-DQA1 as a novel genetic risk of anti-MDA5 antibody-positive dermatomyositis

OBJECTIVES

Antimelanoma differentiation-associated gene 5-positive dermatomyositis (anti-MDA5+ DM) is a rare subtype of myositis with a poor prognosis and insufficient genetic understanding. Our study aimed to identify risk variants associated with anti-MDA5+ DM and to assess their correlation with clinical outcomes.

METHODS

We enrolled 231 anti-MDA5+ DM patients, 127 anti-MDA5⁻ DM patients, 1468 patients with non-DM rheumatic disease, and 1027 healthy controls, with an additional 51 anti-MDA5+ DM patients for validation. Whole-exome sequencing was used to identify human leukocyte antigen (HLA) alleles, amino acids, and single nucleotide polymorphisms (SNPs) in major histocompatibility complex (MHC) and non-MHC regions. Association studies were performed to identify genetic variants associated with anti-MDA5+ DM by comparing different sets of control groups. A clinical association study was conducted to further explore the influence of genetic factors on clinical manifestations.

RESULTS

Two novel genetic risks, HLA-DQA1*06:01 and HLA-DQB1*06:09, were significantly associated with anti-MDA5+ DM in both the discovery and validation cohorts. HLA-DQA1*06:01 was particularly prevalent in anti-MDA5+ DM (20.4%) compared with anti-MDA5⁻ DM (6.69%) and non-DM rheumatic disease (5.93%). Besides, the strongest associated amino acid was HLA-DQα1:69 (P = 3.27 × 10-11), and 1 SNP in the ARHGAP22 gene (rs76208937) showed suggestive significance (P = 7.99 × 10-6). In addition, HLA-DQA1*06:01 was linked to acute rapidly progressive interstitial lung disease (P < .001), elevated levels of lactate dehydrogenase (P = .026), and death (P = .049) in patients with anti-MDA5+ DM.

CONCLUSIONS

HLA-DQA1*06:01 is a new genetic and prognostic factor for anti-MDA5+ DM, potentially serving as a biomarker for early diagnosis and intervention.

Integration of transcriptome and immunophenotyping data highlights differences in the pathogenetic kinetics of B cells across immune-mediated disease

OBJECTIVE

To elucidate crucial immune cell subsets and associated immunological pathways by stratifying patients with immune-mediated diseases (IMDs) using immunophenotyping and transcriptomic approaches.

METHODS

We conducted flow cytometric and transcriptomic analyses in 23 immune cell subsets derived from 235 patients with six IMDs, using our database, utilizing our database, ImmuNexUT. Patients were stratified based on immunophenotyping data. Subsequently, we examined clinical and transcriptomic differences among these stratified clusters.

RESULTS

Patients with IMDs were stratified into two clusters based on their immunophenotypes. Cluster 1 was enriched with differentiated B cells, including unswitched memory B cells (USM B), switched memory B cells, double-negative B cells and plasmablasts, while cluster 2 was enriched with naïve B cells. Higher disease activity in rheumatoid arthritis and decreased respiratory functions in systemic sclerosis were observed in cluster 1, whereas the disease activity of systemic lupus erythematosus was higher in cluster 2. Numerous differentially expressed genes were detected in USM B. Cluster 1 was associated with glycosylation processes in USM B and elevated B cell-activating factor signalling from myeloid cells in B cells, while cluster 2 exhibited higher B-cell receptor signalling in USM B. Patients in cluster 2, which had an elevated age-associated B-cell signature, exhibited more frequent flares, suggesting that an increased proportion of naïve B cells with this signature is associated with poor prognosis.

CONCLUSION

Immunophenotyping-based clusters and transcriptome-based states revealed quantitative and qualitative differences in B cells. To predict IMD prognosis, assessing both the quantity and quality of naïve B cells may be crucial.

Hyperhomocysteinemia in Takayasu arteritis-genetically defined or burden of the proinflammatory state?

Takayasu arteritis (TAK) is associated with high plasma homocysteine (Hcy) and elevated Hcy predicts ischemic events. Thus, this study aims to compare the frequency of single-nucleotide polymorphisms (SNPs) of genes involved in Hcy metabolism between TAK and controls and analyze associations with Hcy levels, TAK features, and acute ischemic arterial events (AIAEs). A cross-sectional study was performed with 73 TAK patients and 71 controls. SNPs of genes involved in the Hcy metabolism, plasma Hcy, and risk factors were analyzed for hyperhomocysteinemia (HHcy), cardiovascular disease (CVD), and AIAEs. Patients presented a higher frequency of risk factors for CVD and HHcy. At least one AIAE was observed in 27 (37.0%) patients and one control. The frequency of the SNPs was similar between both groups, and there was no association between SNP carriage and AIAEs. TAK patients presented higher Hcy levels than controls (13.9 ± 5.6 µmol/L vs. 8.6 ± 4.0 µmol/L; p < 0.001), and patients carrying MTHFR677TT presented higher Hcy levels than those carrying MTHFR677CT (20.4 ± 7.8 µmol/L vs. 13.7 ± 5.2 µmol/L; p = 0.02) or MTHFR677CC (20.4 ± 7.8 µmol/L vs. 13.1 ± 4.7 µmol/L; p = 0.009). TAK was an independent risk factor for HHcy [odds ratio (OR) = 10.20; 95% confidence interval (95% CI): 4.16-25.00; p < 0.001], and in TAK, thiazide diuretic use was a risk factor for HHcy (OR = 11.61; 95% CI: 1.63-82.63; p < 0.01). In conclusion, TAK was a risk factor for HHcy but not related to SNPs in genes encoding Hcy metabolism enzymes. The burden of chronic inflammation and thiazide diuretics contribute to HHcy in TAK.

Does the Combined Arteritis Damage Score (CARDS) in the Diagnosis of Takayasu Arteritis Predict Prognosis and Need for Biologic Therapy?

BACKGROUND

We aimed to investigate the prognostic value of the combined arteritis damage score (CARDS) in Takayasu arteritis (TAK) patients to predict the need for biologic treatment at diagnosis and the possible contribution of wall thickness (WT).

MATERIALS AND METHODS

Blind evaluation of MRA/CTA at the time of diagnosis was performed by a reader rheumatologist (RR) and an interventional radiologist (RIR). The CARDS damage score for 21 arterial regions was assessed as normal, mild or moderate/severe stenosis, occclusion or aneursym/dilatation. Additionally, WT was scored for all regions as present or absent. A modified CARDS (mCARDS) was calculated as the sum of CARDS and the number of WT areas.

RESULTS

According to follow-up treatment, 10 patients with non-biologic treatment (non-BT) (F/M:8/2, median age 37.5 years) and 15 patients with biologic treatment (BT) (F/M:13/2, median age 30 years) were included. Indian Takatasu Arteritis Score (ITAS), CRP, and ESR levels were similar in both groups. CARDS (1.4 (0-7.2) vs 4.5 (.6-19), P: .003), WT (1.5 (0-8) vs 7 (1-21), P < .001), and mCARDS (4 (0-14.2) vs 11.4 (1.6-40), P < .001) scores were significantly higher in the BT group compared to nonBT group. Cohen's kappa coefficient between RR and RIR for WT was .99 with 99.6% aggrement, and CARDS was .98 with 99.6% agreement. The AUC values for CARDS, WT, and mCARDS scores were .748 (.605-.892), .837 (.723-.950), and .847 (.735-.958), respectively, and P value was <.0001.

CONCLUSIONS

The prediction of prognosis and biologic treatment need at TAK diagnosis using non-invasive angiographic images can improve outcomes and prompt closer follow-up. The combination of CARDS and WT as mCARDS achieved the highest sensitivity and specificity, and all scores appear useful for predicting prognosis.

Predictors of Cardiovascular Events in Patients With Takayasu Arteritis

BACKGROUND

This study aimed to analyze the factors associated with cardiovascular events and develop a prediction model to predict 10-year cardiovascular events probability in patients with Takayasu arteritis (TAK).

METHODS

Patients with TAK were prospectively enrolled from 7 clinical centres between July 2013 and March 2021. The Cox proportional hazard regression was used to assess factors associated with cardiovascular events and develop a prediction model. The model performance was measured by Harrell's concordance index (C-index), Brier score, and calibration plots. The nomogram was used to calculate the 10-year cardiovascular events probability.

