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Sharma S, Pandey NN, Sinha M, Chandrashekhara SH. Etiology, Diagnosis and Management of Aortitis. Cardiovasc Intervent Radiol 2020; 43:1821-1836. [PMID: 32390100 DOI: 10.1007/s00270-020-02486-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 04/08/2020] [Indexed: 01/02/2023]
Abstract
Aortitis includes conditions with infectious or non-infectious etiology, characterized by inflammatory changes in one or more layers in aortic wall. Age at onset, geographic predilections, distribution and pattern of involvement in aorta, its branches and pulmonary arteries, and systemic associations provide a clue to etiology. Clinical presentations are often non-specific. An integrated approach including clinical, laboratory and imaging assessment is essential to confirm diagnosis and plan treatment. Assessment of disease activity is the key as it influences timing and outcome of treatment. Markers of activity include clinical, laboratory and imaging. Medical management remains the first-line therapy. Revascularization is indicated in the presence of hemodynamically significant stenosis and inactive disease. In the presence of flash pulmonary edema, left ventricular dysfunction or hypertensive encephalopathy, revascularization is performed irrespective of disease activity. Endovascular management is favored over surgery due to its high success and low restenosis rates. Symptomatic aneurysmal disease is usually managed by surgery.
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Affiliation(s)
- Sanjiv Sharma
- Department of Cardiovascular Radiology and Endovascular Interventions, All India Institute of Medical Sciences, New Delhi, 110029, India.
| | - Niraj Nirmal Pandey
- Department of Cardiovascular Radiology and Endovascular Interventions, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Mumun Sinha
- Department of Cardiovascular Radiology and Endovascular Interventions, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - S H Chandrashekhara
- Department of Cardiovascular Radiology and Endovascular Interventions, All India Institute of Medical Sciences, New Delhi, 110029, India
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Shankarrao Dekate P, Reddy S, Prasad VSV, Boda S, Saini L, Patil P. An Uncommon Cause of Hypertensive Urgency in Young Adolescent: Case Report. Indian J Crit Care Med 2019; 23:339-341. [PMID: 31406445 PMCID: PMC6686575 DOI: 10.5005/jp-journals-10071-23210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Mid aortic syndrome is rare cause of hypertensive urgency in children with poor outcome if left untreated, high index of suspicion with prompt management is the key to survival with good outcome. A 12-year-old boy was presented with fever, puffiness of face, and breathing difficulty. Clinically, he had hypertension with differential pulsation and BP in upper and lower limbs. He had peak systolic gradient of 80 mm Hg between upper and lower limb. His echocardiography and CT angiography was suggestive of significant isolated 80% narrowing of abdominal aorta without involvement any other large vessels. Percutaneous balloon dilatation of aorta was done considering multiple parameters. Post procedure, there was significant improvement in BP and we could wean his multiple anti-hypertensive drugs to keep his blood pressures below 95th centile. His BP remained control with minimum upper and lower limb gradient on follow up of almost 1 year. HOW TO CITE THIS ARTICLE Dekate PS, Reddy S, Prasad VSV, Boda S, Saini L, Patil P. An Uncommon Cause of Hypertensive Urgency in Young Adolescent: Case Report. Indian J Crit Care Med 2019;23(7):339-341. KEY MESSAGE Mid aortic syndrome is most uncommon amongst them. With prompt diagnosis and proper selection of therapeutic options like balloon dilatation or surgical correction, it has good prognosis. Aortic narrowing because of different diseases is an uncommon cause of HT urgency in children.
