Early and long-term results of subclavian angioplasty in aortoarteritis (Takayasu disease): comparison with atherosclerosis

Severe aortic valve regurgitation in patient with Takayasu arteritis: a case report

Background

Takayasu arteritis (TAK) is a systemic non-inflammatory vasculitis that primarily affects large- and medium-sized arteries.

Case summary

We report the case of a 57-year-old woman with a history of coronary artery bypass grafting (CABG) 7 years prior, who was referred for a stress echo due to chest pain. Transthoracic echocardiography revealed the left ventricle at the upper limits of normal with preserved contractility, as well as circumferential thickening of the aortic root, causing severe aortic regurgitation (AR). Cardiac computed tomography and angiography demonstrated diffuse thickening of the aortic wall from the aortic root to the descending thoracic aorta, extending to the left carotid artery and significant stenosis of the left subclavian artery. Coronary angiography showed severe narrowing of the left main coronary ostium with ostial stenosis and total occlusion of the right coronary and left internal mammary arteries. Magnetic angiography highlighted thickening of the aortic wall, while no active inflammation was detected on positron emission tomography. These findings suggested Takayasu aortitis with chronic inflammation.

Discussion

In young patients, particularly women, who present with angina and coronary ostial stenosis, Takayasu arteritis should be considered in the differential diagnosis. Aortic regurgitation (AR) is a serious complication, and its surgical management can be challenging.

Drug-Coated Balloon Angioplasty for Carotid Artery Occlusion Caused by Takayasu Arteritis

A 27-year-old male patient suffering from dizziness and right amaurosis was diagnosed with Takayasu arteritis (TA). Computed tomography angiography showed that all the supra-aortic arteries were occluded except an aberrant right subclavian artery. The patient underwent drug-coated balloon dilatation at the lesion of the right common carotid artery and performed well after the procedure. Six months later, the patient's symptoms have not recurred and computed tomography angiography showed the right carotid artery remains patency. The supra-aortic artery lesions in TA may be a potential novel indication for a drug-coated balloon.

Intervention in Takayasu Aortitis: When, Where and How?

Takayasu arteritis is a large vessel vasculitis which commonly affects the aorta and its major branches. Active arterial inflammation is characterised by the presence of T and B lymphocytes, natural killer cells, macrophages and occasional multinucleate giant cells. Uncontrolled vascular inflammation can progress to cause arterial stenosis, occlusion or aneurysmal dilatation. Medical treatment involves combination immunosuppression and more recently biologic therapies targeting TNF-α and IL-6. Due to the typical delays in diagnosis and accumulation of arterial injury, open and endovascular surgical intervention are important and potentially life-saving treatment options for Takayasu arteritis. Common indications for surgery include aortic coarctation and ascending aortic dilatation ± aortic valve regurgitation, renal artery stenosis, ischaemic heart disease, supra-aortic disease, mesenteric ischaemia, severe limb-threatening claudication and aneurysm repair. Surgical outcomes are markedly improved in patients with clinically inactive disease and those who receive adequate periprocedural immunosuppression. Decisions regarding surgical approaches are best made as part of a multi-disciplinary team.

Management of Takayasu arteritis: a systematic literature review informing the 2018 update of the EULAR recommendation for the management of large vessel vasculitis

Objective

To collect available evidence on management of large vessel vasculitis to inform the 2018 update of the EULAR management recommendations.

Methods

Two independent systematic literature reviews were performed, one on diagnosis and monitoring and the other on drugs and surgical treatments. Using a predefined PICO (population, intervention, comparator and outcome) strategy, Medline, Embase and Cochrane databases were accessed. Eligible papers were reviewed and results condensed into a summary of findings table. This paper reports the main results for Takayasu arteritis (TAK).

Results

A total of 287 articles were selected. Relevant heterogeneity precluded meta-analysis. Males appear to have more complications than females. The presence of major complications, older age, a progressive disease course and a weaker inflammatory response are associated with a more unfavourable prognosis. Evidence for details on the best disease monitoring scheme was not found. High-quality evidence to guide the treatment of TAK was not found. Glucocorticoids are widely accepted as first-line treatment. Conventional immunosuppressive drugs and tumour necrosis factor inhibitors were beneficial in case series and uncontrolled studies. Tocilizumab failed the primary endpoint (time to relapse) in a randomised controlled clinical trial; however, results still favoured tocilizumab over placebo. Vascular procedures may be required, and outcome is better when performed during inactive disease.

Conclusions

Evidence to guide monitoring and treatment of patients with TAK is predominantly derived from observational studies with low level of evidence. Therefore, higher-quality studies are needed in the future.

