Balloon angioplasty of the aorta in Takayasu's arteritis: Initial and long-term results

Left ventricular function assessment after aortic and renal intervention in Takayasu arteritis by speckle tracking echocardiography: a pilot study

Background

Overt left ventricular (LV) dysfunction and congestive heart failure are known entities in Takayasu arteritis (TA). Subclinical LV dysfunction may develop in these patients despite normal LV ejection fraction (LVEF). Moreover, effect of treatment of aortic or renal artery narrowing in such patients is unknown.

Methods

This study included 15 angiographically confirmed TA patients undergoing aortic and/or renal intervention. A comprehensive clinical, biochemical and echocardiographic (2-dimensional, speckle tracking and tissue doppler imaging) evaluation were done at baseline, 72 h, and six months post intervention.

Results

Six patients (40%) had reduced LVEF (<50%) at baseline while rest 9 (60%) patients had reduced global longitudinal strain (GLS) but normal EF. Diastolic filling pattern was abnormal in all the patients. In patients with baseline reduced EF, mean EF improved from 24.62 ± 12.14% to 45.6 ± 9.45% (p = 0.001), E/e’ ratio decreased from 15.15 ± 3.19 to 10.8 ± 2.56 (p = 0.005) and median NT pro BNP decreased from 1673 pg/ml (970–2401 pg/ml) to 80 pg/ml (40–354 pg/ml) (p = 0.001) at 6 months after interventional procedure. In patients with baseline normal EF, median NT pro BNP decreased from 512 pg/ml (80–898.5 pg/ml) to 34 pg/ml (29–70.8 pg/ml) (p < 0.01), mean GLS improved from −8.80 ± 0.77% to −16.3 ± 0.78% (p < 0.001) and mean E/e’ decreased from 12.93 ± 2.63 to 7.8 ± 2.73 (p = 0.005) at 6 months follow up.

Conclusion

LV dysfunction is common in patients with TA and obstructive lesions in aorta or renal arteries. GLS can be used to assess subclinical systolic dysfunction in these patients. Timely intervention can improve LV dysfunction and can even reverse the subclinical changes.

The study of novel inflammatory markers in takayasu arteritis and its correlation with disease activity

Objectives

Currently, erythrocyte sedimentation rate (ESR) and highly sensitive serum C-reactive protein (hsCRP) levels are used to monitor disease activity and guide therapy in Takayasu Arteritis (TA). However, non-specificity of these markers suggests the need for novel biomarkers. In this pilot study, we explore the role of novel biomarkers for evaluating disease activity in TA.

Methods

A total of 40 patients with TA were divided into active and stable disease groups. Disease activity was assessed according to the National Institutes of Health criteria proposed by Kerr et al. Routine blood investigations were obtained and serum tumor necrosis factor (TNF)-α, interleukin (IL)-1, IL-6, IL-18, ESR, hsCRP levels and NLR (neutrophil to lymphocyte ratio) were assayed at baseline and after 6 months.

Results

Among the 40 patients enrolled, 18 were classified as active while 22 were stable at baseline and with a similar pattern at 6 months. Along with ESR and hsCRP, IL-6 and IL-18 levels were significantly higher in the active disease group than in the stable disease group (p < 0.005). The levels of other novel biomarkers (IL-1, TNF-α) and NLR were not significantly higher in active disease group.

Conclusion

Serum IL-6 and IL-18 levels correlates well with disease activity in TA which suggests their important role in disease pathogenesis and may be helpful in guiding and monitoring therapy in active TA patients.

Etiology, Diagnosis and Management of Aortitis

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.

Clinical Outcome of Extraanatomic Bypass for Midaortic Syndrome Caused by Takayasu Arteritis

BACKGROUND

We investigated long-term outcomes and cardiac function after extraanatomic bypass surgery for Takayasu arteritis and midaortic syndrome.

METHODS

Between 2007 and 2016, 14 patients underwent extraanatomic bypass for Takayasu arteritis. Median age was 56.6 years. Median systolic pressure gradient in the stenotic lesion was 79 mm Hg. Nine patients underwent bypass surgery from the ascending aorta to the infrarenal aorta, 2 from the ascending aorta to the distal descending thoracic aorta, 1 from the ascending aorta to the supraceliac abdominal aorta, 1 from the descending thoracic aorta to the infrarenal abdominal aorta, and 1 from the descending thoracic aorta to the descending thoracic aorta. Five underwent additional 6 peripheral bypass procedures, and 6 underwent concomitant heart surgery.