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Affiliation(s)
- Parag Shankarrao Dekate
- Department of Pediatrics, PICU, Lotus Hospital for Women and Children, Lakdikapool, Hyderabad, Telangana, India
| | - Satyanarayana Reddy
- Department of Pediatrics, PICU, Lotus Hospital for Women and Children, Lakdikapool, Hyderabad, Telangana, India
| | - VSV Prasad
- Department of Pediatrics, PICU, Lotus Hospital for Women and Children, Lakdikapool, Hyderabad, Telangana, India
| | - Sudha Boda
- Department of Pediatrics, PICU, Lotus Hospital for Women and Children, Lakdikapool, Hyderabad, Telangana, India
| | - Lokesh Saini
- Department of Pediatrics, PICU, Lotus Hospital for Women and Children, Lakdikapool, Hyderabad, Telangana, India
| | - Prashant Patil
- Department of Pediatrics, PICU, Lotus Hospital for Women and Children, Lakdikapool, Hyderabad, Telangana, India
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Pilati M, Pongiglione G, Gagliardi MG. Percutaneous treatment of abdominal coarctation in children using a covered stent. Pediatr Cardiol 2014; 34:2080-5. [PMID: 23515761 DOI: 10.1007/s00246-013-0690-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2012] [Accepted: 03/08/2013] [Indexed: 11/25/2022]
Abstract
Coarctation of the abdominal aorta is extremely rare. It generally involves a long segment of the descending aorta and causes uncontrolled and unexplainable hypertension in children. The therapeutic choice is very challenging because acute and chronic complications are reported for both the surgical and the percutaneous approaches. The two reported cases of abdominal coarctation were treated primarily and successfully through the use of covered stents. Three covered stents were implanted in two children. No complication occurred with either procedure. At this writing, an 18-month follow-up assessment has found the patients in good health with no restenosis at the coarctation site. Covered stent implantation in children with abdominal coarctation is a feasible, safe, and effective procedure. It provides adequate relief of symptoms and reduces the risk of aneurysm formation. To avoid covering important side branches with polytetrafluoroethylene, this type of procedure must be preceded by precise study of the aorta and its branches.
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Affiliation(s)
- Mara Pilati
- Medical and Surgical Department of Pediatric Cardiology, Ospedale Pediatrico Bambino Gesù, IRCCS Piazza S. Onofrio 4, 00165, Rome, Italy,
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Midaortic syndrome: 30 years of experience with medical, endovascular and surgical management. Pediatr Nephrol 2013; 28:2023-33. [PMID: 23775038 PMCID: PMC3822337 DOI: 10.1007/s00467-013-2514-8] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2012] [Revised: 04/09/2013] [Accepted: 05/13/2013] [Indexed: 12/20/2022]
Abstract
BACKGROUND Midaortic syndrome is often associated with refractory hypertension. The aim of our study was to better understand the short- and medium-term outcomes in this patient population utilizing a multidisciplinary management approach. METHODS We conducted a review of patients with midaortic syndrome treated at our institution over the past 30 years. RESULTS Fifty-three patients presented at a median age of 6.7 years (birth to 28.7 years). Thirty-five patients (66 %) underwent invasive management (percutaneous techniques: 21; surgical techniques: 5; both: 9). Percutaneous interventions were acutely successful in decreasing the gradient across the obstruction and degree of luminal stenosis. However, freedom from reintervention was 58 % at 1 year and 33 % at 5 years. Freedom from reintervention after a surgical procedure was longer: 83 % at 1 year and 72 % at 10 years. At the most recent follow-up, the majority of patients (69 %) were normotensive. The median duration between time of presentation and achievement of blood pressure control was 5.7 (0.4-21.1) years. The median number of anti-hypertensive medications was 1 (0-5). CONCLUSIONS A multidisciplinary management strategy which couples comprehensive medical management with catheter-based and surgical interventions can lead to adequate blood pressure control and preservation of end-organ function in patients with midaortic syndrome.
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Descending thoracic and abdominal aortic coarctation in the young: Surgical treatment after percutaneous approaches failure. J Vasc Surg 2008; 47:865-7. [DOI: 10.1016/j.jvs.2007.10.048] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2007] [Revised: 10/19/2007] [Accepted: 10/24/2007] [Indexed: 11/18/2022]
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Park MC, Lee SW, Park YB, Lee SK, Choi D, Shim WH. Post-interventional immunosuppressive treatment and vascular restenosis in Takayasu's arteritis. Rheumatology (Oxford) 2005; 45:600-5. [PMID: 16352637 DOI: 10.1093/rheumatology/kei245] [Citation(s) in RCA: 93] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To investigate the outcome of vascular interventions and the effect of post-interventional immunosuppressive treatment on the occurrence of vascular restenosis in patients with Takayasu's arteritis (TA). METHODS Forty-two patients with TA who had undergone vascular intervention and had serial angiographies before and after intervention were enrolled. The demographic and clinical data were collected at the time when the interventions were performed, and the intervention modalities and post-interventional medical treatments were evaluated. RESULTS Sixty-three interventions were performed in 42 patients. Twenty (31.7%) interventions restenosed 24.0 +/- 21.9 months after intervention; the likelihood decreasing as time passed. Estimates of arterial patency after intervention were 90.1% at 1 yr, 75.5% at 2 yr, 68.4% at 3 yr, 61.6% at 5 yr and 49.3% at 10 yr. According to the log rank test, interventions that were performed during the stable stage of the disease (P = 0.039) and those that were followed by treatment with glucocorticoids and immunosuppressive agents (P = 0.044) were independent variables for the maintenance of arterial patency. Their hazard ratios were 0.30 and 0.41, respectively. CONCLUSION Restenosis occurred in 31.7% of TA patients after intervention. A lower restenosis rate was observed when the vascular interventions were performed at the stable stage and when post-interventional immunosuppressive treatment was implemented.