RESULTS

A total of 702 patients (aged 29.2 ± 9.9 years; 623 [88.7%] women) were included. Cardiovascular events were observed in 94 patients (13.4%) after a median follow-up of 67 months (interquartile range [IQR]: 46-99). Elevated erythrocyte sedimentation rate (ESR) at disease onset (hazard ratio [HR], 2.30 [1.47-3.60]), pulmonary hypertension (HR, 1.87 [0.93-3.77]), pulselessness (HR, 1.73 [1.14-2.63]), diagnostic delay ≥ 3 years (HR, 1.63 [1.01-2.65]), aortic regurgitation (HR, 1.61 [1.01-2.56]), and age at diagnosis (HR, 1.05 [1.02-1.07]) independently increased cardiovascular events and were included in the final model. The optimism-corrected C-index and Brier score of prediction model were 0.71 (0.66-0.76) and 0.072, respectively, and the calibration plots suggested good agreement between the observed and predicted probability of cardiovascular events.

CONCLUSIONS

Patients with TAK were at high risk of cardiovascular events. Advanced age at diagnosis, diagnosis delayed over 3 years, pulselessness, pulmonary hypertension, aortic regurgitation, and elevated ESR at disease onset were risk factors for cardiovascular events.

CLINICAL TRIAL REGISTRATION

JS-2038.

Downregulated Expression of miR-200c-3p in Plasma Exosome as a Potential Biomarker in Takayasu's Arteritis

Our previous work identified several differentially expressed miRNAs (DEmiRNAs) in plasma exosomes from Takayasu's arteritis (TAK) patients. This study aimed to validate these findings and explore the correlation between DEmiRNAs and clinical parameters in untreated TAK. Plasma exosomes were isolated from 30 untreated TAK patients and 20 healthy controls. qPCR was used to quantify miR-34a-5p, miR-143-3p, miR-22-3p, miR-200c-3p, and miR-21-5p expression. Correlations between miRNA levels, clinical data, inflammation markers, and T helper cell frequencies were analyzed. The target genes of validated DEmiRNAs were identified using mirDIP, and pathway enrichment analysis was performed using GO/KEGG. The effect of validated DEmiRNAs on the MAPK pathway and proliferation in human aortic endothelial cells (HAECs) was investigated in vitro. Only miR-200c-3p expression was validated as significantly downregulated in plasma exosomes from untreated TAK patients. Lower miR-200c-3p levels correlated negatively with ITAS-2010 scores and were associated with relapsed disease. MiR-200c-3p levels also negatively correlated with circulating Th17.1 cell frequencies. In vitro, the TAK exosome treatment activated ERK1/2 and JNK pathways and promoted HAEC proliferation, which was inhibited by the miR-200c-3p mimic. The pathway enrichment analysis showed that the MAPK pathway may be involved. This study confirms the reduced miR-200c-3p expression in plasma exosomes from TAK patients, suggesting its potential as a biomarker for vascular inflammation. MiR-200c-3p may exert protective effects in TAK by suppressing MAPK pathway activation and EC proliferation.

Clinical characterization of aortitis and periaortitis: study of 134 patients from a single university hospital

Aortitis and periaortitis refer to the inflammation of the aortic wall and the surrounding tissues. Both conditions are associated with various diseases and express nonspecific manifestations. Early diagnosis and treatment are crucial to improve the prognosis of the disease. This study aimed to assess the causes and main clinical features of aortitis and periaortitis in patients from a single centre in Spain. Observational, retrospective study of patients diagnosed with aortitis or periaortitis at a Spanish referral center over the last decade. 134 patients (87 female; mean age of 55.1 ± 9.1 years) were recruited, 132 of which had aortitis and two periaortitis. Aortitis was associated with giant cell arteritis (n = 102), Takayasu's arteritis (n = 6), IgG4-related disease (n = 6), infectious diseases (n = 3), malignancy (n = 1), drugs (n = 1), isolated aortitis (n = 1), and other immune-mediated inflammatory diseases (IMIDs) (n = 12). IMIDs included were Sjögren's syndrome (n = 2), sarcoidosis (n = 2), rheumatoid arthritis (n = 2), axial spondyloarthritis (n = 2), inflammatory bowel disease (n = 1), primary biliary cirrhosis (n = 1), idiopathic pulmonary fibrosis (n = 1), and polyarteritis nodosa (n = 1). Periaortitis was due to idiopathic retroperitoneal fibrosis in both cases. Imaging techniques used for diagnosis included 18F-FDG PET/CT scan (n = 133), CT-angiography (n = 44), and/or MRI-angiography (n = 33). Polymyalgia rheumatica (52.2%) and asthenia (53.7%) were the most common manifestations, followed by limb claudication (23.9%) and inflammatory back pain (26.9%). Acute-phase reactants were typically increased. Aortitis is a common condition and may be associated with multiple non-infectious diseases. Its clinical presentation is often unspecific, requiring a high level of suspicion to get an early diagnosis and treatment.

Epidemiology of systemic vasculitis

PURPOSE OF REVIEW

Ongoing research contributes to our understanding of the epidemiology of vasculitis and its outcomes across the globe. This review aims to summarize important research studies published on this topic in the last 18 months.

RECENT FINDINGS

The implementation of rapid referral systems and use of large vessel imaging have improved the diagnosis of giant cell arteritis. A population-based study in immunoglobulin G4-related disease provides incidence and prevalence estimates for the United States for the first time. Recently published data supported viral infectious triggers for Kawasaki disease and immunoglobulin A vasculitis. Population studies in antineutrophil cytoplasmic antibody associated vasculitis report an increase in the incidence of eosinophilic granulomatosis with polyangiitis and have provided further insights into the burden of cardiovascular disease in these patients. Data on Behçet's disease continues to show increased all-cause mortality and need for better treatment strategies.

SUMMARY

Recent literature highlights the heterogeneity of the epidemiology of vasculitis in different parts of the world as well as associated outcomes, comorbidities, and potential triggers. Thought new classification criteria are being employed in some forms of vasculitis, standardization of case identification remains an unmet need in multiple other forms of vasculitis.

Childhood-onset versus adult-onset Takayasu arteritis: A study of 239 patients from China

OBJECTIVE

We aimed to compare clinical features, vascular involvement, disease activity, and management between Chinese patients with childhood-onset Takayasu arteritis (cTAK) and adult-onset Takayasu arteritis (aTAK).

METHODS

In total, 239 patients with TAK from the pediatric and adult rheumatology departments of two tertiary care centers were retrospectively evaluated. Data on demographic characteristics, laboratory results, disease activity, vascular involvement, and management regimens were collected and compared between the cTAK and aTAK patients.

RESULTS

In total, 85 cTAK and 154 aTAK patients were enrolled. There was a significant difference in the female/male ratio between the cTAK and aTAK groups (2.3:1 vs. 10.8:1, P<0.001). Fever, hypertension, arrhythmia, and heart failure were more frequent in the cTAK group. The median Indian Takayasu Clinical Activity Score-scores were significantly higher in the cTAK group compared to the aTAK group (5 vs. 3, P=0.004). The prevalence of supra-aortic artery involvement was significantly higher in the aTAK group than in the cTAK group (P<0.05). The rate of involvement of coronary and renal arteries was significantly lower in the aTAK group than in the cTAK group (P<0.05). Compared to the aTAK patients, the cTAK patients were more likely to be treated with biological agents (76.5% vs. 9.1%, P<0.001).

CONCLUSION

cTAK patients had more severe disease and inflammation. Coronary and renal artery involvement was more common among cTAK patients, whereas supra-aortic artery involvement was more common in aTAK patients increasing their risk of cerebral infarction. Biologics were used more frequently in cTAK patients.

Pregnancy and childbirth in Takayasu arteritis in Japan: A nationwide retrospective study

OBJECTIVES

This study aimed to understand the status quo of medical treatments and pregnancy outcomes in patients with Takayasu arteritis (TAK) and children's birth outcomes.

METHODS

This study retrospectively enrolled patients with TAK who conceived after the disease onset and were managed at medical facilities participating in the Japan Research Committee of the Ministry of Health, Labour, and Welfare for Intractable Vasculitis.

