Surgical intervention and its role in Takayasu arteritis

Chinese guideline for the diagnosis and treatment of Takayasu's arteritis (2023)

Takayasu's arteritis (TAK) is a chronic granulomatous inflammatory disease that involves aorta and its primary branches. It is characterized by wall thickening, stenosis/obliteration or aneurysm formation of the involved arteries. In order to standardize the diagnosis and treatment of TAK in China, a clinical practice guideline with an evidence-based approach is developed under the leadership of National Clinical Medical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID). Eleven recommendations for 11 clinical questions that are important to the diagnosis and treatment of TAK are developed based on the latest evidence and expert opinions combined with real clinical practice in China.

Long-term patency of aorto-biiliac endoprosthesis for critical lower limb ischaemia in Takayasu arteritis after complicated angioplasty with a drug-coated balloon: Effect of dual antiplatelet therapy combined with tocilizumab

Takayasu arteritis is a chronic granulomatous vasculitis of unknown aetiology affecting the aorta and its major branches. Critical limb ischaemia may occur and eventually require surgical intervention. Surgical outcomes are influenced by disease activity, age, and comorbidities. We report a 43-year-old woman with Takayasu arteritis and stenosis of the left common iliac artery and occlusion of the left external iliac artery with limiting vascular claudication, who underwent angioplasty of the iliac artery with drug-eluting stent while being treated with infliximab. The artery ruptured a week later but was contained by the ilio-psoas muscle. She required subsequent stent placement to correct the lesion. Treatment comprised aspirin and clopidogrel, and the biological was switched to monthly intravenous tocilizumab. During an 8-year follow-up, serial imaging examinations showed a patent aorto-biiliac endoprosthesis, without evidence of thrombosis or restenosis. Clinically, the patient denies vascular claudication and pulses remain palpable in the left lower limb. This case highlights the risks inherent to these procedures in patients with large artery vasculitis and reinforces that the effectiveness of endovascular intervention can be increased by detailed preoperative evaluation, associated with a drug strategy including immunomodulatory and antiplatelet therapy as directed by the multispecialty team. Periodic imaging examinations are required because of the reported high rate of restenosis.

Isolated pulmonary artery involvement in Takayasu arteritis: case report and review of the literature

BACKGROUND

Takayasu arteritis (TAK) is a chronic inflammatory arteritis. It most often affects non-specific large vessel progressively, such as the aorta and its branches. The diagnosis in TAK is typically delayed. Isolated pulmonary artery involvement in Takayasu arteritis is uncommon. Owing to its rarity, the diagnosis is challenging and requires an integrated approach comprising clinical and imaging findings. In order to facilitate early diagnosis of TAK for clinicians, wider use of non-invasive imaging is impacting this.

CASE PRESENTATION

In this report, we present the imaging characteristics of a rare isolated pulmonary artery involvement in Takayasu arteritis. Pulmonary computed tomography angiography revealed only limited thick walls of both proximal pulmonary artery and stenosis of pulmonary artery lumen, and the other large blood vessels were not involved. The patient undergone pulmonary endarterectomy and pulmonary angioplasty. Then, approximately one month afterward, she passed away due to heart failure.

CONCLUSIONS

Imaging examination is the main basis for diagnosing this disease. This impression might improve disease awareness among doctors and progress in diagnosis.

A case of aortic root replacement for annuloaortic ectasia due to Takayasu's arteritis in active inflammatory phase

A 39-year-old man was admitted with acute heart failure due to severe aortic regurgitation induced by annuloaortic ectasia associated with Takayasu's arteritis. Because of the active inflammatory phase associated with Takayasu's arteritis, surgery is typically performed following immune suppression by steroid therapy. Herein, we report a favorable recovery in the active inflammatory phase. Steroid therapy was initiated shortly following surgery. The decision to perform aortic root replacement without prior steroid therapy was made because the patient's risk of subsequent heart failures was deemed high and was complicated by other comorbidities.