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Affiliation(s)
- M C Park
- Department of Internal Medicine, Yonsei University College of Medicine, Seodaemun-gu, Seoul 120-752, Korea
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Saxena A, Kothari SS, Sharma S, Juneja R, Srivastava S. Percutaneous transluminal angioplasty of the aorta in children with nonspecific aortoarteritis: acute and follow-up results with special emphasis on left ventricular function. Catheter Cardiovasc Interv 2000; 49:419-24. [PMID: 10751769 DOI: 10.1002/(sici)1522-726x(200004)49:4<419::aid-ccd15>3.0.co;2-i] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Nonspecific aortoarteritis (NSAA) is a chronic disease of unknown etiology and may result in stenosing and obstructive lesions of the aorta. Transluminal balloon angioplasty was carried out in 17 children, 4-12 years of age (mean 8.9 +/- 2.7 years) with symptomatic stenosis of thoracic or abdominal aorta due to NSAA. Hypertension was present in 15 children, and 11 had significant left ventricular dysfunction. All children had a clinically inactive disease. The stenosis was in descending thoracic aorta in 10, thoracoabdominal in 3 and only abdominal in 4. Symptomatic improvement with relief of stenosis was seen in 16 of 17 children, although in 3, the results were suboptimal. The peak systolic gradient fell from 70.9 +/- 19.3 mmHg to 32.0 +/- 19.2 mmHg immediately after dilation (P < 0.0001). Angiographically measured luminal diameter stenosis also fell from 82.5 +/- 7.7% to 19.4 +/- 11.8% (P < 0.0001). Dissection flap was seen in 13 cases. It was large in cases with long, diffuse and eccentric stenosis of the thoracic or thoracoabdominal aorta. On follow-up (available for 14 of 16 cases for a period of 2-87 months mean 20.7 +/- 21.5 months, median 15.5 months) two patients developed restenosis. Left ventricular function improved in all 8 children that had sustained benefit of angioplasty. Blood pressure normalized in 9 of 13 children and the drug requirements fell in 4 others. Further remodeling of the lesion with decrease in gradients and luminal stenosis was observed in 11 children that have been restudied. Balloon angioplasty of aorta in children with NSAA is a feasible and safe procedure. Small intimal flap is seen in the majority, extensive dissection is more likely in the long diffuse lesions in descending thoracic aorta. Hypertension and left ventricular dysfunction improve after relief of obstruction.
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Affiliation(s)
- A Saxena
- Cardiothoracic Centre, All India Institute of Medical Sciences, New Delhi, India.