RESULTS

This study enrolled 51 cases and 68 pregnancies during 2019-21. Of these, 48 cases and 65 pregnancies resulted in delivery and live-born babies. The median age of diagnosis and delivery was 22 and 31 years, respectively. Preconception therapy included prednisolone (PSL) in 51 (78.5%, median 7.5 mg/day), immunosuppressants in 18 (27.7%), and biologics in 12 (18.5%) pregnancies. Six cases underwent surgical treatment before pregnancy. Medications during pregnancy included PSL in 48 (73.8%, median: 9 mg/day), immunosuppressants in 13 (20.0%), and biologics in 9 (13.8%) pregnancies. TAK relapsed in four (6.2%) and eight (12.3%) pregnancies during pregnancy and after delivery, respectively. Additionally, 13/62 (20.9%) preterm infants and 17/59 (28.8%) low-birth-weight infants were observed, and none had serious postnatal abnormalities.

CONCLUSIONS

Most pregnancies in TAK were manageable with PSL at ≤10 mg/day. Relapse during pregnancy and postpartum occurred in <20% of pregnancies.

Exosome miR-199a-5p modulated vascular remodeling and inflammatory infiltration of Takayasu's arteritis

BACKGROUND

Advances in treatment have swiftly alleviated systemic inflammation of Takayasu's arteritis (TAK), while subclinical vascular inflammation and the ensuing arterial remodeling continue to present unresolved challenges in TAK. The phenotypic switching of vascular smooth muscle cells (VSMC) is regarded as the first step in vascular pathology and contributes to arterial remodeling. Exosomes facilitate the transfer and exchange of proteins and specific nucleic acids, thereby playing a significant role in intercellular communication. Little is known about the modulatory role of serum exosomes in phenotypic switching of VSMC and vascular remodeling in TAK.

METHODS

Serum exosomes isolated from TAK patients were co-cultured with VSMC to identify the modulatory role of exosomes. VSMC were transfected with miR-199a-5p mimic and inhibitor. CCK8 assays and EdU assays were performed to measure proliferative ability. The migration of VSMC was evaluated by scratch assays and transwell migration assays. The flow cytometry was employed to identify apoptosis of VSMC. Dual-luciferase reporter assay, RNA immunoprecipitation assay and fluorescence in situ hybridization were utilized to validate the target gene of miR-199a-5p. The correlational analysis was conducted among exosome miRNA, serum MMP2, TIMP2 and clinical parameters in TAK patients.

RESULTS

The coculture of VSMC with serum exosome mediated dedifferentiation of VSMC. Through gain- and loss-of-function approaches, miR-199a-5p over-expression significantly increased expression of VSMC marker genes and inhibited VSMC proliferation and migration, whilst the opposite effect was observed when endogenous miR-199a-5p was knocked down. The overexpression of miR-199a-5p suppressed VSMC apoptosis. Further, MMP2 serves as functional target gene of miR-199a-5p. The correlation analyses revealed an inverse correlation between Vasculitis Damage Index and exosome miR-199a-5p level or serum MMP2, which requires validation in a larger cohort.

CONCLUSION

Our study indicated that the miR-199a-5p/MMP2 pathway played a role in inhibiting the migration, proliferation and apoptosis of VSMC. The decreased secretion of MMP2 may potentially prompt the intimal infiltration of inflammatory cells within the vascular wall, offering a novel therapeutic opportunity by tackling both inflammatory responses and the neointimal overgrowth associated with TAK arterial damage. Moreover, exosome miR-199a-5p and MMP2 derived from serum possess potential as future biomarkers for vascular injury.

Active withdrawal of corticosteroids using tocilizumab and its association with autoantibody profiles in relapsed Takayasu arteritis: a multicentre, single-arm, prospective study (the Ab-TAK study)

Objectives

The feasibility of corticosteroid withdrawal (CW) for Takayasu arteritis (TAK) remains uncertain. Two autoantibodies (Abs) are identified against endothelial protein C receptor (EPCR) and scavenger receptor class B type 1 (SR-BI) in TAK, determining its three subgroups. This study aimed to evaluate CW using tocilizumab (TCZ) and its association with the Ab profile.

Methods

This prospective study, lasted for 24 weeks, included patients with relapsed but stable TAK. Scheduled tapering of prednisolone (PSL) was performed with subcutaneous TCZ (CW at week 20). The primary endpoint was the difference in type A remission, defined by CW and the absence of inflammatory signs, according to the Ab profile at week 24.

Results

Twenty patients were included and 18 patients with a mean PSL dose of 4.9 ± 2.8 mg/day were analysed. Anti-EPCR Ab-positive (E+), anti-SR-BI Ab-positive (S+), and double-negative (DN) groups included four (22.2%), eight (44.4%), and six (33.3%) patients, respectively. At week 24, the mean PSL dose was 2.0 ± 2.7 mg/day. Type A remission was observed in eight patients (44.4%), with significant differences based on the Ab profile: E+ (three patients, 75%), S+ (five patients, 62.5%), and DN (zero patients, 0%) (P=0.018). Besides, age, disease duration, PSL dose, type V arterial lesion, arterial dilation, and C-reactive protein >0.01 mg/dL were identified as risks for CW failure.

Conclusion

CW using TCZ was achieved in 44.4% of patients with TAK relapse and was significantly higher in E+ and S+ patients. CW can be a feasible target, and the precise selection of patients is critical.

Brain computed tomography perfusion alterations in patients with Takayasu arteritis with steno-occlusive carotid arteries: a retrospective study

INTRODUCTION/OBJECTIVE

Data on computed tomography perfusion (CTP) in Takayasu arteritis (TAK) patients are limited. Herein, we used CTP combined with computed tomography angiography (CTA) to investigate the brain hemodynamic status in TAK patients with stenosis/occlusive carotid arteries.

METHODS

We retrospectively analyzed 49 TAK patients with carotid artery stenosis or occlusion who had ischemic manifestations and completed a one-stop aortic CTA and brain CTP at Xijing Hospital between 2021 and 2023. Hemodynamic parameters, including cerebral blood flow (CBF), cerebral blood volume (CBV), mean transit time (MTT), and time to maximum (Tmax), were compared between groups using independent samples t-test or the Mann-Whitney U test. Relationships among CTP parameters and disease activity were evaluated by correlation analyses.

RESULTS

Among 49 patients (43 females; age 38.7 ± 11.1 years), 15 had common carotid artery occlusion (four bilateral, six right, and five left). Compared with the non-occlusion group, the occlusion group had longer MTT and Tmax (p < 0.05) but showed no differences in CBV and CBF values. Patients with different degrees of lesions on two sides of the carotid artery (n = 31) had lower mean CBF on the severely affected side than on the contralateral side (p = 0.022). In contrast, mean MTT (p = 0.036) and Tmax (p = 0.024) were longer. Patients with more severe ischemic symptoms had longer Tmax than patients with mild symptoms (p < 0.05). Tmax was moderately correlated with disease activity indices (p < 0.05).

CONCLUSIONS

Alterations in cerebral hemodynamic perfusion were observed in TAK patients. The implications of these findings in evaluating brain ischemia and dysfunction require further investigation. Key Points • Alterations in cerebral hemodynamic perfusion were observed in TAK patients. • Compared with patients without common carotid artery occlusion, patients with occlusion had longer MTT and Tmax values. • In patients with different degrees of lesions on the two sides of the carotid artery, the severely affected side had a lower CBF and prolonged MTT and Tmax than the contralateral side. • Patients with moderate-to-severe ischemic manifestations had a longer Tmax than patients with mild symptoms, and MTT and Tmax correlated with disease activity indices.

Expression of RAG and secondary gene rearrangement of BCR in mature peripheral B lymphocytes in Takayasu arteritis

To evaluate the expression of recombinant activating gene (RAG) and B cell receptor (BCR) gene rearrangements in mature peripheral B lymphocytes in Takayasu arteritis (TA) to explore the possible mechanism of humoral immune response in TA. Ten patients with TA and 10 age- and sex-matched healthy volunteers (control group) from Beijing Shijitan Hospital, Capital Medical University and Peking Union Medical College Hospital, between 2022 and 2023, were included in this study. The mRNA of the RAG was measured using real-time quantitative PCR (RT-PCR). Western blotting was used to detect RAG protein expression levels. NGS technology was used to detect BCR gene rearrangement. The mRNA expression level of RAG1 and RAG2 in peripheral mature B lymphocytes in patients with TA was significantly higher than in the control group (RAG1 5.56 ± 1.71 vs. 1.94 ± 0.86, p < 0.05; RAG2 5.26 ± 1.59 vs. 1.65 ± 0.64, p < 0.05), respectively. The protein expression level of the RAG1 and the RAG2 in peripheral mature B lymphocytes in patients with TA was significantly higher than in the healthy control group (RAG1 4.33 ± 1.58 vs. 1.52 ± 0.59, p < 0.001; RAG2 4.67 ± 1.88 vs. 1.59 ± 0.56, p < 0.001). The number of peripheral B lymphocyte BCR clonotypes in the group of patients with TA was significantly higher than in the normal control group (1574 ± 317.7 vs. 801.3 ± 202.1, p < 0.05). The abundance of IGHV clones in patients with TA was higher than in the normal control group (31.185% vs. 13.449%), which was positively correlated with the expression levels of RAG1 and RAG2 (correlation coefficient r = 1.00, p < 0.001), respectively. High expression of the RAG gene coexists with secondary BCR gene rearrangement in mature peripheral B lymphocytes in patients with TA, providing important clues regarding the potential humoral response in TA; however, further studies with larger samples are needed.