Design and Protocol for Beijing Hospital Takayasu Arteritis (BeTA) Biobank

BACKGROUND

Although hundreds of studies have been conducted, our understanding of the pathogenesis, indications for surgical intervention, and disease markers of Takayasu arteritis (TAK) are still limited. Collection of biological specimens, clinical data and imaging data will facilitate translational research and clinical studies. In this study, we aim to introduce the design and protocol for the Beijing Hospital Takayasu Arteritis (BeTA) Biobank.

METHODS

Based in the Department of Vascular Surgery of Beijing Hospital and Beijing Hospital Clinical Biological Sample Management Center, the BeTA Biobank is composed of clinical data and sample data from patients with TAK requiring surgical treatment. All clinical data of participants are collected, including demographic characteristics, laboratory tests, imaging results, operation information, perioperative complications, follow-up data, etc. Both blood samples including plasma, serum and cells, and vascular tissues or perivascular adipose tissue are collected and stored. These samples will promote the establishment of a multiomic database for TAK and help to identify disease markers and to explore potential targets for specific future drugs for TAK.

Clinical and vascular lesion characteristics of the patients with takayasu arteritis manifested firstly as acute myocardial infarction at onset

Objective

To explore clinical and vascular lesion characteristics of the patients with Takayasu arteritis (TA) manifested firstly as acute myocardial infarction (AMI) at onset and to improve the diagnostic rate of TA.

Methods

The clinical and angiographic data of six patients with TA manifested firstly as AMI at onset were retrospectively analyzed.

Results

Of six patients (16-25 years old), 83.33% (five cases) was female, three patients had a history of hypertension and three patients did not have any medical history. One patient had intermittent effort chest tightness. On admission patients all presented with chest pain, dyspnea, hypotension, cardiogenic shock, abnormal electrocardiogram, and elevated cardiac troponin I. The vessel involvement was left coronary main trunk 83.33%, left anterior descending artery 33.33% and left circumflex branch 16.67%, right coronary artery 66.67%, subclavian artery 83.33%, and renal artery 50%. Five patients received the emergency PCI. One patient died of heart failure. During follow-up 3 patients received again PCI treatment.

Conclusion

Clinical and vascular lesion characteristics of those patients were no discomfort before admission, and the suddenly typical manifestation of AMI. Severe stenosis or occlusion occurred in main coronary artery ostia and peripheral large artery. For the TA patients with hemodynamic instability the effectiveness of emergency PCI is positive.

Case report: Aggressive progression of acute heart failure due to juvenile tuberculosis-associated Takayasu arteritis with aortic stenosis and thrombosis

Background

Takayasu arteritis (TA) is a chronic granulomatous vasculitis with unknown pathophysiology. TA with severe aortic obstruction has a poor prognosis. However, the efficacy of biologics and appropriate timing of surgical intervention remain controversial. We report a case of tuberculosis (TB)-associated TA with aggressive acute heart failure (AHF), pulmonary hypertension (PH), thrombosis, and seizure, who failed to survive after surgery.

Case presentation

A 10-year-old boy who developed a cough with chest tightness, shortness of breath, hemoptysis with reduced left ventricular ejection fraction, PH, and increased C-reactive protein and erythrocyte sedimentation rate was hospitalized at the pediatric intensive care unit of our hospital. He had strongly positive purified protein derivative skin test and interferon-gamma release assay result. Computed tomography angiography (CTA) showed occlusion of proximal left subclavian artery and stenosis of descending aorta and upper abdominal aorta. His condition did not improve after administration of milrinone, diuretics, antihypertensive agents, and intravenous methylprednisolone pulse followed by oral prednisone. Intravenous tocilizumab was administered for five doses, followed by two doses of infliximab, but his HF worsened, and CTA on day 77 showed complete occlusion of the descending aorta with large thrombus. He had a seizure on day 99 with deterioration of renal function. Balloon angioplasty and catheter-directed thrombolysis were performed on day 127. Unfortunately, the child's heart function continued to deteriorate and died on day 133.