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Tyagi S, Kaul UA, Arora R. Endovascular stenting for unsuccessful angioplasty of the aorta in aortoarteritis. Cardiovasc Intervent Radiol 1999; 22:452-6. [PMID: 10556402 DOI: 10.1007/s002709900431] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
PURPOSE The efficacy and safety of endovascular stent implantation to correct dissection or a suboptimal result after percutaneous transluminal angioplasty (PTA) was evaluated in patients suffering from aortic stenosis due to aortoarteritis. METHODS Twelve children and young adults [aged (mean +/- SD) 18.2 +/- 8.7 years] underwent stent implantation after PTA of the aorta, seven for obstructive dissection, four for ineffective balloon dilatation, and one for recurrent restenosis. Nine patients underwent implantation of self-expandable stents and three received balloon-expandable Palmaz stents. RESULTS Stent implantation could be successfully performed in all 12 patients. After stent implantation, the peak systolic pressure gradient decreased from 91 +/- 33.5 mmHg to 12.4 +/- 12.5 mmHg (p < 0.001). The diameter of the stenosed segment increased from 4.6 +/- 0.8 mm to 11.1 +/- 1.9 mm (p < 0.001). The dissection was completely covered in all seven patients with dissection. Except for epigastric pain with vomiting in one patient, there was no complication. On follow-up, over 12-57 months (mean 26.8 +/- 10.8 months), 11 patients (91.6%) had marked improvement in their blood pressure. Patients with congestive heart failure and claudication also showed improvement. Repeat catheterization in five patients, between 6-30 months (mean 16.8 +/- 9.1 months) after stent implantation, showed sustained improvement in four and a fusiform, long segment, intrastent restenosis after 30 months in one child. The stenosis was safely redilated. CONCLUSION Endovascular aortic stent implantation is safe and provides good immediate relief in patients with unsatisfactory results after balloon angioplasty. Improvement is sustained in most patients on intermediate-term follow-up.
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Affiliation(s)
- S Tyagi
- Department of Cardiology, G. B. Pant Hospital and Maulana Azad Medical College, New Delhi 110002, India
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Nomura M, Kida S, Yamashima T, Yamashita J, Yoshikawa J, Matsui O. Percutaneous transluminal angioplasty and stent placement for subclavian and brachiocephalic artery stenosis in aortitis syndrome. Cardiovasc Intervent Radiol 1999; 22:427-32. [PMID: 10501899 DOI: 10.1007/s002709900421] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
A 43-year-old man with progressive right common carotid, subclavian artery, and brachiocephalic artery stenoses due to aortitis syndrome is presented. The patient's right common carotid artery had been treated by percutaneous transluminal angioplasty (PTA) four times previously, but it was finally occluded. The right subclavian artery was treated by PTA once, which resulted in restenosis. The stenosis extended to the brachiocephalic artery. For this patient, PTA followed by stent placement was performed for the right subclavian and brachiocephalic artery stenosis. Because arterial stenosis is progressive in cases of aortitis syndrome, simple PTA alone does not appear to be sufficient for treatment. We suggest that PTA followed by stent placement may be an alternative treatment for recurrent stenosis in aortitis syndrome.
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Affiliation(s)
- M Nomura
- Department of Neurosurgery, Kanazawa University School of Medicine, 13-1 Takara-machi, Kanazawa 920-8641, Japan
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Sharma S, Bahl VK, Saxena A, Kothari SS, Talwar KK, Rajani M. Stenosis in the aorta caused by non-specific aortitis: results of treatment by percutaneous stent placement. Clin Radiol 1999; 54:46-50. [PMID: 9915510 DOI: 10.1016/s0009-9260(99)91239-4] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
AIM To evaluate the short-term results of percutaneous stent placement in treating stenosis in the aorta caused by non-specific aortitis (Takayasu's disease). METHOD Five patients were treated by this method, all of whom had uncontrolled hypertension, haemodynamically significant stenosis in the aorta and a clinically inactive disease. Stents were placed to treat an obstructing dissection in four and recurrent stenosis in one patient. All procedures were carried out via the percutaneous transfemoral route, utilizing self-expanding stents. RESULTS The lesion was located in the thoracic aorta in three patients and in the abdominal aorta in two patients. The stenosis decreased from 81+/-2 to 7+/-3%, the pressure gradient fell from 97+/-5 to 9+/-2 mmHg, the blood pressure improved from 200+/-3/124+/-2 to 131+/-2/81+/-2 mmHg, and the drug requirement fell from 4+/-.2 to 1.3+/-.3 (P value for all <0.001). No complication was encountered. At follow-up at 13+/-4 months, all of the patients had improved clinically. Intimal hyperplasia within the stent was seen in two patients who underwent follow-up angiograms. CONCLUSION Percutaneous aortic stenting is useful in treating selected patients with non-specific aortitis. Further information about the long-term behaviour of intimal hyperplasia and the response of stented segments to the aging process needs to be understood before elective stenting in this young patient population can be advocated.
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Affiliation(s)
- S Sharma
- Department of Cardiovascular Radiology, All India Institute of Medical Sciences, New Delhi
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