Revascularization of Remaining Branch of Aorta in Advanced Takayasu Arteritis Protects Against Wide Range of Perfusion

BACKGROUND

Stroke is a major factor of morbidity in the patients with Takayasu arteritis (TA). Restenosis is more common with endovascular intervention than after bypass surgery, but vascular anastomosis is difficult due to calcification involving the whole thickness of the arterial wall in the burned-out stage of TA. We report a case of advanced TA in which endovascular treatment of the left subclavian artery improved cerebral blood flow (CBF) over a wide range of perfusion in the posterior and anterior circulation.

CASE DESCRIPTION

During medical treatment for TA, a 57-year-old male patient gradually developed ischemic symptoms of both upper limbs and dizziness. Angiography showed occlusion of the brachiocephalic artery and severe stenosis of the left common carotid artery and left subclavian artery. Preoperative single-photon emission computed tomography revealed reductions in the resting CBF and vascular reactivity in the area of the carotid artery and vertebral basilar artery. Chest computed tomography showed calcification of the aortic arch and its branches, and this advanced diffuse calcification indicated probable difficulties in bypass surgery. Therefore we performed percutaneous transluminal angioplasty and stenting for the left subclavian artery. Postoperative single-photon emission computed tomography showed increases in resting CBF in the area of the bilateral internal carotid artery, as well as the vertebrobasilar artery. The patient's various ischemic symptoms improved significantly.

CONCLUSIONS

As collateral circulation is common in advanced TA, the ischemic area is large when the remaining proximal large vessels are occluded. Therefore revascularization of the remaining branch of the aorta in advanced TA may protect against a wide range of perfusion.

Aortitis and aortic aneurysm in systemic vasculitis

The term "large-vessel vasculitis" refers to chronic inflammation affecting the elastic arteries, mainly aorta and its major branches. Large-vessel vasculitis affecting the aorta is termed as "aortitis." This leads to diffuse wall thickening, loss of elasticity, stenosis, occlusion, dissection, calcification or aneurysm formation. Vasculitis involving the aorta includes Takayasu arteritis (commonest large-vessel vasculitis in India), giant cell arteritis (GCA), the periaortitis spectrum (including inflammatory abdominal aortic aneurysm), rheumatic diseases and IgG4-related disease. It is important for physicians to be aware of the aortic manifestations of common vasculitis-so that clinically relevant aortic involvement is not missed. Also, it is equally important for surgeons to keep in mind that aortic aneurysms can have an inflammatory aetiology. The primary reason for this is the central role that immunosuppressive therapy plays in the management of inflammatory aortic aneurysms. Surgical or percutaneous interventions, when needed, are most likely to succeed when performed after activity control; perioperative steroids may be beneficial in select cases, and postoperative disease activity control is imperative.

Takayasu's arteritis: a review of the literature and the role of endovascular treatment

Takayasu's arteritis (TA) is a chronic non-specific vasculitis with variable presentation in different ethnicities and countries. Treatment options vary and are dependent on the stage and presentation of the disease. We aimed to review current literature related to TA, focusing on the role of endovascular treatment in revascularisation. The temporal course of the disease and stage at presentation influence the management of TA. Treatment options include medical therapy, endovascular intervention or surgical vascular reconstruction. The decision to intervene is individualised according to vascular anatomy and the presence of haemodynamically significant lesions. There are currently no clear guidelines regarding the choice between the endovascular and open surgical approaches, but studies have shown that endovascular procedures are associated with slightly higher rates of restenosis while surgical procedures have higher rates of thrombosis. Periprocedural immunosuppression is suggested if the disease is active at the point of intervention. This improves outcomes but at the cost of immunosuppression-related side effects. Careful long-term follow-up is essential due to the risk of disease activation or flare-up, requiring appropriate evaluation of the diseased vessels.

Surgical intervention and its role in Takayasu arteritis

Vascular surgery remains an important option in the management of Takayasu arteritis (TA). Its use is predominantly confined to the treatment of symptomatic organ ischaemia or life-threatening aneurysm formation. In most cases, this follows the failure of medical therapy to prevent arterial injury. Open surgery and endovascular approaches are used. The choice between them, at least in part, is determined by the site and nature of the lesion. Open surgery, although more invasive, offers enhanced duration of arterial patency, whereas for endovascular intervention, primary angioplasty without stenting is preferred, with stenting reserved for primary or secondary angioplasty failures. Although there is increasing interest in the role of stent grafts and tailor-made endovascular stents, long-term outcomes remain to be reported. Interventional outcomes are improved and complications reduced by therapeutic control of disease activity before and after surgery. The wider use of combined immunosuppression and the introduction of biologic therapy for refractory TA may reduce future requirements for surgical intervention.

