Endovascular Revascularization for Carotid Artery Occlusion in Patients with Takayasu Arteritis

Surgical intervention of Takayasu's arteritis with supraaortic arterial occlusive disease and critical ischemia of upper extremity: A case report

Type I Takayasu's arteritis is a rare form of large vessel vasculitis with an unknown etiopathogenesis. It is characterized by progressive chronic inflammation and occlusive thromboaortopathy affecting the aorta and its main branches. Type I Takayasu's arteritis predominantly affects women and is most commonly observed in their third decade of life. In this report, we present the case of a 32-year-old female patient who exhibited severe long-segment stenosis in the left common carotid artery and total occlusion of the left subclavian artery. The patient experienced significant ischemic symptoms of the left upper extremity and had previously been diagnosed with Takayasu's arteritis, being followed up under maintenance corticosteroid therapy. To address these complications, we conducted a surgical bypass using a prosthetic graft. The graft was inserted intrathoracically, extending from the patient's ascending aorta to both the left common carotid artery and the left distal subclavian artery. This approach was designed to closely mimic anatomical routes, promoting optimal graft patency. In the context of this case, we highlight the importance of surgical intervention in alleviating ischemia and explore potential surgical alternatives for treating patients with Takayasu's arteritis involving the supraaortic region.

Angioplasty for Supra-Aortic Arterial Lesions from Takayasu Arteritis: Efficacy of Cutting Balloon Angioplasty Versus Conventional Balloon Angioplasty

BACKGROUND

This retrospective study aimed to evaluate the safety and efficacy of cutting balloon angioplasty and conventional balloon angioplasty in supra-aortic arterial lesions caused by Takayasu arteritis.

METHODS

A total of 46 patients with supra-aortic arterial lesions between January 2011 and December 2018 were included. Cutting balloon angioplasty was applied for 17 patients with 24 supra-aortic arterial lesions (group A), while 29 patients with 36 supra-aortic arterial lesions received conventional balloon angioplasty (group B). The preoperative clinical manifestation, operation result, and postoperative outcomes were recorded and compared in the 2 groups.

RESULTS

Dizziness, visual disturbance, and unequal/absent pulses were the most common manifestations. The technical success of revascularization was 93.5% (43/46) in patients and 93.3% (56/60) in lesions. The stent implantation rate in group A was significantly lower than that in group B (4.2% vs. 50% in lesions, P < 0.05). Restenosis was the most common complication in both groups. Although the early (≤30 days) and late (>30 days) complications in group A were less than those in group B, there was no significant difference between the 2 groups (P > 0.05). Moreover, the primary-assisted patency of cutting balloon angioplasty and conventional balloon angioplasty at 1, 2, and 5 years were 66.7%, 62.5%, and 62.5% and 61.1%, 58.2%, and 49.8%, there was no significant difference between the 2 groups (P > 0.05), respectively.

CONCLUSIONS

Compared with conventional balloon angioplasty, cutting balloon angioplasty could be considered a safe and effective alternative for supra-aortic arterial lesions caused by Takayasu arteritis, demonstrating better patency and clinical benefit.

Endovascular Intervention in a Narrowing Vessel of the Left Vertebral Artery with Bilateral Common Carotid Artery Occlusion and Aneurysm Rupture and Hemorrhage in the V4 Segment of the Right Vertebral Artery