Conclusion

TB infection may be related to juvenile TA. The biologics, thrombolysis, and surgical intervention failed to achieve the anticipated effect in our case with aggressive AHF due to severe aortic stenosis and thrombosis. More studies are needed to determine the role of biologics and surgery in such dire cases.

Advances in Takayasu arteritis: An Asia Pacific perspective

Takayasu Arteritis (TA) is a rare form of chronic granulomatous large vessel vasculitis that is more common in Asia compared to other parts of the world. There have been several developments in the field of Takayasu arteritis in relation to genetics, classification, clinical features, imaging, disease activity assessment and management and much of these works have been done in the Asia Pacific region. We will be discussing selected few in the current review.

An Update on Childhood-Onset Takayasu Arteritis

Takayasu Arteritis (TAK) is a rare large vessel vasculitis affecting the aorta and its major branches. The heterogeneous and often severe clinical manifestations result from systemic and local inflammation as well as end-organ ischemia. Disease flares are common and contribute to accrued damage over time with significant morbidity and mortality. Newer understanding of the pathogenesis in TAK has paved the way for the use of pathway targeting agents such as tumor necrosis factor (TNF)α- or interleuking (IL)-6-inhibitors with improved disease control. Nevertheless, long-term data are lacking, particularly in children; prognosis often remains guarded and the disease burden high. This article aims at providing a comprehensive review of childhood-onset TAK with a focus on recent publications.

Therapeutic Management of Ocular Ischemia in Takayasu's Arteritis: A Case-Based Systematic Review

Background

Takayasu’s arteritis (TA) is a rare, chronic granulomatous large-vessel vasculitis that can lead to ocular ischemia. Ocular outcomes after therapeutic management in TA remain largely unknown. We herein conduct a case-based systematic review to address the current treatment options in this particular cohort.

Methods

PubMed, Medline, and EMBASE databases were searched pertaining to ocular outcomes after systemic treatment in TA. Studies reporting ocular examinations before and after treatment in TA patients with ocular ischemia were included. Clinical characteristics, therapies, ocular outcomes, and complications were recorded.

Results

A 29-year-old woman with newly diagnosed TA showed dramatic regression of Takayasu’s retinopathy (TR) following balloon angioplasty. Optical coherence tomography angiography (OCTA) was used as a novel strategy for subsequent follow-up. A total of 117 eyes of 66 patients with a median age of 27 years were included for systematic review. TR was the most common ocular manifestation. Oral steroids were prescribed in nearly all patients (n = 65), followed by the use of methotrexate and antiplatelet therapy. Of the patients, 65.8% and 34.2% underwent open surgery and endovascular procedure, respectively. The median follow-up period was 12 weeks (interquartile range 8–33.5). Surgical therapy showed better ocular improvement (including visual and imaging responses) in both acute and chronic vision loss, along with fewer complications than medical therapy alone. In the surgical group, the visual prognosis was significantly better in patients with initial visual acuity better than 20/200 (p = 0.03) and those who underwent surgery before stage III TR (p = 0.01). Ocular outcomes were equivalent in the two surgical approaches.

Conclusion

Clinicians should be familiar with ophthalmic manifestations of this potentially treatable complication in TA. Compared with medical therapy alone, surgical intervention might be a better choice for both acute and chronic vision loss. Surgery is best recommended before the onset of irreversible ischemia to the globe. A combined regimen (oral steroids, immunosuppressants, and antiplatelet drugs) might be effective for those with surgical contradictions or reluctance to an invasive procedure. Physicians should be aware of the importance of ocular examinations, including OCTA, during the diagnosis and follow-up in TA.

Carotid intima-media thickness/diameter ratio and peak systolic velocity as risk factors for neurological severe ischemic events in Takayasu's arteritis

Objective

To characterize Takayasu arteritis (TAK) with supra-aortic involvement and determine the associations between clinical features, carotid ultrasonographic (US) parameters, and neurological severe ischemic events (SIE).