Efficacy of secukinumab in Takayasu arteritis with myocardial infarction complicated with generalized pustular psoriasis: A case report

RATIONALE

Takayasu arteritis (TAK) is an autoimmune disease that causes chronic inflammation targeting the aortic wall. Since many patients are resistant to steroid treatment, multiple immunosuppressants or interleukin-6 (IL-6) suppression therapy have served as treatment alternatives. However, there are very few reports on the effectiveness of biologics against inflammatory cytokines upstream of IL-6.

PATIENT CONCERNS

We present a case of TAK in a 51-year-old female presenting with a myocardial infarction. She had persistent carotid wall thickening despite glucocorticoid (GC) therapy, and IL-6 suppression therapy was being proactively considered. While the GC was being tapered, widespread pustules appeared all over her body.

DIAGNOSIS

TAK complicated with generalized pustular psoriasis (GPP).

INTERVENTIONS

Aside from GC, the patient was treated with secukinumab (SEC), an anti-IL-17A monoclonal antibody.

OUTCOMES

Immediately after treatment with SEC, the pustules disappeared, and the thickening of the common carotid artery wall improved on ultrasound.

LESSONS

Since IL-17 is an important cytokine in the pathogenesis of TAK, anti-cytokine therapy targeting IL-17 may be effective for TAK.

Incidence, risk factors for active tuberculosis infection and changes of IGRA in patients with Takayasu arteritis: a prospective cohort study

There is limited evidence to support the association between tuberculosis (TB) and the occurrence of Takayasu arteritis (TAK). To investigate the incidence of active TB (ATB) in TAK and explore the impact of anti-rheumatic therapy on the occurrence of ATB or reactivation of Latent TB infection (LTBI) and their effect on interferon-γ release assay (IGRA) results, we conducted a prospective study based on the Chinese Registry for Systemic Vasculitis cohort. The standard incidence ratio (SIR) was calculated and stratified by age. Kaplan-Meier analysis was used to determine the effect of variables on ATB or LTBI reactivation in patients with TAK. Data from 825 patients with TAK in the registry were analysed. During a median follow-up of 5 years, 5 patients developed ATB with a crude incidence of 154 (95%CI:57-381) person-years/100,000. The SIR was 5.59 (95%CI:1.81-13.04). Glucocorticoids and conventional disease-modifying anti-rheumatic drugs (cDMARDs) did not increase the risk of ATB or LTBI reactivation (P > 0.05). However, the use of tumour necrosis factor inhibitor (TNFi) increased the risk of ATB in patients with LTBI (P < 0.001). Furthermore, the value of the IGRA assay decreased after treatment (P < 0.05). In conclusion, the incidence of TB infection is markedly increased in patients with TAK and patients with TAK are at high risk of developing ATB. Treatment with glucocorticoids and cDMARDs does not significantly increase the risk for ATB in patients with TAK. Moreover, IGRA may have limited effectiveness in monitoring ATB infection or LTBI reactivation in patients with TAK.

Treatment of Crohn's Disease With Infliximab and Subsequent Development of Takayasu's Arteritis

A 23-year-old man was diagnosed with Crohn's disease (CD) of the large intestine after colonoscopy revealed longitudinal ulcers, and pathology revealed non-caseating epithelioid cell granulomas and anal fistulas. The CD relapsed, and therefore prednisolone (PSL) and infliximab (IFX) treatment was initiated. The PSL was gradually tapered. Steroid-free remission was maintained with IFX. The patient subsequently developed a high fever and headache, while CD-related symptoms did not worsen. Laboratory data showed white blood cells at 14,200/µL and C-reactive protein at 17.2 mg/dL. Contrast-enhanced computed tomography revealed thoracoabdominal aortitis, and the patient was consequently diagnosed with Takayasu's arteritis (TA). We therefore again initiated PSL treatment that immediately reduced the fever and headache. The PSL dose was again tapered and the administration of IFX was resumed to maintain CD remission. No further episodes of aortitis relapse were noted after restarting IFX, and the CD currently remains in remission. This is a rare case of TA onset during IFX treatment for CD, and, as such, contributes to the limited literature on such cases. More specifically, this case highlights that when patients with CD present with symptoms such as fever or headache, it is necessary to investigate the possibility of vasculitis.

Increased mortality rate in Takayasu arteritis is largely driven by cardiovascular disease: a cohort study

OBJECTIVES

To analyse the risk, causes and predictors of mortality in Takayasu arteritis (TAK).

METHODS

Survival was assessed in a cohort of patients with TAK using Kaplan-Meier curves. Age- and sex-standardized mortality ratio (SMR = observed: expected deaths) for TAK were calculated by applying age- and sex-specific mortality rates for the local population to calculate expected deaths. Hazard ratios (HR with 95%CI) for predictors of mortality based on demographic characteristics, presenting features, baseline angiographic involvement, disease activity, number of immunosuppressive medications used, procedures related to TAK and any serious infection were calculated using Cox regression or exponential parametric regression models.

RESULTS

Among 224 patients with TAK (159 females, mean follow-up duration 44.36 months), survival at 1, 2, 5 and 10 years was 97.34%, 96.05%, 93.93% and 89.23%, respectively. Twelve deaths were observed, most of which were due to cardiovascular disease (heart failure, myocardial infarction, stroke). Mortality risk was significantly higher with TAK (SMR 17.29, 95%CI 8.95-30.11) than the general population. Earlier age at disease onset (HR 0.90, 95%CI 0.83-0.98; or pediatric-onset vs adult-onset disease, HR 5.51, 95%CI 1.57-19.32), higher disease activity scores (ITAS2010: HR 1.15, 95%CI 1.05-1.25, DEI.TAK: HR 1.18, 95%CI 1.08-1.29), any serious infections (HR 5.43, 95%CI 1.72-17.12), heart failure (HR 7.83, 95%CI 2.17-28.16) or coeliac trunk involvement at baseline (HR 4.01, 95%CI 1.26-12.75) were associated with elevated mortality risk.

CONCLUSION

Patients with TAK had an elevated risk of mortality as compared with the general population. Cardiovascular disease was the leading cause of death in TAK.

Renal artery angioplasty in Takayasu disease: Difficult anatomy addressed with a novel technique

Takayasu arteritis is a well-established medical entity involving inflammatory changes in large arteries. We describe a characteristic case of Takayasu arteritis, in a young woman with significant renal artery stenosis, presenting with hypertensive urgency. Unsuccessful guide wire passage due to fibrotic septae in lumen of the left renal artery necessitated an innovative interventional approach, using an IMA-guide catheter and a UB3 coronary guidewire to cross the lesions, followed by placement of a coronary drug eluting stent, with an aim to avoid restenosis.

Multi-Omics Exploration of the Role of PTGS2 as a Hub Gene in Ferroptosis Within the Artery of Takayasu Arteritis

Introduction

Takayasu arteritis (TAK) is an autoimmune disease affecting the aorta and its branches. Despite anti-inflammatory treatments, some patients require surgical vascular reconstruction due to rapid disease progression. The mechanisms behind persistent inflammation are unclear due to a lack of arterial samples. This study explores ferroptosis in TAK using high-throughput and single-cell transcriptomics.

Methods

Transcriptomic data were collected from 8 TAK patients (2 for single cell RNA-seq and 6 for bulk RNA-seq) and 8 renal transplant donors, with single-cell data from 3 public carotid artery samples for control. Bioinformatic analysis was performed to identify ferroptosis-related genes in inflamed arteries.