RESULTS

There were no early deaths. Median hospital stay was 10.5 days. Median follow-up duration was 36.3 months, and late death occurred in 2 patients. One died at 1 year postoperatively because of an infection due to pancreatic injury and mediastinitis. The other was lost to follow-up, and death was confirmed through the national insurance database. No anastomotic site stenosis or aneurysmal change occurred. The number of antihypertensive medications was reduced significantly in all but 1 patient, and organ ischemia symptoms, including dizziness, visual disturbance, and claudication, improved in all patients. Interventricular septal diameter and left ventricular mass index decreased significantly. Serum creatinine level also decreased. Overall estimated 5-year survival was 79% ± 13%.

CONCLUSIONS

Extraanatomic bypass for Takayasu arteritis is safe and effective and can be useful for left ventricular unloading and reduction of organ ischemia.

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.

Two Years Efficacy of Paclitaxel-Coated Balloon Dilation for In-Stent Renal Artery Restenosis Due to Takayasu Arteritis

Patient: Female, 19

Final Diagnosis: Renovascular hypertension

Symptoms: Hypertension

Medication: Anti-hypertensive agents

Clinical Procedure: Percutaneous transluminal renal angioplasty

Specialty: Cardiology

An Uncommon Cause of Hypertensive Urgency in Young Adolescent: Case Report

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.

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.

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.

OUTCOME OF ENDOVASCULAR PROCEDURES ON OCULAR FINDINGS IN TAKAYASU ARTERITIS

PURPOSE

To evaluate the outcome of endovascular procedures on ocular findings in patients with Takayasu arteritis.

METHODS

Retrospective study of patients who underwent percutaneous endovascular stenting of aortic arch arteries for Takayasu arteritis (TA) and who had documented retinopathy findings before and after the procedure. Change in visual acuity, regression of retinopathy, and development of complications after endovascular procedure were studied over a follow-up of 6 months.

RESULTS

Ten eyes of five patients were included. Eyes which had Stage II or less of retinopathy before the endovascular procedure had favorable outcome; however, those with advanced stage of retinopathy at presentation had poor outcomes. Patients who underwent revascularization of both-sided arteries within 1 month had better anatomical and functional outcomes as compared with those who underwent sequential endovascular procedures on their arteries after a gap of 3 months or more.

CONCLUSION

Percutaneous endovascular stenting of aortic arch arteries, affected in TA, can lead to reversal of retinopathy changes and restoration of vision if done before neovascular complications set in.

Surgical strategy for refractory aortitis

In some instances, we encounter cases suffered from inflammatory aortic diseases (aortitis) in Japan, some of which are at the active stages with systemic inflammation. Most of them are refractory with some technical difficulties of surgical treatment. The aortic wall, particularly, at the active stage, is too fragile to hold the surgical sutures. Consequently, the suture reinforcement with Teflon felt is required. In the late stage after surgery, false aneurysms on the suture line, that is, suture detachment potentially occur. To prevent such sequelae in the early and late phases, continuous (life-long) as well as perioperative inflammation control using corticosteroid as an initial drug and/or other immunosuppression agents. This decade, instead of the conventional open surgical repairs, endovascular treatments have widely spread, predominantly for stenotic aortic/arterial lesions. In particular, for more difficult patients suffered from more troublesome Behçet disease, endovascular treatments would have greater advantages to avoid more occasionally occurred pseudo-aneurysm on the other parts as well as the surgical suture lines. The key issues on surgical treatment for refractory aortitis are perioperative inflammation control including the long term with corticosteroid and/or immunosuppressive agents, appropriate open surgical or endovascular treatment approaches, and sufficient reinforcement of surgical suture lines.

Takayasu's aorto-arteritis: Not your regular lesion for angioplasty

We report a case of a 6-year-old female child with Takayasu's aorto-arteritis (TA) with severe coarctation of the aorta which resulted in an aortic dissection post-ballooning. This happened despite ensuring that markers for disease activity were negative, with appropriate corticosteroid therapy started before the procedure, and using a low-profile, low-pressure, and slightly undersized balloon for dilating the stenotic segment. It required immediate endovascular stenting to tide over the crisis. Following the procedure, she became normotensive with well-palpable lower limb pulses.

