A successful surgical repair of pulmonary stenosis caused by isolated pulmonary Takayasu's arteritis

Pulmonary endarterectomy in patients with occlusive isolated pulmonary vasculitis

BACKGROUND

Isolated pulmonary vasculitis (IPV) is a rare, insidious, and localized inflammatory disease affecting the pulmonary arteries, often leading to severe luminal obstruction. The prognosis for patients with occlusive IPV is poor, and there is currently a lack of effective treatments. The objective of this study was to evaluate the performance of pulmonary endarterectomy (PEA) as a treatment for occlusive IPV.

METHODS

This single-center retrospective analysis included patients who received PEA for occlusive IPV between January 2018 and June 2022. Clinical characteristics and hemodynamic parameters were evaluated at baseline and follow-up.

RESULTS

Among 114 consecutive patients who underwent PEA, occlusive IPV was identified in 7 patients. Two patients underwent bilateral PEA for the involvement of both pulmonary arteries. Patch angioplasty was performed to treat four severe constrictions. One patient died from residual pulmonary hypertension after limited PEA of a transmural vascular lesion. In addition, no obvious surgical complications were observed. Three months after PEA, a substantial relief in symptoms was achieved. Also, there is a decrease in the mean pulmonary artery pressure (median 33 [20-48] mmHg before versus median 21 [16-26] mmHg after; P < 0.018) and pulmonary arterial resistance (median 234 [131-843] dyn.s.cm-5 versus median 180 [150-372] dyn.s.cm-5; P = 0.310). Three patients experienced a relapse of restenosis of the treated arteries within a 6-month follow-up period, despite daily oral prednisolone administration. They were treated with balloon pulmonary angioplasty of both the main pulmonary arteries and branches.

CONCLUSIONS

PEA is a valuable choice for treating occlusive IPV, with notable hemodynamic and clinical advantages. To increase long-term vascular patency, complete management should be optimized.

4D-flow MRI assessment of blood flow before and after endovascular intervention in a patient with pulmonary hypertension due to isolated pulmonary artery involvement in large vessel vasculitis

A 43-year-old woman presented with dyspnea during exertion and lower leg edema. Contrast-enhanced computed tomography images demonstrated extensive proximal narrowing in the right main pulmonary artery with thickening and enhancement. Right heart catheterization revealed the presence of precapillary pulmonary hypertension with a mean pulmonary arterial pressure of 45 mm Hg. The patient was diagnosed with large-vessel vasculitis with isolated pulmonary artery involvement. Takayasu's arteritis was suspected, but histological examination was not performed. Several sessions of pulmonary arterial intervention were stratified for the right main pulmonary artery. After treatment, mean pulmonary arterial pressure had decreased to 22 mm Hg with improvement in symptoms. Thoracic 4D-flow magnetic resonance imaging was performed before and after intervention to evaluate the volume flow rates of pulmonary arteries. The rates increased at the inlet of the right pulmonary artery (before: 23 mL/s vs after: 47.5 mL/s) and the main pulmonary artery (before: 71.2 mL/s vs after: 82.5 mL/s), and decreased at the inlet of the left pulmonary artery (before: 46.2 mL/s vs after: 31.7 mL/s). The split ratio of volume flow rate between the right and left pulmonary arteries improved after treatment (before. right:left = 33.1:66.9; after, right:left = 60.0:40.0), approaching normal values. This report quantitatively describes perioperative hemodynamic changes in a patient with pulmonary hypertension using 4D-flow magnetic resonance imaging. Stent placement for stenosis in the right pulmonary artery resulted in an increase in overall pulmonary blood flow and also improved blood flow balance between the right and the left pulmonary arteries.

Pitfalls in the management of isolated pulmonary Takayasu's arteritis after surgery: a case report of an experience during 34 months after a pulmonary artery graft replacement

Background

Several controversial matters still remain unresolved in the management of Takayasu’s arteritis, especially after vascular intervention. First, a definitive diagnostic tool has not been established to assess disease activity correctly. Second, the optimal medical regimen has not been established to prevent restenosis of the vascular lesion.

Surgical treatments have been rarely performed to relieve critical vascular stenosis in isolated pulmonary Takayasu’s arteritis, but their postoperative courses on long-term follow-up periods have not been sufficiently reported.