Results

We identified 1526 differentially expressed genes and 46 ferroptosis-related genes, with 6 genes including PTGS2 and HIF1A as hub genes. Single-cell analysis of 27,828 cells revealed increased M1-like macrophages, with PTGS2 highly expressed in these cells. Enrichment analysis indicated NF-κB signal pathway involvement.

Conclusion

PTGS2 is a core ferroptosis-related gene in TAK vascular inflammation, highly expressed in M1-like macrophages, potentially upregulated via the IL1B-NF-κB pathway.

Takayasu's arteritis associated with tuberculosis: a retrospective study

BACKGROUND

Takayasu arteritis (TA) and tuberculosis (TB) share similar histopathological and immunological characteristics. Studies comparing patients with TA with or without active or latent TB infection (LTBI) have revealed some differences in clinical and angiographic profiles. Patient with TA and history of TB exhibited more constitutional symptoms and structural damage to the aorta. This study compared the clinical and radiological features of patients with TA with and without active TB or LTBI.

METHODS

We retrospectively analyzed the data of patients with TA at a public tertiary referral outpatient clinic in northeast Brazil from January 2017 to June 2022. Comparisons of clinical features were made according to the presence of TB.

RESULTS

Fifty patients met the eligibility criteria, and a association with TB was identified in 20 (40%) patients (active TB in six and LTBI in 14). There was a predominance of females, and the average age of patients was 40 years. Weight loss was more common in patients with TA and TB (p = 0.005). No significant intergroup differences were noted in terms of comorbidities, medications, erythrocyte sedimentation rates, or C-reactive protein levels. Significant differences were found in abdominal aortic involvement (25% of patients with TA and TB vs. 11.4% in subjects with TA without TB; p = 0.013). Dilations and aneurysms were significantly more common in patients with TA and TB (p = 0.009 and p = 0.027, respectively).

CONCLUSION

Patients with TA and TB have a higher prevalence of dilatation and aneurysms, most commonly in the abdominal aorta.

Serum p-Glycoprotein and Monomeric C-Reactive Protein are Elevated in Takayasu Arteritis

Purpose

Existing biomarkers including C-reactive protein (CRP) do not adequately distinguish active and inactive TAK. We compared serum p-glycoprotein (p-gp)/Multidrug Resistance Protein 1 (MDR1), monomeric CRP (mCRP), CRP, and mCRP:CRP ratio in Takayasu arteritis (TAK) and healthy controls and their relationship with disease activity.

Patients and Methods

Serum p-gp mCRP (ELISA) and CRP (nephelometry) were compared between consecutive adults with TAK (>18 years) enrolled from a prospective cohort (n = 92) and healthy controls (n = 29), and between active vs inactive TAK (n = 46 each). In a subset of active immunosuppressive-naïve TAK (n = 29), correlation was assessed between serum p-gp and p-gp expression on circulating T helper lymphocyte populations: overall (CD4+), Th17 (CD4+IL-17+), Th17.1 (CD4+IL-17+IFN-γ+) lymphocytes [normalized to Tregs (CD4+CD25+FoxP3+)]. Changes in serum p-gp, mCRP, CRP, and mCRP:CRP were compared before and after immunosuppression (n = 29). Data was represented using median (Q1-Q3). Receiver operating characteristics (ROC) curves were generated for TAK vs controls, and active vs inactive TAK with serum p-gp, mCRP, CRP, and mCRP:CRP. Multivariable-adjusted linear regression was used to predict active disease with serum p-gp, mCRP, CRP, or mCRP:CRP.

Results

Serum p-gp (11.19 vs 8.05 ng/mL), mCRP (1.61 vs 1.25 µg/L), and CRP (5.40 vs 2.1 mg/L) were elevated in TAK vs controls (p <0.05 for all). CRP was higher and mCRP:CRP ratio was lower in active vs inactive TAK (p < 0.001). ROC curves identified moderate prediction for active disease with CRP and inactive disease with serum p-gp (area under ROC curve 0.705 and 0.392, respectively). Multivariable-adjusted linear regression confirmed association of CRP with active disease (p = 0.009) and serum p-gp with inactive disease (p = 0.041). In treatment-naïve TAK, serum p-gp negatively correlated with p-gp+Th17.1 lymphocytes (Spearman's rho=-0.39, p = 0.046). CRP and serum p-gp were significantly lowered following immunosuppressive therapy in treatment-naïve TAK (p < 0.05).

Conclusion

Serum p-gp and mCRP are elevated in TAK. Serum p-gp is associated with inactive disease.

Current and Emerging Approaches to Imaging Large Vessel Vasculitis

Large vessel vasculitides (LVV) comprise a group of inflammatory disorders that involve the large arteries, such as the aorta and its primary branches. The cause of LVV is often rheumatologic and includes giant cell arteritis and Takayasu arteritis. Giant cell arteritis is the most common form of LVV affecting people >50 years of age with a slight female predominance. Takayasu arteritis is more frequently seen in younger populations and is significantly more common in women. Prompt identification of LVV is crucial as it can lead to debilitating complications if left untreated, including blindness in the case of giant cell arteritis and large artery stenosis and aneurysms in the case of all forms of LVV. Noninvasive imaging methods have greatly changed the approach to managing LVV. Today, imaging (with ultrasound, magnetic resonance imaging, computed tomography, and positron emission tomography) is routinely used in the diagnosis of LVV. In patients with giant cell arteritis, imaging often spares the use of invasive procedures such as temporal artery biopsy. In addition, vascular imaging is also crucial for longitudinal surveillance of arterial damage. Finally, imaging is currently being studied for its role in assessing treatment response and ongoing disease activity and its potential value in determining the presence of vascular wall remodeling (eg, scarring). This review explores the current uses of noninvasive vascular imaging in LVV.

Imaging Challenges and Developments in Large-vessel Vasculitis

Vascular imaging is an integral part of large-vessel vasculitis (LVV) evaluation and management. Several imaging modalities are currently employed in clinical practice including vascular ultrasound, computed tomography angiography, MRI and magnetic resonance angiography, and 18F-fluorodeoxyglucose PET. Well-established roles for imaging in LVV include disease diagnosis and assessment of luminal lesions reflecting vascular damage. The ability of imaging to determine treatment response, monitor disease activity, and predict future arterial damage is an area of active research.

Assessment of Coronary Involvement with MDCT and Long-term Outcomes in Patients with Takayasu's Arteritis

RATIONALE AND OBJECTIVES

Takayasu's arteritis (TA) mainly affects the aorta and its branches involving the coronary arteries. Coronary CT angiography can be used to detect coronary artery lesions. Outcome of TA patients with coronary involvement has not been well established. Our study aimed to systematically analyze coronary lesions in patients with TA and to access long-term outcome in TA patients with coronary involvement.

MATERIALS AND METHODS

A retrospective cohort study of TA patients with coronary CT angiography was conducted between January 2009 and October 2021. Baseline clinical characteristics, laboratory parameters, imaging features and therapeutic features were collected and analyzed. Follow-up was scheduled since the onset of TA. Overall survival and major adverse cardiovascular events (MACE) were analyzed in patients with coronary lesions.

RESULTS

48 (59.3%) TA patients had coronary involvement. Coronary ostial stenosis was detected in 31 (64.6%) patients by MDCT. Prevalence of disease activity (p = 0.007) was higher in patients with ostial stenosis. The median follow-up was 10.0 years. Death was observed in nine patients including seven died from myocardial infarction. TA patients with ostial stenosis had higher rate of MACE (p = 0.013). Baseline activity(HR: 5.250, 95%CI 2.004-8.639), ostial involvement(HR:8.954, 95%CI 3.875-56.038), stenosis≥ 70% (HR: 10.822, 95%CI 2.764-61.230) and activity recurrence (HR:11.913, 95%CI 2.321-85.747) were independently associated with increased major cardiovascular events.

CONCLUSION

MDCT should be performed in patients suspected with coronary involvement to make early diagnosis. Myocardial ischemia is the major cause of longterm death in TA patients with coronary lesions. Baseline disease activity, coronary ostial stenosis, stenosis ≥ 70% and activity recurrence were independent risk factors of cardiovascular events in TA patients.

Epidemiology of large vasculitis in Shanghai, China: A 10-year multicenter hospital-based study and systematic review

BACKGROUND

Takayasu arteritis (TAK) and giant cell arteritis (GCA) are two major large vessel vasculitis, with varied epidemiology by geographical location, age, and race. However, the epidemiological data in Chinese population is rarely reported. This study estimated the epidemiology of TAK and GCA in Shanghainese individuals residing in China over a 10-year period.