Rheumatology science and practice in India

The practice of rheumatology in a country like India presents its own unique challenges, including the need to manage patients in a cost-constrained setting, where the lack of uniform government funding for healthcare merits the need to optimize the use of cheaper medicines, as well as devise innovative strategies to minimize the use of costlier drugs such as biologic disease-modifying agents. Use of immunosuppressive agents is also associated with increased risks of infectious complications, such as the reactivation of tuberculosis. In this narrative review, we provide a flavor of such challenges unique to Rheumatology practice in India, and review the published literature on the management of common rheumatic diseases from India. In addition, we critically review existing guidelines for the management of rheumatic diseases from this part of the world. We also discuss infectious etiologies of rheumatic complaints, such as leprosy, tuberculosis, and Chikungunya arthritis, which are often encountered here, and pose a diagnostic as well as therapeutic challenge for clinicians. There remains a need to identify and test more cost-effective strategies for Indian patients with rheumatic diseases, as well as the requirement for more government participation to enhance scant facilities for the treatment of such diseases as well as foster the development of healthcare services such as specialist nurses, occupational therapists and physiotherapists to enable better management of these conditions.

Restoration of vision by endovascular revascularization in Takayasu arteritis: A case series

Takayasu arteritis (TA) is a rare, inflammatory vasculitis affecting aorta and its branches. Stenotic occlusive lesions of multiple arch arteries can cause severe cerebral ischemia leading to impaired vision. We present three consecutive young patients of TA with severe diminution of vision on upright posture, where we attempted restoration of sight by improving cerebral blood flow by percutaneous endovascular revascularization. All three patients could be successfully revascularized with substantial improvement in vision. There was no complication. On follow up, one patient developed recurrence of visual symptoms due to restenosis, which was successfully treated by cutting balloon angioplasty. The objective of this case series is to highlight the role of endovascular techniques in reversing visual loss in such situations. <Learning objective: Takayasu arteritis (TA) is an inflammatory vasculitis that can affect arch arteries leading to near complete obliteration and often disabling symptoms such as loss of vision. This case series (3 cases) shows that stent-supported angioplasty is a minimally invasive technique which is safe and effective in restoring impaired vision caused by severe cerebral hypoperfusion in TA.>.

Takayasu arteritis in paediatrics

Takayasu arteritis is an idiopathic chronic granulomatous panarteritis predominantly affecting the aorta and its main branches. Although idiopathic, genetic contribution to disease susceptibility is being increasingly recognised. Rare in children, Takayasu arteritis is a worldwide disease with significant morbidity and mortality. Its diagnosis is a challenge and requires awareness of the condition as clinical features at presentation are non-specific and assessing disease activity is difficult. In the inflammatory stage, treatment is essential to prevent the insidious course and vascular damage: stenotic, occlusive lesions, aneurysms, and aortic regurgitation. New imaging modalities, such as CT scan, MRI, and 18F-fluorodeoxyglucose positron emission tomography, have expanded the possibilities for non-invasive diagnosis and monitoring; however, digital subtraction arteriography remains the gold standard for the diagnosis of Takayasu arteritis. Steroids are the first-line medical treatment. The combined use of methotrexate, cyclophosphamide, azathioprine, mycophenolate mofetil, and biological agents is common. Revascularisation therapy should be considered in uncontrolled hypertension secondary to renal artery stenosis, symptomatic coronary ischaemia, cerebrovascular disease, severe aortic regurgitation, limb ischaemia, and aneurysms at risk of rupture, using surgical or endovascular procedures and taking into consideration that complications, especially restenosis, are frequent. Disease activity increases the likelihood of complications after revascularisation. Surgical intervention has shown better long-term outcomes, although the endovascular approach is evolving. The aim of this review was to describe key points of the diagnosis, treatment, and follow-up of Takayasu arteritis in childhood.

Endovascular balloon angioplasty versus stenting in patients with Takayasu arteritis: A meta-analysis

BACKGROUND

Symptomatic or significant vascular lesions of Takayasu arteritis (TA) need interventions. Although percutaneous transluminal angioplasty with balloon is a less invasive and safe method, stent implantation in TA can be an alternative option. However, superiority between balloon angioplasty and stenting in TA is not conclusive.

METHODS

A meta-analysis comparing balloon angioplasty and stenting outcomes was performed using the MEDLINE and EMBASE databases.

RESULTS

A total of 7 studies on 266 patients and 316 lesions were included. Balloon angioplasty was performed in 186 lesions and stenting in 130 lesions. There were no significant differences in the incidence of both restenosis and other complications between balloon angioplasty and stenting [odds ratio (OR) = 2.39, 95% confidence interval (CI) = 0.66-8.66, P = .18; OR = 1.80, 95% CI = 0.49-6.65, P = .38, respectively]. In the renal arteries, the risk of restenosis in stenting was significantly higher than that in balloon angioplasty (OR = 4.40, 95% CI = 2.14-9.02, P < .001). The clinical efficacy of improving renal hypertension between balloon angioplasty and stenting at the renal artery lesions was similar (OR = 0.65, 95% CI = 0.28-1.51, P = .31); however, acute vascular complications were significantly fewer in stenting than in balloon angioplasty (OR = 0.07, 95% CI = 0.02-0.29, P < .001).