Methods

Patients with supra-aortic involvement including brachiocephalic trunk, bilateral common carotid artery and internal carotid artery, and bilateral subclavian and vertebral artery and baseline carotid US examination were enrolled from the East China Takayasu arteritis cohort. Bilateral carotid diameter, intima-media thickness (IMT), and peak systolic velocity (PSV) were measured by US. Then, IMT/diameter ratio (IDR) was calculated. Risk factors associated with neurological SIE were analyzed by multivariate logistic regression.

Results

Totally, 295 patients were included, of whom 260 (88.14%) were female, and 93 (31.53%) experienced neurological SIE. Involved supra-aortic artery distribution (p=0.04) and number (p<0.01) differed between neurologic and non-neurologic SIE subjects, showing higher prevalence of common carotid and vertebral artery involvement after Bonferroni correction and 56.99% patients having more than four involved arteries in neurological SIE group. The bilateral IDR (p<0.01) differed between patients with and without neurological SIE. The carotid IDR (left: cut-off value ≥0.55, odds ratio [OR] 2.75, 95% confidence interval [CI] 1.24-6.07, p=0.01; right: ≥0.58, OR 2.70, 95% CI 1.21-6.02, p=0.01) and left carotid PSV (≤76.00 cm/s, OR 3.09; 95% CI 1.53-6.27; p<0.01) as well as involved supra-aortic artery number (≥4, OR 2.33, 95% CI 1.15-4.72, p =0.02) were independently associated with neurological SIE.

Conclusion

The carotid IDR and PSV might be performed as valuable markers for recognizing neurological SIE in TAK patients with supra-aortic lesions.

Overview of imaging in adult- and childhood-onset Takayasu arteritis

Takayasu Arteritis is an idiopathic large vessel vasculitis, that affects young adults and children and can lead to ischemia and end-organ damage. Vascular imaging is crucial for diagnosis, assessment of disease extent and management of the disease. In this article, we critically review evidence for the clinical use of the different imaging modalities conventional angiography, magnetic resonance imaging, computed tomography, Doppler ultrasound and ¹⁸fluorodeoxyglucose positron emission tomography. We thereby focus on their clinical applicability, challenges and specific use in children.

Superior Mesenteric Artery Stenosis Due to Disseminated Tuberculosis in a Pediatric Patient

Disseminated tuberculosis (TB) associated with mesenteric arteritis has not been established in children. We present the case of an 8-year-old woman who presented with TB and superior mesenteric artery stenosis. Although rare, large vessel involvement from Takayasu arteritis can occur in TB. Evaluation for mesenteric vessel involvement should be considered in pediatric patients presenting with widely disseminated TB and abdominal pain.

Clinical Characteristics of Adult Patients with Systemic Vasculitis: Data of 1348 Patients from a Single Center

OBJECTIVE

To investigate the clinical characteristics of patients with systemic vasculitis in China by analyzing the data from a nationwide registry database, the Chinese Registry for Systemic Vasculitis (CRSV).

METHODS

The demographic data, clinical presentations, image and laboratory test results, disease activity assessment, treatment, and outcome of patients enrolled with the confirmed diagnosis of systemic vasculitis, including Takayasu's arteritis (TAK), ANCA-associated vasculitis (AAV), Behcet's syndrome (BD), Polyangitis nodosa (PAN), and unclassified systemic vasculitis (USV), were collected since July 2013 in the CRSV. The data during July 2013 and February 28 of 2020 were retrieved and analyzed.