METHODS

TAK data for individuals over 16 years and GCA data for individuals over 50 years were retrieved from 38 comprehensive hospitals in Shanghai, China through the electronic medical record systems between January 1, 2011, and December 31, 2020. A systematic literature review was performed to determine the global distribution of TAK and GCA by searching PubMed, Ovid-Medline, Excerpta Medica Database (EMBASE), and Web of Science.

RESULTS

In 173 identified TAK cases (67% females; mean age, 46 ± 15 years), the period prevalence was 11.72 cases per million, and the mean annual incidence was 1.33 cases per million. The highest prevalence (17.74 cases per million) and incidence (1.71 cases per million) were observed in the 16- to 34-year-old age group. In 92 identified GCA cases (56% females; age, >50 years), the period prevalence was 2.73 cases per 100 000 persons, and the mean annual incidence was 1.91 cases per 100 000 persons. Meta-analysis of the incidence study of TAK and GCA showed that the pooled incidence rate of TAK and GCA was 1.29 per million and 15.48 per 100 000 person-years, respectively. Subgroup analysis showed that the incidence of TAK was significantly higher in Asia than in other regions, while the incidence of GCA was higher in Europe, especially North Europe.

CONCLUSION

The epidemiological patterns of TAK and GCA were comprehensively mapped globally and locally, in Shanghai, China.

The Use of Shear Wave Elastography in the Diagnosis of Prestenotic Phase of Takayasu's Aortoarteritis

We report the use of shear wave elastography with dispersion imaging in diagnosing a case of prestenotic Takayasu's arteritis which presented with symptoms of fever of unknown origin with persistently raised C-reactive protein levels. Vessel wall inflammation was detected in the carotid arteries on dispersion and shear wave imaging along with increased wall stiffness which was characteristic of vasculitis seen in a prestenotic phase of Takayasu's disease. These findings preceded the sonographic finding of vessel wall thickening described as the earliest sign of the disease on routine ultrasonography and not only helped to make an early diagnosis in a patient with a fever of unknown origin but also in the posttreatment follow-up.

Role of Optical Coherence Tomography in Vasculitis-Associated Pulmonary Hypertension and Chronic Thromboembolic Pulmonary Hypertension

BACKGROUND

Identifying and understanding the microstructural changes within the wall of the pulmonary artery (PA) is crucial for elucidating disease mechanisms and guiding treatment strategies. We assessed the utility of optical coherence tomography (OCT) in identifying such changes within segmental/subsegmental PAs and compared the morphological variations in WHO group 4 pulmonary hypertension associated with Behcet Disease (BD), Takayasu arteritis (TA) and chronic thromboembolic pulmonary hypertension (CTEPH). Idiopathic pulmonary arterial hypertension (IPAH) patients served as controls.

METHODS AND RESULTS

A total of 197 cross-sectional images were analyzed from 20 consecutive patients. BD patients exhibited lower %wall area and mean wall thickness (MWT) compared with CTEPH, TA and, IPAH patients. TA patients showed a notably higher %wall area, which was significant in IPAH and BD patients. Variations in %wall area measurements were observed across distinct cross-sectional segments of the PA within individual patients (22% in CTEPH, 19% in BD, 16% in TA, 23% in IPAH patients). Intravascular webs, bands, and thrombi were observed in BD and CTEPH patients. OCT provided clear delineation of vascular wall calcifications and adventitial vasa vasorum. No procedure-related complications were observed.

CONCLUSIONS

PA involvement differs among the various etiologies of PH, with the PA being heterogeneously affected. OCT offers promise in elucidating microstructural vascular wall changes and providing insights into disease mechanisms and treatment effects.

Acute heart failure due to myocarditis in Takayasu's arteritis

Takayasu's arteritis (TA) is a granulomatous vasculitis that involves the aortic artery and its branches, resulting in stenosis, occlusion, and aneurysmal dilatation. Cardiovascular involvement is one of the main complications and a major cause of mortality in these patients. Herein, we describe the case of a woman with TA who presented with severe acute heart failure secondary to myocarditis and responded well to immunosuppressive therapy.

Alteration of cardiac structure and function and its prognostic value in patients with Takayasu arteritis: a cardiac magnetic resonance study

Purpose

To investigate the prevalence and characteristics of late gadolinium enhancement (LGE) by cardiac magnetic resonance (CMR) and its prognostic value in patients with Takayasu arteritis (TA).

Materials and methods

Sixty TA patients with a CMR examination were retrospectively included. All TA patients were divided into with LGE-positive and LGE-negative groups. Bi-ventricular function and location, distribution, and pattern of left ventricular (LV) LGE were evaluated in both LGE-positive and LGE-negative groups. Primary outcome was defined as a composite of cardiovascular death, hospitalization for heart failure, coronary artery revascularization, and stroke. Univariate and multivariate Cox proportional hazard regression analyses were used to evaluate the association between variables and primary outcomes.

Results

Sixty consecutive TA patients were enrolled in this study. The mean age was 38.2 ± 13.8 years and 54 patients (54/60, 90.0%) were female. LGE-positive was observed in twenty-one (21/60, 35%) patients in the total patients with TA. LGE was predominantly distributed in the middle wall and subendocardial. The patchy and infarcted LGE patterns were the most common. Compared with the LGE-negative group, the LGE-positive group had reduced LV ejection fraction (P = 0.033), elevated LV end-diastolic volume index (P = 0.008), LV end-systolic volume index (P = 0.012), and LV mass (P = 0.008). During a median follow-up period of 1,892 days (interquartile range: 1,764-1,988 days), the primary outcomes occurred in thirteen patients. In the univariate analysis, LGE-positive (hazard ratio [HR] = 4.478, 95% confidence interval [CI]: 1.376-14.570; P = 0.013) were independently associated with the primary outcomes. However, LGE-positive did not retain its value as an independent predictor of primary outcomes in the multivariate analysis. Instead, LVMI (HR = 1.030, 95%CI: 1.013-1.048; P = 0.001) was the strongest independent predictor of primary outcomes in patients with TA. The Kaplan-Meier plot revealed that patients with LVMI ≥ 57.5 g/m2 have a worse prognosis.

Conclusion

LGE-positive detected by CMR was observed in 35% of total TA patients with different distributions and patterns. LGE is associated with adverse LV remodeling and worsen cardiac function. However, LVMI rather than LGE can provide independent prognostic information in patients with TA.

STEMI Following In-Stent Restenosis in Coronary Takayasu Arteritis With Pyoderma Gangrenosum in a Teenaged Athlete

Takayasu arteritis is a rare vasculitis of the aorta and its branches. Here, we present a teenaged athlete with coronary arteritis and pyoderma gangrenosum, the youngest person whose case is described in the literature. She received immune modulation and percutaneous coronary intervention, with subsequent in-stent restenosis and cardiac arrest requiring coronary artery bypass grafting.

Update on Takayasu arteritis: Year in review 2024

Takayasu arteritis is an uncommon systemic inflammatory large vessel vasculitis affecting women in their third and fourth decades frequently. The disease poses considerable morbidity and mortality owing to the involvement of the aorta and its major branches. Treatment comprises medical and vascular interventions, tailored to each patient. We review the high-impact publications of the year 2023 up to April 2024, which provide great insight into clinical, biomarker, imaging, pathogenetic, and therapeutic updates.

Right Ventricular Function in Takayasu's Arteritis Patients With Pulmonary Artery Involvement Using MRI Feature Tracking

BACKGROUND

Pulmonary artery involvement (PAI) is not rare in Takayasu arteritis (TA). Persistently elevated pulmonary arterial pressure in TA-PAI patients leads to pulmonary hypertension (PH), and eventually cardiac death. Thus, the early detection of right ventricular dysfunction before the onset of PH is important.

PURPOSE

To explore the potential of right ventricular global peak longitudinal and circumferential strain (RVGLS and RVGCS, respectively) in detecting right ventricular myocardial damage in TA-PAI patients without PH.

STUDY TYPE

Retrospective.

POPULATION

One hundred and six TA patients (39.6 ± 13.9 years), of whom 52 were non-PAI and 54 were PAI patients (36 without PH and 18 with PH), along with 58 sex- and age-matched healthy volunteers (HVs) (36.7 ± 13.2 years). The involved arteries were validated by aorta magnetic resonance (MR) angiography and pulmonary artery computed tomography angiography.