CONCLUSION

This meta-analysis found that balloon angioplasty can yield better results in renal artery interventions than stenting. Nonetheless, it is desirable to avoid vessel dissections during balloon angioplasty, which can eventually require stent implantations.

Longterm Outcomes of Renal Artery Involvement in Takayasu Arteritis

OBJECTIVE

Takayasu arteritis (TA) involving the renal artery can result in hypertension (HTN), renal dysfunction, and premature death. The aim of this study was to investigate the longterm outcomes and factors that predict outcomes in patients with TA with renal artery stenosis.

METHODS

The medical records of patients diagnosed with TA between January 1997 and December 2014 were reviewed retrospectively. Renal artery involvement was based on computed tomography and/or angiography findings. Poor outcome was defined as refractory HTN, chronic renal insufficiency, or death.

RESULTS

Of the 62 TA patients with renal artery involvement, 11 (17.7%) underwent renal artery revascularization. Younger age, male sex, and more severe stenosis (> 70%) were associated with vascular intervention. After a median followup of 90.6 months, 11 (17.7%) of the 62 patients had refractory HTN and 6 (9.7%) had chronic renal insufficiency. Renal insufficiency [5/15 (33.3%) vs 3/47 (6.4%), p = 0.016] and bilateral involvement [12/15 (80.0%) vs 23/47 (48.9%), p = 0.041] were significantly more frequent in patients with poor than good outcomes. Multivariate Cox analysis revealed that renal insufficiency at presentation (HR 13.778, 95% CI 3.530-53.786, p < 0.001) and bilateral renal artery involvement (HR 5.053, 95% CI 1.179-21.661, p = 0.029) were significant risk factors for poor outcomes at followup, but performance of revascularization procedure was not (HR 0.663, 95% CI 0.176-2.498, p = 0.543).

CONCLUSION

Bilateral lesions and renal functional impairment at presentation, but not implementation of revascularization procedures, were significant factors for outcomes in TA patients with renal artery involvement.

Updates in Pathophysiology, Diagnosis and Management of Takayasu Arteritis

BACKGROUND

Takayasu arteritis (TA) is a rare, systemic, inflammatory vasculitis of granulomatous nature, and still of unknown etiology. It mainly involves the aorta and its major branches and is more commonly seen in women of childbearing age and Asians. TA leads to stenosis, occlusion, or aneurysmal degeneration of large arteries, and its pathogenesis seems to be mainly due to an abnormal cell-mediated immunity, although other molecular and genetic abnormalities may contribute. The diagnosis and treatments lie on clinical and arteriographic findings. Because of its fluctuating course, both clinical scores and biomarkers are currently evaluated. The aim of this review is to report a comprehensive and methodologically robust state of the art about Takayasu arteritis, including the latest data and evidences in the definition, epidemiology, pathogenesis and etiology, clinical manifestations and classification, diagnosis, assessment of disease activity and progression, biomarkers, and treatment.

METHODS

We searched all publications addressing definition, epidemiology, pathogenesis, etiology, classification, diagnosis, biomarkers, and treatment of TA. Randomized trials, cohort studies, and reviews were contemplated to give a breadth of clinical data. PubMed and Scopus were searched from August 2010 to November 2015.

RESULTS

Of the 3,056 records found, 267 matched our inclusion criteria. After reading the full-text articles, we decided to exclude 169 articles because of the following reasons: (1) no innovative or important content; (2) no multivariable analysis; (3) insufficient data; (4) no clear potential biases or strategies to solve them; (5) no clear end-points; and (6) inconsistent or arbitrary conclusions. The final set included 98 articles.

CONCLUSIONS

This review presents the last updates in all fields of Takayasu arteritis. Still today, large areas of TA pathogenesis and disease-activity assessment need to be further investigated to better treat patients with TA.

Percutaneous Angioplasty of the Sole Patent Cerebral Artery in Two Patients with Takayasu's Aortoarteritis

We report two female patients with Takayasu’s aortoarteritis, who presented with symptoms of cerebral ischemia due to critical stenosis of the sole patent cerebral artery. Both had occlusion of both vertebral arteries and one carotid artery with critical stenosis of the other carotid artery and presented with hemiparesis contralateral to the patent but stenosed cerebral artery. They also had transient ischemic attacks attributable to the culprit vessel. In the first patient, balloon angioplasty alone was not successful, and hence, a self-expanding stent was deployed in the right common carotid artery. In the second patient, successful balloon angioplasty was performed for the left common carotid artery. Distal protection devices were not used, and neither patient experienced any periprocedural neurological event. Clinical follow-up at six months revealed no significant cerebral events.