Takayasu's Arteritis: Current Status of Angioplasty and Stenting

Takayasu's arteritis is a chronic inflammatory disease characterized by stenotic occlusive lesions of the aorta and its major branches. The medical management of such lesions is far from satisfactory and surgical treatment is associated with high morbidity and mortality. Angioplasty with or without stenting has emerged as the treatment of choice for such lesions. Angioplasty and stenting of various vessels in Takayasu's arteritis are reviewed, highlighting the advantage of stents in reducing the rate of restenosis in chronically occluded or diffusely diseased vessels.

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.

[Therapeutic endovascular procedures in aortitis]

Aortitis is an inflammation of the aortic wall with an infectious or non-infectious origin, which often progresses to vascular complications. The open surgical approach is a high-risk procedure for these pathologies. Endovascular interventions have improved the prognosis of patients with aortitis complications. This manuscript describes the pathophysiology responsible for vascular complications and the role of endovascular approach for their treatment.

Percutaneous treatment of abdominal coarctation in children using a covered stent

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.

Aortic rupture during aortoplasty in Takayasu arteritis--a rare complication: case report and review of literature

Balloon angioplasty of the stenosed aorta is usually a relatively simple, yet potentially a catastrophic procedure. Aortic rupture during aortoplasty, though uncommon, carries a high mortality. We report case of a 39-year-old female with aortoarteritis with multiple arterial stenoses whose infra-renal abdominal aorta ruptured during balloon dilatation of the stent deployed in that segment. The site of aortic rupture was temporarily occluded by low-pressure inflation of the same balloon and then was sealed using a stent-graft introduced by contra-lateral femoral arterial access.

Midaortic syndrome: 30 years of experience with medical, endovascular and surgical management

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.

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.

[How to manage Takayasu arteritis?]

Thorough clinical and imaging assessment of the arterial tree when a diagnosis of Takayasu arteritis is established. Glucocorticoïd as intiation therapy. Immunosuppresive agent should be considered as adjunctive therapy if resistance or dependance to glucocorticoïd therapy. Supportive care, antihypertensive drugs, glucocorticoïd induced osteoporosis preventive therapy, tuberculosis screening should not be forgiven. Monitoring of therapy should be clinical and supported by biological markers and imaging. Reconstructive surgery should be performed in the quiescent phase of disease.

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.

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.

Intra-abdominal hypertension: evolving concepts

This article focuses primarily on the recent literature on abdominal compartment syndrome (ACS) and the definitions and recommendations published by the World Society for the Abdominal Compartment Syndrome. The definitions regarding increased intra-abdominal pressure (IAP) are listed and are followed by an overview of the different mechanisms of organ dysfunction associated with intra-abdominal hypertension (IAH). Measurement techniques for IAP are discussed, as are recommendations for organ function support and options for treatment in patients who have IAH. ACS was first described in surgical patients who had abdominal trauma, bleeding, or infection; but recently, ACS has been described in patients who have other pathologies. This article intends to provide critical care physicians with a clear insight into the current state of knowledge regarding IAH and ACS.

Takayasu's arteritis treated by percutaneous transluminal angioplasty with stenting in the descending aorta

A 17-yr-old young woman was referred to our hospital with a 2-yr history of claudication of the lower extremities and severe arterial hypertension. Physical examination revealed significantly different blood pressures between both arms (160/92 and 180/95 mmHg) and legs (92/61 and 82/57 mmHg). The hematological and biochemical values were within their normal ranges, except for the increased erythrocyte sedimentation rate (83 mm/hr) and C-reactive protein (6.19 mg/L). On 3-dimensional computed tomographic angiography, the ascending aorta, the aortic arch and its branches, and the thoracic and, descending aorta, but not the renal artery, were shown to be stenotic. The diagnosis of type IIb Takayasu's arteritis was made according to the new angiographic classification of Takayasu's arteritis, Takayasu conference 1994. Percutaneous transluminal angioplasty with stenting was performed on the thoracic and abdominal aorta. After the interventional procedures, the upper extremity blood pressure improved from 162/101 mmHg to 132/85 mmHg, respectively. She has been free of claudication and there have been no cardiac events during 2-yr of clinical follow-up.