FIELD STRENGTH/SEQUENCE

3 T/Cine imaging sequence with a steady-state free precession readout.

ASSESSMENT

Cardiac MRI-derived parameters measured by two radiologists independently were compared among HVs, and TA patients with and without PAI. In addition, these indices were further compared among HVs, and TA-PAI patients with and without PH.

STATISTICAL TESTS

Student's t test, one-way ANOVA analysis, Pearson and Spearman correlation analysis, and reproducibility analysis. A P-value of <0.05 was considered statistically significant.

RESULTS

Although the TA-PAI patients without PH had a similar RV ejection fraction (RVEF) with HV (P = 0.348), RVGLS (non-PH 20.6 ± 3.7% vs. HV 24.0 ± 3.1%) was significantly lower and RVGCS (non-PH 14.8 ± 3.9% vs. HV 13.0 ± 2.7%) higher. The TA-PAI patients with PH had significantly poorer RVGLS (PH 13.5 ± 3.8% vs. non-PH 20.6 ± 3.7%) and RVGCS (PH 10.9 ± 3.2% vs. non-PH 14.8 ± 3.9%) than those without PH.

DATA CONCLUSION

Right ventricular dysfunction was detected in the TA-PAI patients without PH. MR-feature tracking may be an effective method for detecting early cardiac damage in the TA-PAI patients without PH.

LEVEL OF EVIDENCE

3 TECHNICAL EFFICACY: Stage 3.

From low back pain to Takayasu arteritis: A rare case report

Takayasu arteritis (TA) is an uncommon chronic inflammation of blood vessels. It can occur with a range of clinical manifestations. However, low back pain is uncommonly defined as the initial symptom of TA. In this article, we report a 53-year-old woman who presented with low back pain and was diagnosed with TA after a detailed clinical examination and further evaluations. A thorough history and detailed physical examination can help to recognize the underlying cause of low back pain. Takayasu arteritis should be kept in mind as an alternative diagnosis while evaluating low back pain with high inflammation parameters, particularly in women.

Pro-fibrotic effect of the susceptible gene PCSK5 in vascular fibrosis of Takayasu arteritis via TGF-β and SMAD3 signaling pathway activation

BACKGROUND

Vascular fibrosis directly causes vascular thickening in Takayasu arteritis (TAK), in which sustained transforming growth factor beta (TGF-β) activation is critical. Understanding TGF-β activation regulation and blocking it might yield a therapeutic effect in TAK. Proprotein convertase subtilisin/kexin type 5 (PCSK5) rs6560480 (T/C) is associated with TAK development. In this study, we assessed the association between the PCSK5 rs6560480 genotype and PCSK5 expression in TAK and explored its molecular role in TGF-β activation and vascular fibrosis development.

METHODS

In TAK patients, PCSK5 and TGF-β expression in plasma and aortic tissue was examined by ELISA and immunohistochemical staining, and PCSK5 rs6560480 was genotyped. The correlation between PCSK5 and extracellular matrix (ECM) expression was examined by Western blotting (WB) and immunohistochemistry staining. Detection by co-immunoprecipitation was performed to detect the interaction between PCSK5 and TGF-β in adventitial fibroblasts (AAFs). Downstream signaling pathways were detected by WB and validated with appropriate inhibitors. Potential immunosuppressive agents to inhibit the effects of PCSK5 were explored in cell culture and TAK patients.

RESULTS

Patients with PCSK5 rs6560480 TT patients had significantly higher PCSK5 levels and more thickened vascular lesions than patients with PCSK5 rs6560480 CT. PCSK5 expression was significantly increased in alpha smooth muscle actin (α-SMA)-positive myofibroblasts in TAK vascular lesions. Overexpressing PCSK5 facilitated TGF-β and downstream SMAD2/3 activation and ECM expression in AAFs and aorta in in-vitro culture. The mechanistic study supported that PCSK5 activated precursor TGF-β (pro-TGF-β) to the mature form by binding the pro-TGF-β cleavage site. Leflunomide inhibited PCSK5 and pro-TGF-β binding, decreasing TGF-β activation and ECM expression, which was also partially validated in leflunomide-treated patients.

CONCLUSION

The findings revealed a novel pro-fibrotic mechanism of PCSK5 in TAK vascular fibrosis via TGF-β and downstream SMAD2/3 pathway activation. Leflunomide might be anti-fibrotic by disrupting PCSK5 and pro-TGF-β binding, presenting a new TAK treatment approach.

Clinical spectrum and outcome of Takayasu's arteritis in children

OBJECTIVES

We aimed to compare clinical spectrum and outcome between adults and children with Takayasu's arteritis (TAK) in a European population.

METHODS

We made a nationwide retrospective observational study between 1988 and 2019. All adult patients met the ACR diagnostic criteria for TAK and all children met the EULAR/PRINTO/PRES criteria for paediatric TAK.

RESULTS

We identified 46 children and 389 adults with TAK. The male to female ratio was 34/46 (0.74) in the paediatric group compared to 241/274 (0.88) in the adult group (P<0.05). Children presented with significantly more systemic symptoms; i.e., fever (P<0.05), fatigue (P<0.001), weight loss (P<0.001), abdominal pain (P<0.05), and myalgia (P<0.05) while adults had more upper limb claudication (P<0.01). Topography of the lesions differed significantly between the two groups: adults had more damage at the cerebral vasculature (P<0.01), upper and lower limbs (P<0.001) while children had more kidney lesions (P<0.05). Children TAK had more frequent (P<0.01) and higher (P<0.001) biological inflammation than adults. Children received higher dose-weight of corticosteroids (P=0.001) and less biotherapy (P<0.010) at diagnosis. Relapses (P<0.05) and death (8.6% vs 4.9%) were more frequent in children TAK than in adults.

CONCLUSION

Paediatric TAK seems more severe than adult TAK. Therefore, paediatrics patients may require closer monitoring and systemic use of biological treatment.

Application of the 2022 ACR/EULAR criteria for Takayasu arteritis to previously diagnosed patients based on the 1990 ACR criteria

OBJECTIVES

Recently, a joint group of the American College of Rheumatology (ACR) and the European Alliance of Associations for Rheumatology (EULAR) proposed new criteria for Takayasu arteritis (TAK) (the 2022 ACR/EULAR criteria). This study applied the 2022 ACR/EULAR criteria to patients with previously diagnosed TAK based on the 1990 ACR criteria and investigated the concordance rate between the two criteria according to the four imaging modalities.

METHODS

This study reviewed the medical records of 179 patients who met the 1990 ACR criteria for TAK. The imaging modalities included conventional angiography, computed tomography angiography, fluorodeoxyglucose-positron emission tomography, and magnetic resonance angiography.

RESULTS

Regardless of the imaging modalities, the concordance rate between the two criteria was 85.5% when including all patients, whereas it increased to 98.1% when only patients aged ≤60 years were included. Among the four imaging modalities, computed tomography angiography exhibited the highest concordance rate between the two criteria (85.6%). The concordance rate among patients aged >60 years was 95.7%. Only one patient aged 50-60 years was reclassified as having both TAK and giant cell arteritis.

CONCLUSIONS

The concordance rate was 85.5% regardless of the imaging modalities and increased to 86.9% on simultaneous computed tomography angiography and fluorodeoxyglucose-positron emission tomography imaging.

Serum IL-6 level trajectory for predicting the effectiveness and safety of tocilizumab in the treatment of refractory Takayasu arteritis

AIM

To explore the value of serial monitoring of serum interleukin-6 (IL-6) levels for predicting treatment response and occurrence of adverse events during tocilizumab (TCZ) treatment in refractory Takayasu arteritis (TAK).

METHODS

TAK patients receiving TCZ treatment were prospectively recruited and followed up at 1 month, 3 months and then every 3-6 months. Serum IL-6 levels were measured at each visit. Overall response was the combination of complete and partial response, requiring resolution of signs and symptoms, hsCRP and ESR level decreased at least by half, no progression on imaging and dose of glucocorticoid <15 mg/d.