Stent placement for treatment of long-segment (≥40 mm) carotid atherosclerotic stenosis: results and long-term follow-up in a single-center experience

BACKGROUND

Treatment of long segment carotid stenosis (≥40 mm) with carotid artery stenting (CAS) has rarely been reported. In randomized trials, use of longer stents (>40 mm) has been associated with adverse clinical events. Here, we report our preliminary experience on the stent length and outcome in treating long segment carotid arterial stenosis.

METHODS AND RESULTS

Between August 2003 and February 2013, 22 patients with long segment stenosis of the carotid artery were treated by CAS. The mean stent length was 58.5 mm (50-60 mm). The procedures were successful in all patients, and all reported remarkable relief of symptoms immediately after stent placement. Complications included 1 case of cerebral hemorrhage and one death from myocardial infarction at 10 months. The mean follow up was 27.3 months (10-60 months). One follow-up was lost. 2 patients had late stent thrombosis at 22 and 36 months by CTA follow-up. 18 patients had persistent relief, and angiography/CTA showed normal carotid flow.

CONCLUSIONS

Our study showed that stenting for long carotid stenosis (≥40 mm) can be beneficial. Large scale clinical trial is needed to further evaluate its efficacy and safety.

Optimizing the outcome of vascular intervention for Takayasu arteritis

Background

Takayasu arteritis (TA) predisposes to the development of arterial stenoses and aneurysms, and is associated with considerable morbidity and mortality amongst young patients. The aims of this study were to analyse indications and outcomes of surgical intervention, and to assess the potential benefits of immunosuppression and the use of perioperative imaging.

Methods

This was a retrospective review of patients with TA referred between 2001 and 2012.

Results

A series of 97 patients with TA, seen at a single tertiary centre, is reported. Immunosuppression was required in 87 patients (90 per cent). Thirty-seven (38 per cent) underwent 64 procedures: 27 patients underwent 33 open surgical procedures and 20 patients had 31 endovascular procedures. After a median follow-up of 6 years, the overall success rate was 79 per cent for open surgery (mean graft patency 9·4 years) and 52 per cent for endovascular procedures (P = 0·035). Procedural failure was significantly reduced in patients receiving preoperative immunosuppression, and particularly endovascular procedures (P = 0·001). In addition to clinical examination and measurement of acute-phase reactants, combination non-invasive imaging including Doppler ultrasonography, [18F]fluorodeoxyglucose combined positron emission and computed tomography (CT), magnetic resonance angiography and CT angiography was used to identify arterial lesions, establish the diagnosis and monitor treatment outcomes.

Conclusion

Outcomes of vascular intervention in TA may be improved by detailed preoperative assessment including measurement of disease activity, and by ensuring optimal immunomodulatory therapy before and after the procedure.

Takayasu arteritis: criteria for surgical intervention should not be ignored

Takayasu aortoarteritis is a rare, chronic granulomatous panarteritis with significant morbidity amongst young patients. Current challenges include a lack of awareness about the condition, delays in diagnosis due to its varied presentation, and suboptimal methods for assessing disease activity. The development of noninvasive imaging including magnetic resonance angiography and positron emission tomography is aiding earlier diagnosis. Early initiation of immunosuppressive treatment is crucial to control active inflammation and minimize arterial injury. Recent studies investigating biological agents such as tumour necrosis factor-α antagonists are encouraging. Surgical revascularization should only be undertaken following careful consideration, as restenosis is common. The indications for considering intervention include uncontrolled hypertension due to renal artery stenosis, severe symptomatic coronary artery or cerebrovascular disease, severe aortic regurgitation, stenotic or occlusive lesions resulting in critical limb ischemia, and aneurysms at risk of rupture. In these cases, the risk benefit ratio for intervention is good. Open surgery, at present, has better outcomes compared to endovascular techniques. However, technological advances in endovascular treatment are continually improving. Controlling disease activity prior to and following revascularization is key to preventing complications. A multidisciplinary approach to the diagnosis and management of Takayasu arteritis is essential to achieve satisfactory patient outcomes.

Endovascular revascularization of bald aortic arch for severe cerebral ischemia

Takayasu arteritis is a rare form of chronic, inflammatory arteriopathy affecting the aorta and its major branches. Obstructive lesions of all arch vessels lead to ischemic brain symptoms. There is very limited experience of endovascular revascularization in this situation. We report case of a female patient with potentially life threatening cerebral ischemic symptoms due to extra-cranial occlusion of all arch arteries. Stent supported angioplasty of brachiocephalic, right common carotid and right subclavian artery was successfully performed. This improved her cerebral blood flow and relieved her severe, disabling neurologic symptoms.