RESULTS

Up to February 2020, 3852 patients in total were registered in the CRSV. In Peking Union Medical College Hospital (PUMCH), 1348 patients were registered, including 730 patients with TAK, 343 with Behcet's disease (BD), 191 with AAV, 53 with USV, and 31 with PAN. More male patients were found in PAN (64.5%), BD (59.8%), and AAV (52.4%), while TAK was more prevalent in female patients (85.9%). The average age at disease diagnosis was 29.6 in TAK, 33.2 in BD, 28.6 in PAN, 39.4 in USV, and 48.1 in AAV. A significant difference was found between age at diagnosis of TAK and AAV. Gender comparisons revealed that the age at diagnosis of male patients with AAV was older than female patients. Hypertension (57.3%) and stroke (17.5%) were found to be more common in male patients with TAK, vascular involvement (27.3%) was found to be more common in male patients with BD, while neurological involvement (29.0%) was found to be more common in male patients with AAV than in females.

CONCLUSION

This registry is the first in China and provides rich information about the clinical characteristics of Chinese patients with systemic vasculitis. There are significant differences in clinical presentations between different categories of systemic vasculitis.

Bridging Therapy for Acute Stroke as the Initial Manifestation of Takayasu Arteritis: A Case Report and Review of Literature

Takayasu arteritis (TA) is a chronic inflammatory disease involving the aorta and its principal branches. Acute ischaemic stroke (AIS) as the initial manifestation of TA is uncommon. There is little evidence on the efficacy of bridging therapy for AIS induced by TA. A 23-year-old Chinese woman with a suspected stroke presented to our hospital with sudden onset of right-sided weakness, right facial palsy, and aphasia that occurred 1 hour ago. After physical and ancillary examinations, recombinant tissue plasminogen activator was administered to the patient, which led to partial recovery. Her neurological function deteriorated with a large salvageable ischaemic penumbra on computed tomography perfusion. Cerebrovascular angiography showed multiple stenoses in the brachiocephalic trunk, the beginning of the right common carotid artery (CCA), and the bilateral subclavian arteries, as well as occlusion of the left CCA and its branches. Mechanical thrombectomy of the left middle cerebral artery was performed immediately. Percutaneous transluminal balloon angioplasty of the left CCA followed by stent implantation of the proximal left CCA was then performed. A diagnosis of TA was made based on the findings. The patient’s neurological deficit fully recovered with immunosuppressants at the 3 month-follow-up. We report a rare case of a patient with TA initially presenting with AIS treated with bridging therapy with full recovery of neurological function. Bridging therapy should be taken into consideration for AIS in patients with TA. Further study is needed in this regard.

Risk factors for cerebral infarction in Takayasu arteritis: a single-centre case-controlled study

OBJECTIVES

We aimed to investigate the clinical features of Takayasu arteritis (TA) with cerebral infarction (CI) and the risk factors for CI.

METHODS

The study analysed 122 consecutive patients with TA retrospectively. The clinical characteristics of TA patients with and without CI were compared. Binary logistic regression analysis was performed to determine risk factors for CI in TA patients.

RESULTS

CI was present in 42 (34.4%) of 122 patients with TA. There were 33 patients with ischemic stroke and 11 with asymptomatic lacunar infarction, including two patients with both types of infarction. The CI group had a significantly higher proportion of males, higher prevalence of blurred vision, and higher Indian Takayasu Clinical Activity Score (ITAS) 2010 than the non-CI group. Binary logistic regression analysis indicated that hyperlipidaemia (OR 5.549, p = 0.021), ITAS 2010 (OR 1.123, p = 0.023), number of involved arteries (OR 1.307, p = 0.018), and middle cerebral artery (MCA) involvement (OR 4.013, p = 0.029) were significantly associated with CI in patients with TA. Receiver operating characteristic curves indicated fair performance of the ITAS 2010 (> 6) and number of involved arteries (> 7) for distinguishing TA patients at risk of CI from those without such risk.

CONCLUSION

Hyperlipidaemia, higher ITAS 2010, larger number of involved arteries, and MCA involvement are independent risk factors for CI in TA patients.

