Surgical Experience of Behcet's Disease Involving the Peripheral Artery

Optimal timing of surgical treatment for Behcet's disease aortic or peripheral artery pseudoaneurysms

OBJECTIVE

The aim of this study was to assess the optimal thresholds of surgical intervention for Behcet's disease (BD) aortic or peripheral artery pseudoaneurysms.

METHODS

This was a retrospective single-center study of 2138 patients with BD, including 96 patients with vascular BD (4.5%) with 151 pseudoaneurysms between January 2002 and December 2021. Factors associated with mortality were assessed using Cox regression model. The growth rate of each pseudoaneurysm was calculated based on available imaging data in a linear mixed effect model.

RESULTS

Patients in the surgical group (2/56) had significantly lower aneurysm-related mortality than those in the medical treatment group (10/33) (χ2 = 10.34; P = .0013). Surgical intervention (P = .009) and diameter of BD pseudoaneurysm (P = .006) were independently associated with BD aneurysm-related mortality. Rapid growth of BD pseudoaneurysm was achieved once diameter exceeded 4.0 cm for aortic pseudoaneurysm, or 2.5 cm for peripheral artery pseudoaneurysm, accompanied with high risk of rupture (Overall rupture rate: BD aortic pseudoaneurysm, ≥4.0 cm vs <4.0 cm: 63.6% vs 15.4%; BD peripheral artery pseudoaneurysm, ≥2.5 cm vs <2.5 cm: 50.9% vs 0).

CONCLUSIONS

This study verified the critical role of surgical intervention in reducing the mortality rate of patients with BD pseudoaneurysms. BD aortic pseudoaneurysms larger than 4.0 cm in diameter and peripheral artery pseudoaneurysms larger than 2.5 cm in diameter require prompt surgical intervention due to the remarkable increase in the growth rate and greater risk of rupture and death.

Behçet's Disease and Aneurysms: A Case Series of Vascular Involvement and Outcomes

Large vessel vasculitis (LVV) is a group of inflammatory diseases that affect the aorta and its major branches, causing stenosis, aneurysms, or dissections. LVV can be associated with various disorders, such as IgG4-related disease, Takayasu arteritis, giant cell arteritis, and Behcet's disease. Aneurysms due to Behcet's disease are rare and challenging to manage, as they have high rates of morbidity and mortality. Endovascular repair combined with immunosuppression has emerged as a preferred option over open surgery in recent years. However, open repair may still be indicated in some cases where endovascular repair is not feasible or available. We present a case series of four patients with LVV and coexisting aneurysms who underwent surgical repair at tertiary care hospitals in Islamabad and Qatar. Our aim is to demonstrate the clinical presentation, diagnosis, management, and outcomes of these patients and to emphasize the importance of early involvement of vascular surgeons in the care of LVV patients.

Vascular Involvement in Behcet's Disease: An Evaluation of 147 Cases and Literature Review

Objectives

Behcet's disease (BD) is characterized by systemic vasculitis with inflammation that can affect various body organs. In BD, vasculitis primarily manifests with venous involvement, distinguishing it from other forms of systemic vasculitis.

Methods

We retrospectively analyzed the demographic and clinical characteristics of 147 patients diagnosed with vascular BD in our center.

Results

Vascular BD cases accounted for 25.0% (147 out of 589) of all BD patients. A statistically significant correlation was found between gender and vascular involvement that was seen predominantly in males (76.9%). In 71 patients, a vascular event developed during follow-up for BD, while in 76 patients the disease was diagnosed after the occurrence of a vascular event (51.7%). The most common vascular event was deep vein thrombosis in the lower extremities (69.4%). Arterial involvement was primarily observed in the pulmonary arteries (12.9%). Patients with lower extremity deep vein thrombosis tended to be younger, while those with pulmonary artery involvement were typically older. Overall, veins were affected 4.5 times more frequently than arteries.

Conclusion

The prevalent type of venous involvement was deep vein thrombosis in the lower extremities. Thrombotic events in BD cannot be solely attributed to abnormalities in thrombotic factors. The treatment of thrombotic events in BD remains contentious, with anticoagulant efficacy being debated and immunosuppressive therapy representing the primary treatment approach. Behcet's disease should be considered when a young male patient presents with an arterial or venous vascular event, especially if it is recurrent.

Vascular Behçet syndrome: from pathogenesis to treatment

Behçet syndrome is a rare, chronic inflammatory disease of unknown aetiopathogenesis, most commonly presenting with mucocutaneous and ocular manifestations. Vascular involvement, most frequently superficial vein and deep vein thrombosis, can occur in up to 50% of patients with Behçet syndrome. Venous thrombosis at atypical sites (inferior and superior vena cava, suprahepatic veins with Budd-Chiari syndrome, portal vein, cerebral sinuses and right atrium and/or ventricle) and arterial involvement (mostly in situ thrombosis and aneurysms of the pulmonary arteries, as well as aneurysms of the abdominal aorta, and peripheral and visceral arteries) are also unique features of Behçet syndrome. Behçet syndrome is considered a natural model of inflammation-induced thrombosis in humans, with an impaired immune-inflammatory response rather than traditional cardiovascular risk factors contributing to thrombogenesis. Specifically, neutrophil hyperactivation and neutrophil-mediated mechanisms of damage directly promote endothelial dysfunction, platelet activation and thrombogenesis in Behçet syndrome. This unusual pathogenesis directly determines the treatment approach, which relies mostly on immunosuppressants rather than anticoagulants for treatment of thrombosis and for secondary prevention. This Review discusses the main histopathological, pathogenetic and clinical aspects of vascular Behçet syndrome, addressing their implications for therapeutic management. Future perspectives in terms of pathogenetic studies, disease monitoring and treatment strategies are also discussed.

[Multiple aortic and femoral aneurysms: Unusual revelation of Behçet's disease]

Arterial involvement in Behçet's disease is rare, the aortic localization is one of the most severe manifestations of the disease. We present an exceptional case of Behçet's disease revealed by two infrarenal abdominal aorta aneurysms, associated to a femoral artery pseudoaneurysm. The management of aneurysms in Behçet's disease is delicate, and requires the combination of surgical treatment with adjuvant medical drug therapy in order to reduce complications risk.

[Giant ruptured common femoral artery aneurysm revealing Behçet's disease]

Vascular involvement in Behçet's disease is rare. Aneurysmal arterial involvement is the severe form of the disease, it constitutes a therapeutic challenge given its severity, and frequent secondary complications, especially at anastomosis. The systematic immunosuppressive drug treatment and surgical technique thoroughness can reduce relapse rate. We report the case of a young man in whom a ruptured false aneurysm of the common femoral artery revealed Behçet's disease. He underwent an open repair, with prosthetic arterial reconstruction, and anastomosis reinforcement with teflon.