Successful tocilizumab treatment in a child with refractory Takayasu arteritis

Takayasu arteritis (TA) in the child remains a therapeutic challenge because corticosteroids and conventional immunosuppressive agents are not always safe or efficacious. The complex formed by interleukin-6 (IL-6) and soluble IL-6 receptor appears to play a pivotal role in the pathogenesis of TA. We describe a favorable response to the anti-IL-6 receptor antibody tocilizumab (TCZ) in a child with aggressive and refractory TA including an assessment of the proinflammatory cytokine profile. A 3-year-old girl with TA consisting of thickening of the aortic arch wall, severe obstruction of the supra-aortic branches, and complete occlusion of both common carotid arteries failed to respond to corticosteroids, methotrexate, tumor necrosis factor α blockade, cyclophosphamide, and mycophenolate mofetil, and 3 years later, the disease remained active with severe manifestations (brain ischemia). The patient underwent percutaneous angioplasty, although significant restenosis was soon documented. After a severe relapse, the patient started TCZ infusions (8 mg/kg for 2 weeks), and a rapid clinical remission was observed, associated with a drastic reduction of inflammatory markers and IL-6 levels. Corticosteroids were withdrawn, the patient's weight and height improved, and bone mineral density values returned to normal. Two years later, TCZ infusions were extended, with no significant side effects. Cerebral ischemia resolved, and recanalization of the previously occluded supra-aortic branches was performed.

Stent placement for treatment of long segment (≥80 mm) carotid artery stenosis in patients with Takayasu disease

PURPOSE

To evaluate the effectiveness and safety of carotid artery stent (CAS) placement for treatment of long segment stenosis in patients with Takayasu arteritis.

MATERIALS AND METHODS

Between January 2002 and February 2012, all patients with Takayasu arteritis found to have long segment (≥80 mm) carotid artery stenoses at a single institution were retrospectively analyzed. Five patients treated by CAS placement with either long or multiple self-expandable stents were included. All patients had focal neurologic symptoms, including three strokes and two transient ischemic attacks (TIAs). Six self-expanding stents were used in five patients. The mean follow-up period was 19.2 months (range, 6-30 mo); all patients had clinical evaluation, laboratory examination, and vascular imaging follow-up.

RESULTS

Improvement in clinical symptoms was shown after successful angioplasty. There were no perioperative or in-hospital deaths. Four patients exhibited persistent relief, and repeated angiography or computed tomography (CT) angiography showed normal flow. One patient stopped taking her medications after CAS placement and became symptomatic 8 months later as a result of a severe in-stent stenosis.

CONCLUSIONS

CAS placement was shown to be a feasible option for treating long segment (≥80 mm) stenosis of carotid arteries in patients with Takayasu arteritis with encouraging results.

Single stage multiple stenting in Takayasu's arteritis. Case report

A 32-year-old Filipino female presented with Takayasu's arteritis manifesting as an abrupt onset of syncope. Physical examination revealed diminished consciousness, right hemiparesis, and a large discrepancy in blood pressure between the upper and lower extremities. Magnetic resonance imaging revealed cerebral infarcts in the left basal ganglia and the left temporal lobe. Angiography revealed complete occlusion of the left common carotid artery and severe stenosis of the brachiocephalic artery, the right common carotid artery, and the left subclavian artery. Based on the clinical examination and studies, the diagnosis was Takayasu's arteritis, type I. The patient's condition stabilized after 2 months of prednisone and anti-platelet therapy. Single stage multiple stenting in the brachiocephalic artery, the right common carotid artery, and the left subclavian artery was then performed using high pressure inflation to dilate the arteries due to the remarkably rigid lesions that resulted from extensive and diffuse fibrosis throughout the vessel walls. Although a small intimal flap occurred during inflation of the left subclavian artery, re-dilation was possible with the stent. Even with evidence of notable recovery in blood pressure and cerebral blood flow, no further neurological improvement was observed. In view of the favorable short- and intermediate-term results, single stage multiple stenting may be the optimum treatment option for first-line stent-supported angioplasty in patients with Takayasu's arteritis.

Subclavian and vertebral arterial interventions

Endovascular treatment of supra-aortic atherosclerotic arterial stenoses and occlusions using percutaneous transluminal angioplasty (PTA) and stent placement is an accepted first-choice procedure. Technical success, primary success, and midterm patency after PTA and stent placement for the treatment of stenosed or obstructed brachiocephalic arteries are promising and complication rates are low. Permanent miniaturization and device improvement makes treatment of atherosclerotic obstructive disease by endovascular means in brachial and cephalic arteries a safe procedure showing promising midterm patency rates.