Major Aortic Reconstruction with the Replacement of Supra-Aortic Branches: Successful Surgical Treatment of Takayasu Arteritis Initially Presented as Congestive Heart Failure

Takayasu arteritis (TA) is a rare, large vessel vasculitis that affects aorta, its major branches, and occasionally pulmonary arteries. Patients with TA can present with constitutional features and/or various symptoms and signs caused by morphological changes in the blood vessels affected by the inflammatory process. Corticosteroids (CS) and immunosuppressives (IS) are the first line treatment for active TA. Open surgery remains a treatment of choice for TA patients with moderate-to-severe aortic regurgitation (AR) and ascending aortic aneurysm (AAA). We present a 26-year-old female diagnosed with an advanced stage of TA, initially presented as congestive heart failure. Due to a progressive course of the disease (AR 3+, AAA 5.5 cm), surgery of the Aortic valve and root (Bentall procedure), with total arch reconstruction and replacement of supra-aortic branches was performed. The patient has had an uneventful recovery during the postoperative course with no complications at one year follow-up. Normal left ventricle (LV) diameter, LV ejection fraction 67%, and a trace of AR were seen on the last echocardiography.

[Long-term complications, monitoring and interventional treatment of large vessel vasculitis]

Giant cell arteritis (GCA) and Takayasu's arteritis (TAK) both belong to the group of large vessel vasculitides and require long-term drug treatment. Glucocorticoids (GC) are the first choice for the treatment of both diseases. For GCA immunosuppressants, such as tocilizumab or methotrexate should be considered in cases of treatment refractory and relapses or if there is a high risk for GC-related adverse events. In TAK patients the use of immunosuppressive agents should be considered for all patients. In the course of the disease, severe disease-associated and treatment-associated complications can occur. The most frequent disease-associated complications include visual impairment up to blindness in GCA, as well as vascular stenoses with ischemia and aortic aneurysms with possible dissection in GCA and TAK. Percutaneous transluminal angioplasty (PTA) and stenting are minimally invasive, low-risk interventional procedures for GCA and TAK patients with clinically significant vascular stenoses, despite a tendency to restenosis. Interventional procedures should be weighed up against vascular surgical approaches depending on the localization and the total clinical situation. All interventions should be conducted in a phase of stable remission when possible. For monitoring of disease activity in patients with GCA and TAK, assessment of clinical manifestations as well as C‑reactive protein (CRP) and the erythrocyte sedimentation rate (ESR) are useful; however, both are unreliable under interleukin‑6 block with tocilizumab. The value of new biomarkers independent from interleukin‑6 and the importance of imaging (sonography, magnetic resonance angiography, computed tomography and positron emission tomography-CT) for monitoring GCA and TAK still have to be investigated in future studies.

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.

Clinical Scenario and Long-Term Outcome of Childhood Takayasu Arteritis Undergoing 121 Endovascular Interventions: A Large Cohort Over a Fifteen-Year Period

OBJECTIVE

Evidence-based studies on endovascular approaches for childhood Takayasu arteritis (TAK) are limited. Our objective was to present the largest current real-world scenario for patients with childhood TAK undergoing interventions and their postinterventional outcomes.

METHODS

Data were collected for patients with childhood TAK admitted from 2002 to 2017. Complication/reintervention-free survival was projected by Kaplan-Meier methods. Associated factors for intervention and predictors for postinterventional complications/reinterventions were assessed via regression models.

RESULTS

Among 101 patients enrolled, 69 (68.3%) underwent 121 interventions (angioplasty 95, stenting 26) during a 3.1-year follow-up. Compared with the nonintervention group, the intervention group independently associated with a male population (odds ratio [OR] 0.27, P = 0.035) and type IV disease (OR 17.92, P = 0.001). Male sex also marginally indicated a risk for reintervention (hazard ratio [HR] 3.22, P = 0.05). Baseline retinopathy, delay in diagnosis, and descending thoracic aorta involvement were associated with stent insertion (P < 0.05). Hypertension secondary to renal artery stenosis (RAS; 59.4%) or mid-aorta stenosis (MAS; 14.5%), heart failure (21.7%), and claudication (21.7%) were leading clinical hints for interventions. The technical success rate was 96.7%. During a median 2.88-year of follow-up after intervention, 36 lesions occurred with complications in 28 patients, and 22 lesions in 17 patients, particularly on the renal artery or mid-aorta. The 5-year complication-free and reintervention-free survivals were 50.7% and 65.8%, respectively. Peri-interventional dual antiplatelet therapy (DAPT; HR 0.31), concurrent surgery (HR 26.5), and technical failure (HR 3.65) were independent predictors for complications (P < 0.05). Male sex (HR 2.52), retinopathy secondary to hypertension (HR 3.41), and pulmonary artery hypertension (PAH; HR 3.64) were baseline indicators for complications (P < 0.05).