In this study, a case of bilateral common carotid artery occlusion and aneurysm in the V4 segment of the right vertebral artery with constriction of the left vertebral artery is presented. By improving digital subtraction angiography, an elderly female patient with subarachnoid haemorrhage (SAH) was diagnosed with a V4 segment of right vertebral artery aneurysm, a microaneurysm at the beginning of basilar aneurysms, bilateral common carotid artery occlusion, and narrowing vessel of left vertebral artery (DSA). Through the compensation of the basilar artery, the bilateral vertebral arteries provide intracranial and extracranial blood. Because the vertebral artery is narrowed, the right vertebral artery has priority in intracranial and extracranial blood delivery. Many members of the patient's immediate family have vasculitis, which has yet to be proven by appropriate laboratory testing but is thought to be the major cause of big artery occlusion. After cerebral angiography, the major source of this subarachnoid haemorrhage was determined to be a V4 segment of right vertebral artery aneurysm. Endovascular stent-assisted coil embolization was used to treat a V4 section of the right vertebral artery aneurysm. Because the basilar aneurysm was distal to the artery, interventional embolization was difficult to do, and it was not the major cause of the subarachnoid haemorrhage, the patient was advised to have follow-up surveillance, and she recovered well following the procedure. The combination of endovascular intervention of bilateral common carotid artery blockage and V4 segment of right vertebral artery aneurysm yielded excellent clinical outcomes in this instance. Endovascular treatment of a bilateral common carotid artery blockage paired with a V4 segment of a right vertebral artery aneurysm yielded excellent clinical outcomes in this patient, although long-term follow-up is necessary.

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.

2021 American College of Rheumatology/Vasculitis Foundation Guideline for the Management of Giant Cell Arteritis and Takayasu Arteritis

OBJECTIVE

To provide evidence-based recommendations and expert guidance for the management of giant cell arteritis (GCA) and Takayasu arteritis (TAK) as exemplars of large vessel vasculitis.

METHODS

Clinical questions regarding diagnostic testing, treatment, and management were developed in the population, intervention, comparator, and outcome (PICO) format for GCA and TAK (27 for GCA, 27 for TAK). Systematic literature reviews were conducted for each PICO question. The Grading of Recommendations Assessment, Development and Evaluation methodology was used to rate the quality of the evidence. Recommendations were developed by the Voting Panel, comprising adult and pediatric rheumatologists and patients. Each recommendation required ≥70% consensus among the Voting Panel.

RESULTS

We present 22 recommendations and 2 ungraded position statements for GCA, and 20 recommendations and 1 ungraded position statement for TAK. These recommendations and statements address clinical questions relating to the use of diagnostic testing, including imaging, treatments, and surgical interventions in GCA and TAK. Recommendations for GCA include support for the use of glucocorticoid-sparing immunosuppressive agents and the use of imaging to identify large vessel involvement. Recommendations for TAK include the use of nonglucocorticoid immunosuppressive agents with glucocorticoids as initial therapy. There were only 2 strong recommendations; the remaining recommendations were conditional due to the low quality of evidence available for most PICO questions.

CONCLUSION

These recommendations provide guidance regarding the evaluation and management of patients with GCA and TAK, including diagnostic strategies, use of pharmacologic agents, and surgical interventions.

2021 American College of Rheumatology/Vasculitis Foundation Guideline for the Management of Giant Cell Arteritis and Takayasu Arteritis

OBJECTIVE

To provide evidence-based recommendations and expert guidance for the management of giant cell arteritis (GCA) and Takayasu arteritis (TAK) as exemplars of large vessel vasculitis.

METHODS

Clinical questions regarding diagnostic testing, treatment, and management were developed in the population, intervention, comparator, and outcome (PICO) format for GCA and TAK (27 for GCA, 27 for TAK). Systematic literature reviews were conducted for each PICO question. The Grading of Recommendations Assessment, Development and Evaluation methodology was used to rate the quality of the evidence. Recommendations were developed by the Voting Panel, comprising adult and pediatric rheumatologists and patients. Each recommendation required ≥70% consensus among the Voting Panel.

RESULTS

We present 22 recommendations and 2 ungraded position statements for GCA, and 20 recommendations and 1 ungraded position statement for TAK. These recommendations and statements address clinical questions relating to the use of diagnostic testing, including imaging, treatments, and surgical interventions in GCA and TAK. Recommendations for GCA include support for the use of glucocorticoid-sparing immunosuppressive agents and the use of imaging to identify large vessel involvement. Recommendations for TAK include the use of nonglucocorticoid immunosuppressive agents with glucocorticoids as initial therapy. There were only 2 strong recommendations; the remaining recommendations were conditional due to the low quality of evidence available for most PICO questions.

CONCLUSION

These recommendations provide guidance regarding the evaluation and management of patients with GCA and TAK, including diagnostic strategies, use of pharmacologic agents, and surgical interventions.