Outcomes after endovascular treatment of symptomatic patients with Takayasu's arteritis

We report our experience with endovascular treatment of supra-aortic arteries and follow-up results in patients with Takayasu's arteritis (TA) presenting with neurological symptoms. Of the 20 patients with TA who underwent cerebral angiography for neurological manifestations between May 2002 and May 2009, 12 (11 females, one male; mean age, 39 years; range 31-56 years) underwent endovascular treatment and evaluated outcome for 21 lesions, including nine common carotid arteries, four vertebral arteries, four subclavian arteries, two internal carotid arteries, and one brachiocephalic artery. Eight patients underwent multiple endovascular procedures for different lesions in single or multiple stages. Mean angiographic and clinical follow-up durations were 34 months (range, 11-79 months) and 39 months (range 11-91 months), respectively. Technical success was achieved for 20 procedures in 11 patients. One procedure failed, with 50% residual stenosis after stenting due to dense calcification of vessel walls. There were no procedure-related complications. Restenosis occurred at two lesions in two patients were treated by re-stenting. Asymptomatic occlusion occurred at two lesions in one patient. Ten patients remained in 0-1 on the modified Rankin scale (mRs) during mean 39 months. One patient, however, had a score of 3 on mRs due to a traumatic contusion during follow-up. One patient died from cardiac failure 36 months after successful angioplasty.Our data suggest that endovascular treatment of symptomatic supra-aortic lesions of TA is effective and durable in selected patients with neurologic symptoms.

Cardiovascular manifestations of Takayasu arteritis and their relationship to the disease activity: analysis of 204 Korean patients at a single center

Takayasu's arteritis (TA) is primary vasculitis. Cardiac involvements in TA is due to the consequences of the vascular lesions as well as the primary pathology of the heart. The disease activity of TA is known to influence the prognosis of TA. We hypothesized that the cardiovascular involvement of TA is related to the disease activity. We evaluated the cardiovascular manifestations of TA, and we assessed their relation to the disease activity of TA. Two hundred four patients were diagnosed with TA from September, 1994 to March, 2009 according to the diagnostic criteria of the 1990 American College of Rheumatology. Their clinical features and the laboratory, angiographic and echocardiographic findings were retrospectively reviewed. The group with active disease activity was defined as satisfying one of the following criteria: i) an elevated ESR or CRP level, ii) thickened arterial wall with mural enhancement on CT or MR angiography, and iii) carotidynia at the time of the initial diagnosis. One hundred thirty nine patients (69.2%) were classified as the active group. The cardiovascular signs and symptoms were not generally different between the active and inactive groups. The active TA patients had more frequent involvement of the ascending aorta and the aortic arch and its main branches than did the inactive group. The active group showed a higher incidence of significant aortic valve regurgitation and pulmonary hypertension, and a higher level of NT-proBNP. These findings suggest that disease activity plays an important role for the cardiovascular manifestations of TA. The TA patients with higher activity have more cardiovascular morbidity compared to the TA patients with low disease activity.

Takayasu arteritis--advances in diagnosis and management

Takayasu arteritis, a rare granulomatous vasculitis affecting young people, is associated with considerable morbidity and premature mortality. In most patients the diagnosis is delayed until after the development of substantial arterial injury. Studies of noninvasive imaging techniques suggest that these approaches might facilitate earlier diagnosis and have a role in monitoring disease progress; however, they remain limited in their ability to accurately quantify inflammatory disease activity in the arterial wall. A lack of controlled clinical trial data complicates the choice of therapy for Takayasu arteritis, and clinical indices for monitoring disease activity are currently suboptimal. Increasing knowledge of the pathogenesis of the large vessel vasculitides might eventually lead to novel targeted therapies. Preliminary data from open-label trials of anti-tumor necrosis factor therapy are encouraging, but there is an urgent need for controlled clinical trials to establish optimum therapeutic approaches for this disease. These trials should include a prospective assessment of the use of noninvasive imaging modalities in the diagnosis and subsequent management of Takayasu arteritis.

Takayasu arteritis in France: a single-center retrospective study of 82 cases comparing white, North African, and black patients

We conducted a single-center retrospective study to compare the characteristics of Takayasu arteritis (TA) among white, North African, and black patients in a French tertiary care center (Hospital Pitié-Salpêtrière, Paris). Eighty-two patients were studied (82.9% female) during a median follow-up of 5.1 years (range, 1 mo to 30 yr). Among these 82 patients, 39 (47.6%) were white, 20 (24.4%) were North African, and 20 (24.4%) were black patients. Median age at diagnosis was 39.3 years (range, 14-70 yr) in white patients vs. 28.4 years (range, 12-54 yr) in North African (p = 0.02), and 28.0 years (range, 13-60 yr) in black patients (p = 0.08). Patients aged >40 years at TA onset were more frequently white than non-white (40.0% vs. 18.6%, p = 0.03). North African patients had more frequent occurrence of ischemic stroke (p = 0.03) and poorer survival (p = 0.01) than white patients. Type V of the Hata classification was the most frequent type among white (38.5%), North African (65.0%), and black patients (40.0%). Corticosteroids were used in 96.1% of patients. Fifty-three percent of white and North African patients, and 44% of black patients required a second line of immunosuppressive treatment (p = 0.60). Vascular surgical procedures were respectively performed in 46.1%, 50.0%, and 55.0% of white, North African, and black patients, p = 0.81. The 5-year and 10-year survival rates were 100% and 95.0%, respectively, in white patients; 67.4% at both 5 years and 10 years in North African patients; and 100% at both 5 years and 10 years in black patients. This study is one of the first direct comparisons of TA profiles among patients of distinct ethnic backgrounds. Our data support the idea that late-onset TA or an overlap between TA and large-vessel giant cell arteritis may be observed in white patients. North African patients have a higher occurrence of ischemic stroke and poorer survival than white patients.