RESULTS

Thirty-five patients with a median follow up duration of 17 [9-44] months were included. The change of IL-6 after TCZ treatment for 6 months compared to the baseline was significantly lower in patients achieved overall response at 6, 12, 18 and 24 months. The ratio of IL-6 at 6 months to baseline could predict overall response at 12 and 24 months after TCZ treatment. With a cutoff value of 1.6, the sensitivity and specificity were 83.3 % and 87.5 % for 12 months, while 100 % and 88.9 % for 24 months. Patients with the ratio less than 1.6 were also 9 times more likely to achieve sustained improvement without treatment intensification. No correlation between IL-6 dynamics and occurrence of adverse events was found.

CONCLUSIONS

The change of IL-6 levels after TCZ treatment for 6 months compared to the baseline can predict the overall treatment response at 12 months, 24 months and sustained improvement.

Effector CD4+ T-cell subsets in Takayasu arteritis-differences between the peripheral blood and the aorta

Takayasu arteritis (TAK) is a granulomatous vasculitis that affects large arteries. T cells are important in TAK pathophysiology as these cells orchestrate granulomatous infiltration in arteries. This study aims to evaluate effector CD4+ T cells in the peripheral blood and the aortic wall of TAK patients and to analyze associations with disease activity and therapy. We performed a longitudinal study including 30 TAK patients and 30 controls. CD3+ T cells, CD3+CD4- T cells, CD4+ T cells, and Th1, Th2, and Th17 cells were evaluated in peripheral blood by flow cytometry, and the expression of CD4, CD8, Tbet, GATA-3, and RORγT was analyzed in the aorta of six patients by immunohistochemistry. TAK patients presented lower CD3+ T cells and CD4+ T cells (P = 0.031 and P = 0.039, respectively) than controls. Patients with active disease and those in remission had higher proportions of Th17 cells than controls (P = 0.016 and P = 0.004, respectively). Therapy for TAK did not result in significant differences concerning CD4+ effector T-cell subpopulations. Disease duration correlated with the number and percentage of Th2 cells (rho = -0.610 and rho = -0.463, respectively) and with Th17 cells (rho = -0.365 and rho = -0.568). In the aorta, the expression of CD8 was higher than CD4, whereas GATA-3, Tbet, and RORγT were expressed in this order of frequency. In conclusion, TAK patients present an increased Th17 response in the peripheral blood regardless of disease activity, whereas in the aortic tissue CD8 cells and the Th2 response were predominant.

Real-World Biomarkers for Pediatric Takayasu Arteritis

Childhood-onset Takayasu arteritis (TA) is a rare, heterogeneous disease with limited diagnostic markers. Our objective was to identify and classify all candidates for biomarkers of TA diagnosis in children reported in the literature. A systematic literature review (PRISMA) of MEDLINE, EMBASE, Wiley Cochrane Library, ClinicalTrias.gov, and WHO ICTRP for articles related to TA in the pediatric age group between January 2000 and August 2023 was performed. Data on demographics, clinical features, laboratory measurements, diagnostic imaging, and genetic analysis were extracted. We identified 2026 potential articles, of which 52 studies (81% case series) met inclusion criteria. A total of 1067 TA patients were included with a peak onset between 10 and 15 years. Childhood-onset TA predominantly presented with cardiovascular, constitutional, and neurological symptoms. Laboratory parameters exhibited a low sensitivity and specificity. Imaging predominantly revealed involvement of the abdominal aorta and renal arteries, with magnetic resonance angiography (MRA) being the preferred imaging modality. Our review confirms the heterogeneous presentation of childhood-onset TA, posing significant challenges to recognition and timely diagnosis. Collaborative, multinational efforts are essential to better understand the natural course of childhood-onset TA and to identify accurate biomarkers to enhance diagnosis and disease management, ultimately improving patient outcomes.

Successful pregnancies in a patient with Takayasu arteritis and antiphospholipid syndrome, maintained on infliximab corticosteroid-free regimen: case-based review

Takayasu arteritis (TA) is a large vessel vasculitis affecting predominantly females below the age of 40. Patients with TA seem to be at increased risk for adverse pregnancy outcomes, resulting in mother or child complications. Although few studies analyzed the presence of antiphospholipid antibodies (APLA) in TA patients, an association between antiphospholipid syndrome (APS) and TA is rarely reported in the literature, mainly in the form of case reports. In fact, very few data regarding pregnancy outcomes in patients with TA and APS are available. An active form of Crohn's disease (CD) might be another risk factor strongly affecting the fertility rate. Here, we would like to present a 33-year-old woman with TA, double-positive APS and Crohn's disease (CD). The report is followed by the literature review of the association of APLA and/or APS with TA, focusing on analyzing the pregnancy outcomes. To our knowledge, this is the first case describing two successful, naturally occurring pregnancies, in a patient suffering from TA, APS and CD, and maintained on infliximab, azathioprine, and a corticosteroid-free regimen.

[Takayasu arteritis after COVID-19 infection in a 26-year-old female patient with Crohn's disease]

Extraintestinal manifestations, e.g. of the skin, joints or liver, are frequently found in Crohn's disease. We report about a 26-year-old female patient with longstanding Crohn's disease, who was admitted to our hospital with suspicion of an acute attack with suggestive symptoms and increased significantly inflammatory parameters. Shortly before, symptomatic COVID-19 disease (SARS-CoV-2 variant omicron) had been made. Comprehensive endoscopic and imaging diagnostics ruled out active Crohn's disease. However, inflammatory thickening of the aortic arch was seen, and a diagnosis of Takayasu arteritis (type II b) was made. Steroid therapy resulted in a rapid and sustained improvement of clinical symptoms. The occurrence of Takayasu arteritis is extremely rare outside Japan. An coincidence has been described in chronic inflammatory bowel diseases and is discussed as a possible extraintestinal manifestation. The occurrence of immune-mediated disease after COVID-19 disease has been described and may be triggered by the infection. Patients with inflammatory bowel disease may represent a special risk population.

Ultrasound Examination of Common Carotid Adventitial Thickness Can Differentiate Takayasu Arteritis and Large Vessel Giant Cell Arteritis

Pathological studies have demonstrated that the adventitial layer is markedly thickened in Takayasu (TAK) as compared to large vessel giant cell arteritis (LV-GCA). An ultrasound (US) examination of the arterial vessels allows the determination of intima media thickness (IMT) and of adventitial layer thickness (extra media thickness (EMT)). No previous study has evaluated if there are differences in EMT thickness between TAK and LV-GCA. In this cross-sectional retrospective study of stored ultrasound (US) imaging, we have compared common carotid artery (CCA) EMT and IMT in a series of consecutive TAK and LV-GCA patients. US examination CCA IMT and EMT were significantly higher in TAK as compared to LV-GCA. With ROC curve analysis, we have found that an EMT > 0.76 mm has high sensitivity and specificity for TAK CCA examination. The percentage of CCA at EMT > 0.76 mm and the total arterial wall thickening were significantly higher in TAK group examinations. EMT thickness correlated with disease duration and IMT in the TAK group, as well as with the IMT and ESR values in the LV-GCA group. Upon multivariate logistic regression analysis, factors independently associated with TAK CCA were EMT > 0.76 mm and age. No significant variation in IMT and EMT could be demonstrated in subsequent US CCA examinations.

High estrogen induces trans-differentiation of vascular smooth muscle cells to a macrophage-like phenotype resulting in aortic inflammation via inhibiting VHL/HIF1a/KLF4 axis

Estrogen is thought to have a role in slowing down aging and protecting cardiovascular and cognitive function. However, high doses of estrogen are still positively associated with autoimmune diseases and tumors with systemic inflammation. First, we administered exogenous estrogen to female mice for three consecutive months and found that the aorta of mice on estrogen develops inflammatory manifestations similar to Takayasu arteritis (TAK). Then, in vitro estrogen intervention was performed on mouse aortic vascular smooth muscle cells (MOVAS cells). Stimulated by high concentrations of estradiol, MOVAS cells showed decreased expression of contractile phenotypic markers and increased expression of macrophage-like phenotypic markers. This shift was blocked by tamoxifen and Krüppel-like factor 4 (KLF4) inhibitors and enhanced by Von Hippel-Lindau (VHL)/hypoxia-inducible factor-1α (HIF-1α) interaction inhibitors. It suggests that estrogen-targeted regulation of the VHL/HIF-1α/KLF4 axis induces phenotypic transformation of vascular smooth muscle cells (VSMC). In addition, estrogen-regulated phenotypic conversion of VSMC to macrophages is a key mechanism of estrogen-induced vascular inflammation, which justifies the risk of clinical use of estrogen replacement therapy.