Endovascular management of symptomatic stenosis of supra-aortic arteries in patients with Takayasu arteritis

BACKGROUND

Endovascular management is used to treat Takayasu arteritis (TA) involving the supra-aortic branches. However, the long-term outcome of this treatment remains unclear. Here, technical safety, outcomes, and restenosis management of supra-aortic arteries in TA patients receiving endovascular treatment were evaluated.

METHODS

TA patients with symptomatic supra-aortic stenosis who underwent percutaneous angioplasty and stenting between 2008 and 2018 at our institute were enrolled in this study. Pre- and post-procedural magnetic resonance imaging (MRI) evaluations, including high-resolution vessel wall imaging (HR-VWI), were performed. Technical efficacy, peri-procedural complications, early post-procedural MRI results, and stent patency were examined.

RESULTS

All six patients successfully received stent placement or percutaneous transluminal angioplasty in a total of 22 treated arteries without neurologic complications. During follow-up (mean, 56.3 ± 41.1 months), no recurrent stroke occurred, yet significant restenosis developed in 12 of 22 (54.5%) of the treated arteries. Three of the patients underwent HR-VWI before surgery. Concentric wall thickening and enhancement of the left common carotid artery was detected in one patient, indicating acute inflammation. Angioplasty with drug-eluting balloon (DEB) successfully treated a case of refractory restenosis. Among 10 early post-procedure MRI performed, only two asymptomatic new lesions were detected with diffusion-weighted imaging.

CONCLUSION

Endovascular treatment of supra-aortic arteries of TA patients was safe and effective, yet was associated with a high restenosis rate. Thus, close follow-up is needed. HR-VWI is helpful for pre-procedural selection of patients for percutaneous angioplasty and stenting and drug-eluting balloon angioplasty appears to be a promising treatment for refractory in-stent restenosis.

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.

Multiple occlusions in extracranial arteries in patients with aortic arch syndrome: is minimally invasive treatment still possible? Technical aspects of the treatment based on our own experience and a review of the literature

Takayasu arteritis is a large vessel vasculitis of granulomatous nature and unknown aetiology affecting predominantly the aorta and its major branches, which may lead to ischaemic symptoms of many organs including the central nervous system. To decrease the risk of neurological complications and improve the quality of life, an arterial revascularisation may be necessary. The treatment options include pharmacotherapy as well as both open surgical and endovascular procedures, which has to be carefully chosen to obtain clinical success. There is an ongoing debate on the advantages, possibilities, and indications for implementing endovascular and open surgical methods, especially in high-risk patients. In this article we present our own experience in the treatment of an unusually complex and high-risk patient with multiple occlusion of supra-aortic branches, focusing on the technical aspects of the procedures and the decision-making process, as well as to confront with contemporary medical knowledge.

Surgery and Endovascular Management in Patients With Takayasu's Arteritis: A Ten-Year Retrospective Study

BACKGROUND

Takayasu's arteritis (TA) is an uncommon chronic vasculitis, and there is a lack of long-term large cohort studies regarding the optimal revascularization outcomes of patients with TA.

METHODS

One hundred and sixteen patients with TA who underwent surgery or endovascular repair over a 10-year period were studied retrospectively. One hundred and fifty-four vascular procedures were performed consisting of 69 open and 85 endovascular repairs.

RESULTS

After a mean follow-up period of 48.5 ± 38.5 months, three cases each of cerebrovascular accident (CVA) and death occurred in the open repair group while two cases of CVA and 4 deaths were observed in the endovascular repair group. At 1, 3, 5, and 10 years of follow-up, the primary patency rates were 97.3%, 86.2%, 70.5%, and 48.8% in the open repair group and 93.3%, 73.1%, 57.5%, and 31.8% in the endovascular repair group, respectively. The primary assisted patency rates were 98.2%, 90.3%, 73.2%, and 47.2% in the open repair group and 95%, 81%, 64.4%, and 35% in the endovascular repair group, respectively. The secondary patency rates were 98.2%, 96.1%, 83.5%, and 56.2% in the open repair group and 98.7%, 86%, 71.2%, and 44.9% in the endovascular repair group, respectively. The cumulative survival rates were 96.9%, 96.9%, 96.9%, and 90% in the open repair group and 97.4%, 97.4%, 88%, and 79.2% in the endovascular repair group, respectively.