Percutaneous transluminal angioplasty and stenting for pulmonary stenosis due to Takayasu's arteritis: clinical outcome and four-year follow-up

BACKGROUND

Percutaneous transluminal angioplasty and stent implantation for stenotic lesions of renal arteries and other branches of the aorta in Takayasu's arteritis have been reported to show good outcomes. However, this form of therapy has been reported in few cases with pulmonary artery involvement.

HYPOTHESIS

The aim of this study was to evaluate the role of this interventional treatment for pulmonary stenosis due to Takayasu's arteritis.

METHODS

A total of 4 patients (3 female and 1 male, ages 30-40 yrs) with Takayasu's pulmonary arteritis underwent percutaneous transluminal balloon angioplasty and stent implantation and were followed up for 1 to 4 years.

RESULTS

One patient underwent balloon angioplasty alone, 3 patients underwent balloon angioplasty and stent implantation. The stenoses were relieved acutely, oxygen saturation improved immediately due to improvement in lung perfusion and relief of dyspnea. The pressure gradient fell from 58.3 +/- 8.7 mm Hg to 14 +/- 3.2 mm Hg and mean pulmonary arterial pressure decreased from 48.5 +/- 12.0 mm Hg to 37.3 +/- 6.0 mm Hg. At a follow-up period of 34.5 +/- 15.8 months, the patient with balloon angioplasty alone developed a recurrence of symptoms 18 months after the procedure. The other 3 patients continued to be asymptomatic and the stent remained patent without restenosis after the procedure.

CONCLUSION

Percutaneous transluminal angioplasty and stent implantation is a safe and effective treatment in patients with pulmonary stenosis caused by Takayasu's arteritis.

[Large-vessel vasculitis. Imaging and interventional therapy]

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

Progressing takayasu arteritis successfully treated by common carotid-internal carotid crossover bypass grafting: technical case report

OBJECTIVE

This report describes a unique case of Takayasu arteritis with occlusion of the left common carotid artery (CCA) and the right internal carotid artery (ICA), which was successfully treated by right CCA-left ICA crossover bypass grafting using the saphenous vein. The histological findings of the original occluded prosthetic graft are also described.

CLINICAL PRESENTATION

A 63-year-old woman with a history of Takayasu arteritis was admitted to our hospital with a history of progressive dizziness, frequent syncopal attacks, and repetitive blurred vision in the left eye. She had undergone repeat transthoracic bypass surgeries, including grafting with the use of a Gore-Tex (W.L. Gore & Associates, Inc., Flagstaff, AZ) prosthesis between the left external ilioaxillary bypass and the left CCA. However, cerebral angiography demonstrated total occlusion of the left CCA, the right ICA, and the bilateral subclavian arteries. On admission, I-iodoamphetamine single-photon emission computed tomography showed a decreased cerebrovascular reactivity to acetazolamide in the bilateral cerebral hemispheres. Moreover, cerebral angiography revealed an occlusion of the Gore-Tex graft, whereas the left ICA was opacified through the retrograde filling in the left external carotid artery.

INTERVENTION

Crossover bypass grafting was performed using the saphenous vein between the right CCA and the left ICA. The Gore-Tex graft was partially removed, and myointimal hypertrophy with an inflammatory response around the wall was found histologically. The postoperative course was uneventful. A normalized cerebrovascular reserve in both cerebral hemispheres was demonstrated on I-iodoamphetamine single-photon emission computed tomography.

CONCLUSION

Although it is not frequently indicated, crossover bypass grafting using the saphenous vein between bilateral carotid arteries is considered to be a feasible alternative procedure in patients with Takayasu arteritis.

Takayasu's disease: a review

Takayasu's disease is a rare chronic vasculitis of unknown aetiology. Initial symptoms and signs are non-specific, and a high index of suspicion is needed to make the correct diagnosis. The disease is associated with a high incidence of morbidity, and a significant risk of premature death. Serological tests have proved unreliable in distinguishing active from quiescent disease, with non-invasive imaging currently offering the best option for early diagnosis, and monitoring the response to treatment. In this review, we detail the epidemiology, pathophysiology, clinical features, imaging characteristics, and currently available treatments.