CONCLUSION

Over two-thirds of patients with childhood TAK require interventions, and the 5-year complication-free survival is 50.7%. Male sex, retinopathy, and PAH at baseline indicate the possibility of unfavorable outcomes. Interventions on MAS or RAS in childhood TAK raise specific concerns. DAPT peri-intervention appears to protect patients with childhood TAK from postinterventional complications.

Pathophysiology and therapy of systemic vasculitides

Systemic vasculitides represent uncommon conditions characterized by the inflammation of blood vessels that can lead to different complex disorders limited to one organ or potentially involving multiple organs and systems. Systemic vasculitides are classified according to the diameter of the vessel that they mainly affect (small, medium, large, or variable). The pathogenetic mechanisms of systemic vasculitides are still partly unknown, as well as their genetic basis. For most of the primary systemic vasculitides, a single gold standard test is not available, and diagnosis is often made after having ruled out other mimicking conditions. Current research has focused on new management protocol and therapeutic strategies aimed at improving long-term patient outcomes and avoiding progression to multiorgan failure with irreversible damage. In this narrative review, authors describe different forms of systemic vasculitides through a review of the literature, with the aim of highlighting the current knowledge and recent findings on etiopathogenesis, diagnosis and therapy.

Biologic therapy in supra-aortic Takayasu arteritis can improve symptoms of cerebral ischaemia without surgical intervention

OBJECTIVES

Takayasu arteritis commonly results in severe arterial injury with stenoses, occlusions and occasionally aneurysms. Arterial disease may compromise organ blood flow and result in significant cardiovascular morbidity and premature mortality. Involvement of the supra-aortic arteries is common, and in its most severe form may compromise cerebral blood supply, resulting in signs of cerebral ischaemia including visual impairment, dysphasia, transient hemiparesis, loss of consciousness and stroke. In addition to combination immunosuppression, the management paradigm for symptomatic cerebral ischaemia includes revascularization. The invasive nature of this surgery, the risk of complications and the relatively high rate of re-stenosis is of concern to patients and their physicians alike. The aim of this study was to determine whether combined immunosuppression with early escalation to biologic therapy improved outcomes and reduced the need for high risk surgical intervention.

METHODS

A retrospective review of 145 Takayasu arteritis patients attending Imperial College Healthcare between 2010-2018 was conducted to identify those with cerebral ischaemia secondary to supra-aortic disease and to analyse their treatment and outcomes.

RESULTS

Eight patients (5.5%) were identified. Seven patients received long-term combined immunosuppressive therapy and six were prescribed biologics. The data revealed a higher than expected comprehensive response to therapy, with significant falls in disease activity, the cerebral ischaemia score and the prednisolone dose required, over a median follow-up of 37 months. Serial imaging analysis detected no arterial disease progression after the initiation of optimal therapy. Only one patient required surgical intervention for persistent neurological symptoms.

CONCLUSION

Early use of biologic therapy in those with supra-aortic Takayasu arteritis presenting with cerebral ischaemia may reduce the numbers of patients requiring surgical intervention and improve outcomes.

