Analysis of 27 cases of large vascular lesions in 161 cases of Behcet's disease: clinical manifestations and treatment outcome

Cluster analysis of phenotypes of patients with Behçet's syndrome: a large cohort study from a referral center in China

INTRODUCTION

Behcet's syndrome (BS) is a complex, heterogeneous disorder. However, classification of its subgroups is still debated. The purpose of this study was to investigate the clinical features and aggregation of patients with BS in China, based on manifestations and organ involvements.

METHODS

This was a cross-sectional study of BS patients in Huadong Hospital of Fudan University between September 2012 and January 2020. We calculated relative risks (RRs) of clinical variables according to sex. Moreover, we conducted a hierarchical cluster analysis applied according to eighteen variables to determine subgroups of patients.

RESULTS

A total of 860 BS patients were included. Male sex was associated with ocular involvement (RR 2.32, 95% CI 1.67, 3.22, P < 0.0001), vascular involvement (RR 2.00, 95% CI 1.23, 3.23, P = 0.004), cardiac lesion (RR 5.46, 95% CI 2.33, 12.77, P < 0.0001), and central nervous system involvement (RR 2.95, 95% CI 1.07, 6.78, P = 0.007) and was negatively associated with genital ulcers (RR 0.84, 95% CI 0.79, 0.91, P < 0.0001). Five clusters (C1-C5) were observed. C1 (n = 307) showed the skin and mucosa type. In C2 (n = 124), all had articular involvement, barely having major organ involvement except for 18 cases with intestinal lesions. In C3 (n = 156), the gastrointestinal type, 144 patients presented with intestinal involvement, and 36 patients with esophageal ulcers. In C4 (n = 142), all subjects presented with uveitis. C5 (n = 131) consisted of 44 patients with cardiac lesions, 58 with vascular involvement, and 26 cases having central nervous system involvement.

CONCLUSION

Our analysis confirmed sex differences in phenotypes of BS. Cluster analysis identified gastrointestinal, uveitis, and cardiovascular involvement cluster separately in different subsets, which represents the most commonly involved organs. Further research is required to replicate and clarify the patterns of phenotype in BS.

Surgical Removal of a Ruptured Radiculomedullary Artery Aneurysm: A Case Report

Subarachnoid hemorrhage due to a solitary spinal aneurysm is extremely rare, and diagnosis and treatment are challenging. We report a rare case of a ruptured radiculomedullary artery aneurysm in a patient with Behçet disease. A 49-year-old man presented with severe lower abdominal and leg pain. Magnetic resonance imaging was performed and an enhanced intradural-extramedullary lesion at the T12 spinal level with subarachnoid hemorrhage was identified. Diagnostic spinal angiography was performed to evaluate the vascular lesion, and a radiculomedullary artery aneurysm at the T12 level was identified. We performed surgical resection of the aneurysm and a good neurological outcome was obtained.

Behçet's Disease and Nervous System Involvement

OPINION STATEMENT

Management of neuro-Behçet's disease can be divided into two stages: treatment of acute attacks and prevention of relapses. Treatment of acute attacks is accomplished by high-dose intravenous corticosteroids followed by maintenance treatment with oral steroids for 6-12 months depending on the type and severity of the neurological involvement. Relapses can be prevented by using immunosuppressants. Oral immunosuppressants such as azathioprine and mycophenolate are the most widely utilized agents for this purpose. Patients who are refractory or who cannot tolerate these medications can be managed by cyclophosphamide, interferon alpha, or anti-TNF-α monoclonal antibodies such as infliximab, etanercept, and adalimumab. Recent reports showed that newer agents such as tocilizumab, canakinumab, and anakinra, which exert their biological activity through IL-1 and IL-6 pathways, are also promising treatment alternatives for progressive or relapsing patients.

Endovascular Treatment of a Ruptured Innominate Artery Aneurysm in Behcet Disease

In Behcet disease (BD), vascular complication such as false aneurysm formation is common after surgical treatment in the arterial lesion, and the optimal treatment method remains controversial. Concerning the innominate artery aneurysm, lack of experience due to its rarity in vasculo BD makes decision making even more difficult. We report a ruptured innominate artery aneurysm in a 70-year-old man with BD, which was successfully treated by innominate artery stent grafting through the right common carotid artery, axillo-axillary artery bypass grafting, and right subclavian artery coil embolization. The patient is doing well without any vascular complications at eighth postoperative month.

Outcomes of vascular intervention and use of perioperative medications for nonpulmonary aneurysms in Behçet disease

BACKGROUND

Aneurysms attributable to Behçet disease (BD) are not common but are associated with a poor prognosis because of a high risk of rupture. Special considerations are required for vascular intervention, because the intense local inflammation may increase complications. The aim of this study was to assess the outcome of operative intervention and the use of perioperative medical therapy for aneurysms in patients with BD.

MATERIALS AND METHODS

We reviewed retrospectively the medical records of patients with BD admitted to Peking Union Medical College Hospital between January 1995 and January 2015.

RESULTS

Among 874 patients diagnosed with BD, 176 patients had vascular involvement, of whom 59 had arterial aneurysms. Thirty-six patients with 51 arterial aneurysms underwent operative intervention. The 51 primary operative interventions included 20 open operations and 31 endovascular interventions. Eleven (22 %) recurrent aneurysms developed in 10 patients and 5 (10%) thrombosis occurred in 5 patients. Of the 19 endovascular stents placed for aortic aneurysms, 1 type I endoleak, 1 graft occlusion, 3 recurrent aneurysms, and 1 recurrent aneurysmal rupture occurred. Among the revascularization procedures for extremity arteries, there were more complications with endovascular intervention than with open surgery. The cumulative risk of recurrent aneurysmal formation at the operative site was significantly less in patients treated with operative intervention combined with use of immunosuppressants than those treated with operative intervention alone (P = .01).

CONCLUSION

In patients with BD, an endovascular approach is feasible and effective for aortic aneurysms, whereas bypass surgery appears to provide better outcomes for extremity arterial aneurysms than placement of endovascular stents. The administration of corticosteroids combined with cyclophosphamide perioperatively decreases the cumulative risk of recurrent aneurysm.