Primary Stent Placement for Infrarenal Aortic Stenosis: Immediate and Midterm Results

PURPOSE

To evaluate the safety and the long-term clinical and hemodynamic results of primary stent placement of atherosclerotic calcified stenosis of the infrarenal aorta.

MATERIAL AND METHODS

Between July 1996 and July 1999, 15 patients (nine male, si- female; mean age, 53.9 years) with symptomatic, calcified aortic stenosis were treated with primary stent placement. Patients underwent abdominal aortography and bilateral lower extremity arteriography. Follow-up was performed in all 15 patients. Technical success was defined as residual stenosis of less than 30% or a resting trans-systolic pressure gradient of less than 10 mm Hg after stent placement. Clinical patency was defined as the absence or improvement of symptoms after stent placement. Hemodynamic patency was defined as a normal triphasic Doppler waveform in the common femoral artery, an ankle-brachial index greater than 0.90, or the absence of a thigh-brachial pressure gradient at rest in either limb.

RESULTS

Technical success was achieved in 13 of 15 patients. The two patients considered to be technical failures had resting trans-systolic pressure gradients of 12 and 13 mm Hg, respectively, after stent placement. After the mean follow-up of 36 months, primary clinical and hemodynamic patency rates were 85% and the secondary hemodynamic patency rate was 100%. Two of five symptomatic recurrences during the 36-month follow-up period (range, 12-46 months) were a result of aortic restenosis and were treated with repeated percutaneous transluminal angioplasty. None of the patients required aortic surgery. Complications of the primary procedure included one puncture site infection, one pseudoaneurysm, and one distal embolization, which delayed discharge of three patients. There was no morbidity during the secondary interventions.

CONCLUSION

Primary stent placement as treatment of calcified infrarenal aortic stenosis proved to be safe and also provided durable long-term clinical improvement.

Endovascular stent implantation for severe pulmonary artery stenosis in aortoarteritis (Takayasu's arteritis)

Symptomatic pulmonary artery stenosis is a relatively uncommon manifestation of aortoarteritis. We describe a patient of aortoarteritis with severe proximal right pulmonary artery stenosis who presented with dyspnea on exertion and central cyanosis. The pulmonary artery stenosis was successfully relieved by percutaneous transluminal balloon angioplasty and implantation of a balloon-expandable stent. This resulted in immediate improvement in oxygen saturation, disappearance of cyanosis, relief of dyspnea, and marked improvement in right lung perfusion as demonstrated by pre- and postangioplasty technetium lung ventilation-perfusion scans. The changes in the pulmonary arterial wall morphology were detected precisely by intravascular ultrasound imaging.

Endovascular treatment of aortic rupture during angioplasty for aortic in-stent restenosis in aortoarteritis

Aortic rupture during balloon angioplasty for in-stent restenosis without attempting to overexpand it is a rarity. We report a case of a young woman with aortoarteritis who had aortic rupture during angioplasty for in-stent restenosis. The balloon used was of the same diameter as the previously implanted stent and was completely within the stent during inflation. The disruption was successfully treated by percutaneous placement of a self-expandable endovascular stent graft.

Recent advances in the management of non-specific aorto-arteritis

Non-Specific Aorto-arteritis or Takayasu's arteritis (TA) is a chronic inflammatory disease of the aorta and its major branches which either presents with constitutional symptoms in its active phase or with steno-occlusive symptoms in the healing phase. In children, it is an aggressive disease and often lethal. Congestive heart failure is more common in children than adults. TA often goes undiagnosed till it is too late and death rate of 35% or more is observed in 5 years. Therapeutic Interventional Cardiology offers new hope and saves the children with TA from certain death. Today, percutaneous transluminar balloon angioplasty (PTBA) has emerged as a non-surgical, safe, effective alternative therapeutic option and endovascular stents have revolutionised the management. The disease must be suspected and diagnosed precisely with echocardiography and angiography before it is too late to manage.

Percutaneous transluminal angioplasty of the aorta in children with nonspecific aortoarteritis: acute and follow-up results with special emphasis on left ventricular function

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.

Endovascular stenting for unsuccessful angioplasty of the aorta in aortoarteritis

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.

Stenosis in the aorta caused by non-specific aortitis: results of treatment by percutaneous stent placement

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.