Case Presentation

A 48-year-old man underwent a successful graft replacement for severe right main pulmonary artery stenosis due to isolated pulmonary Takayasu’s arteritis. The patient had remained asymptomatic with no clinical inflammatory signs under adequate anticoagulation therapy since then. However, stenosis of the prosthetic graft accompanied by marked pulmonary hypertension was detected 18 months after surgery. Anti-inflammatory treatment with only 5 mg/day of oral prednisolone was then implemented, and the stenosis remained unchanged with the patient being stable for the next 16 months.

Conclusions

This is the first published case report that describes the actual clinical course with a long-term follow-up period after surgery for isolated pulmonary Takayasu’s arteritis, including images of the stenosed prosthetic graft.

This case suggests that patients should be followed with multiple complementary diagnostic techniques on the assumption that restenosis is highly possible and unpredictable even after surgery. Besides, sufficient anti-inflammatory treatment should be applied as soon as possible after surgery no matter how inactive the disease appears to be, although its optimal regimen especially during the inactive inflammatory phase needs to be further established.

A novel susceptibility locus for Takayasu arteritis in the IL12B region can be a genetic marker of disease severity

Takayasu arteritis (TAK) is an acute and chronic vasculitis of unknown etiology. Recently, our group reported that SNP rs6871626 in the IL12B region had significant association with disease susceptibility to TAK. However, association of the SNP with clinical characteristics of TAK has yet to be determined. Therefore, we assessed whether this SNP was associated with TAK disease severity as represented by early onset and/or refractoriness to medical therapy. A total of 90 patients were genotyped for rs6871626 and their clinical charts were reviewed retrospectively. By examining the relationship between genotype and clinical profiles of patients, we found a strong association between the number of risk alleles and the frequency of severe cases as defined by (1) age at onset <20 years old, (2) steroid resistance, and/or (3) a relapse of disease [p = 0.03; odds ratio 3.75 (95 % confidence interval 1.13-13.5)]. Thus, our study points to potential diagnostic use of SNP rs6871626 for predicting disease severity of TAK, with the goal of genotyping-oriented therapy in the near future.

Late aneurysm formation of Valsalva sinus after aortic valve replacement due to Takayasu's arteritis

Takayasu's arteritis (TA) is an inflammatory disease of unknown etiology involving the aorta and its branches, and also causes aortic regurgitation (AR). One of the most serious but rare complications after aortic valve replacement (AVR) in TA is aneurysm formation of the sinus of Valsalva. A 64-year-old woman had undergone AVR with a prosthetic valve for AR due to TA 4 years earlier and had received an implanted permanent pacemaker for complete atrioventricular block (AVB) 2 years later. Aortography 4 years postoperatively demonstrated aneurysm formation (47 mm in diameter) at the sinus of Valsalva although preoperative aortography showed severe AR without dilatation of the sinus of Valsalva. We recommended reoperation for the aneurysm but the patient refused. The perioperative histopathological examination revealed extensive destruction of the medial elastic fibers. Both the fragility of the sinus of Valsalva and the residual inflammation could have caused the patient's aneurysm formation. Moreover, extension of TA into the ventricular septum or mechanical compression of the aneurysm against the conduction system might have caused her progressive AVB. Close and lifelong follow-up for patients with TA regarding development of aneurysm after surgical treatment is indispensable when fragility of the aortic root had been confirmed.

Successful percutaneous transluminal angioplasty for the treatment of renovascular hypertension with an atrophic kidney

Renovascular hypertension is an important cause of secondary hypertension. We present the case of a 61-year-old man with renovascular hypertension caused by chronic total occlusion of the left renal artery resulting in an atrophic kidney. Although renography indicated almost no residual function of the left kidney, renal vein sampling showed a significant increase of renin secretion in the left kidney. The endocrine function of the left kidney was believed to be preserved; thus, we performed percutaneous transluminal renal angioplasty with stent placement. After the procedure, the patient’s blood pressure decreased gradually to within the normal range without adverse events. The laboratory data on endocrine function and the renography findings drastically improved. Percutaneous transluminal renal angioplasty is a promising therapeutic procedure for renovascular hypertension with an atrophic kidney.