Childhood-onset Takayasu Arteritis

Childhood-onset Takayasu Arteritis (cTAK) is a rare, large-vessel type of vasculitis seen in children, mainly affecting the aorta and its major branches. Clinical manifestations are often severe and arise as a result of systemic and local inflammation, along with end-organ ischemia. Disease flares are common and the disease burden is high, with a significant rate of morbidity and mortality. Recent advances in understanding the underlying disease pathobiology resulted in the use of pathway-targeting agents, such as TNF- or IL-6 inhibitors with improved disease control. Nonetheless, the prognosis often remains guarded and the accrued damage is significant. This review aims at summarizing the recent evidence and observations regarding this condition, with a focus on pediatric publications.

Surgical Treatment in Patients With Aortic Regurgitation Due to Takayasu Arteritis

BACKGROUND

Aortic regurgitation is a common complication in patients with Takayasu arteritis. Severe aortic regurgitation requires surgical treatment. We investigated the outcomes of aortic valve replacement (AVR) and composite graft replacement (CGR) in patients with Takayasu arteritis and aortic regurgitation.

METHODS

We retrospectively reviewed the data from 41 patients with Takayasu arteritis and aortic regurgitation treated by AVR (n = 23) and CGR (n = 18) from January 1992 to December 2016.

RESULTS

The mean age at operation was 40.3 years, and 61.0% were women. Concurrent procedures were performed in 43.9% of patients. The preoperative aortic root diameter in the AVR and CGR groups was 41.5 ± 7.9 and 47.8 ± 9.5 mm, respectively. The cardiopulmonary bypass time was longer in the CGR group (140.2 ± 44.8 minutes) than in the AVR group (105.2 ± 32.5 minutes). No in-hospital death occurred. During a median follow-up of 6.6 years (interquartile range, 0.6-9.4) we observed 10 patients with composite adverse events in the AVR group (1 death, 3 reoperations, 3 residual ascending aorta aneurysms, 6 paravalvular leaks, and 1 valve detachment) and 2 composite events in the CGR group (2 deaths and 1 paravalvular leak). The unadjusted 5-year event-free rate was 55.8% and 91.7% in the AVR and CGR groups, respectively (log-rank P < .05). CGR was associated with nominally lower events on adjusted analysis (hazard ratio, 4.212; 95% confidence interval [0.910, 19.509]; P = .066).

CONCLUSIONS

Paravalvular leak was the main postoperative complication. CGR was associated with nominally fewer adverse events.

[Revascularization of supra-aortic trunks in Takayasu's arteritis]

INTRODUCTION

Takayasu's disease is an inflammatory arteritis mainly affecting the aorta, its main divisional branches and pulmonary arteries. The arterial damage during Takayasu's disease is essentially occlusive and preferentially affects supra-aortic trunks. Indications for revascularization of supra-aortic trunks are clear but results are rarely reported. The purpose of this study was to evaluate the results of supra-aortic trunk revascularization in Takayasu's arteritis.

PATIENTS AND METHODS

We report a retrospective study conducted between 2012 and 2018 about patients with Takayasu's arteritis who underwent revascularization of supra-aortic trunks.

RESULTS

Our series consisted of six patients. All patients were female. The average age was 29 (range 18-48) years. The operative indication was cerebrovascular ischemic symptoms in five patients and intermittent claudication of the upper limb in one. We performed aorto-bi-carotid bypass in four patients, a subclavian artery angioplasty in one and a vertebral artery angioplasty in one. At 1 month, operative mortality was zero and morbidity was marked by hemorrhagic stroke in one patient operated by conventional surgery. The average follow-up was 4 years (1.8). During the follow-up, one patient was reoperated after 18 months for an anastomotic false aneurysm in the ascending aorta. We noted a favorable outcome with total resolution of the symptomatology for the other patients and Doppler ultrasound confirmed patency during follow-up.

CONCLUSION

Surgical revascularization of supra-aortic trunks in Takayasu's arteritis can be associated with a risk of stroke and a risk of anastomotic pseudoaneurysms. Endovascular revascularization appears to be less invasive but its long-term results are rarely reported.