[Takayasu's arteritis: vascular investigations and therapeutic management. Experience with 16 patients]

PURPOSE

There is no consensus in regard to vascular explorations and therapeutical management of Takayasu's arteritis. The objective of this study was therefore to establish the most appropriate vascular explorations and to analyze current treatments.

METHODS

Clinical, biological and morphological findings related to either diagnosis or treatment were retrospectively evaluated in sixteen patients diagnosed with Takayasu's arteritis according to the American College of Rheumatology criteria.

RESULTS

Median delay between the occurrence of the first symptoms and the diagnosis was 9 months. Aortic lesions and aortic valvular incompetence were more frequent. Statistical analysis showed the existence of a correlation between the lack of relapse and corticosteroid therapy (Fisher exact test, P = 0.021). Percutaneous transluminal angioplasty led to stabilization of vascular lesions. Surgical management led to satisfactory results, except for patients with aortic lesions, as survival was then less than 1 year.

CONCLUSION

Early diagnosis is mandatory in patients with Takayasu's arteritis in order to propose appropriate therapy, particularly corticosteroid therapy. Surgery and angioplasty prove to be useful in occlusive forms. Late diagnosis is accompanied by severe aortic lesions and fatal outcome.

Treatment of Takayasu's aortitis with percutaneous transluminal angioplasty and wall stent--a case report

The authors describe a young woman who developed severe toxemia during pregnancy, requiring emergency lower segment cesarian section at 27 weeks of gestation. Postpartum angiography showed a discrete stenotic lesion of the abdominal aorta proximal to the origin of the renal artery. Angioplasty was performed, followed by the insertion of a wall stent at the site of the stenosis. Her hypertension control improved dramatically after the stenting. This is, so far, the first reported case using a wall stent following angioplasty to relieve abdominal aortic stenosis due to Takayasu's arteritis.

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

PURPOSE

To compare the early and long-term outcomes of subclavian artery angioplasty in patients with aortoarteritis and atherosclerosis.

METHODS

Sixty-one subclavian artery angioplasties were performed in 55 consecutive patients with aortoarteritis (n = 32) and atherosclerosis (n = 23) between 1986 and 1995. An arch aortogram followed by a selective subclavian artery angiogram was done to profile the site and extent of the lesion, its relation to the vertebral artery, and the distal circulation. Percutaneous transluminal angioplasty (PTA) was performed via the femoral route for 56 stenotic lesions and 5 total occlusions.

RESULTS

PTA was successful in 52 (92.8%) stenotic lesions and 3 (60%) total occlusions. Three patients (5.4%) had complications, that could be effectively managed nonsurgically. Compared with atherosclerosis, patients with aortoarteritis were younger (27.4 +/- 9.3 years vs 54.5 +/- 10.5 years; p < 0.001), more often female (75% vs 17.4%; p < 0.001), gangrene was uncommon (0% vs 17.4%; p < 0.05), and diffuse involvement was seen more often (43.8% vs 4.4%; p < 0.001). The luminal diameter stenoses were similar before PTA (88.6 +/- 9.7% vs 89.0 +/- 9.1%; p = NS). Higher balloon inflation pressure was required to dilate the lesions of aortoarteritis (9.9 +/- 4.6 ATM vs 5.5 +/- 1.0 ATM; p < 0.001). This group had more residual stenosis (15.5 +/- 12.4% vs 8.3 +/- 9.4%; p < 0.05) after PTA. There were no neurological sequelae, even in PTA of prevertebral lesions. On 3-120 months (mean 43.3 +/- 28.9 months) follow-up of 40 patients, restenosis was more often observed in patients with aortoarteritis, particularly in those with diffuse arterial narrowing. These lesions could be effectively redilated. Clinical symptoms showed marked improvement after successful angioplasty.

CONCLUSION

Subclavian PTA is safe and can be performed as effectively in aortoarteritis as in atherosclerosis, with good long-term results. Long-term follow-up shows that it provides good symptomatic relief.

Stent placement in a patient with Takayasu's arteritis

A 49-year-old woman with a history of Takayasu's arteritis underwent stent placement of the celiac and mesenteric arteries after unsuccessful balloon angioplasty. Stents may prove to be a beneficial alternative to angioplasty for treatment of the dense fibrotic lesions often associated with this disease.