CONCLUSIONS

Both surgical repair and endovascular management are safe and efficient modes of treatment of TA. Surgical repair showed long-term durability, and it is suitable for complex lesions and failed cases of endovascular management.

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.

[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.

Simultaneous Multi-Supra-Aortic Artery Bypass Successfully Implemented in 17 Patients with Type I Takayasu Arteritis

OBJECTIVE

Type I Takayasu arteritis is common in Chinese patients and usually leads to cerebral ischaemia. There are limited data regarding simultaneous multi-supra-aortic artery (SMSAA) bypass in patients with type I Takayasu arteritis. The present study shares experience of using this method.

METHODS

Seventeen patients with Takayasu arteritis who received SMSAA bypass from June 2012 to March 2016 were included in this analysis. Demographic features and basic information were recorded. Follow up results, including major complications, patency rates, and survival rates, were also obtained. The EQ-5D questionnaire was also administered to evaluate the quality of life of patients.

RESULTS

Among these 17 patients, there were 77 supra-aortic arteries affected by TA and 37 arteries were reconstructed, 10 with great saphenous vein and 27 with artificial blood vessels. All the operations were technical successes and the mean operation time was 396.6 ± 93.4 min. The patients were followed for a mean of 25.2 ± 12.3 months. Two graft restenoses were found, and both were successfully recanalised by balloon dilatation. One patient suffered a minor stroke but was free from obvious sequelae. No major complications, recurrent symptoms, or deaths occurred during the follow up period. The EQ-5D questionnaire scores were significantly improved after the operation compared with the pre-operative scores (87.14 ± 8.25 vs. 58.93 ± 14.4, p < .01), and all the patients enjoyed a satisfactory quality of life.

CONCLUSION

SMSAA bypass in type I Takayasu arteritis can be effectively and safely performed with rigorous peri-operative management. Maintaining the patency of the bypass graft relieves the symptoms of cerebral ischaemia and helps sustain patients' quality of life.

Takayasu&rsquo;s arteritis: a review of the literature and the role of endovascular treatment

Takayasu's arteritis (TA) is a chronic non-specific vasculitis with variable presentation in different ethnicities and countries. Treatment options vary and are dependent on the stage and presentation of the disease. We aimed to review current literature related to TA, focusing on the role of endovascular treatment in revascularisation. The temporal course of the disease and stage at presentation influence the management of TA. Treatment options include medical therapy, endovascular intervention or surgical vascular reconstruction. The decision to intervene is individualised according to vascular anatomy and the presence of haemodynamically significant lesions. There are currently no clear guidelines regarding the choice between the endovascular and open surgical approaches, but studies have shown that endovascular procedures are associated with slightly higher rates of restenosis while surgical procedures have higher rates of thrombosis. Periprocedural immunosuppression is suggested if the disease is active at the point of intervention. This improves outcomes but at the cost of immunosuppression-related side effects. Careful long-term follow-up is essential due to the risk of disease activation or flare-up, requiring appropriate evaluation of the diseased vessels.

Surgical intervention and its role in Takayasu arteritis

Vascular surgery remains an important option in the management of Takayasu arteritis (TA). Its use is predominantly confined to the treatment of symptomatic organ ischaemia or life-threatening aneurysm formation. In most cases, this follows the failure of medical therapy to prevent arterial injury. Open surgery and endovascular approaches are used. The choice between them, at least in part, is determined by the site and nature of the lesion. Open surgery, although more invasive, offers enhanced duration of arterial patency, whereas for endovascular intervention, primary angioplasty without stenting is preferred, with stenting reserved for primary or secondary angioplasty failures. Although there is increasing interest in the role of stent grafts and tailor-made endovascular stents, long-term outcomes remain to be reported. Interventional outcomes are improved and complications reduced by therapeutic control of disease activity before and after surgery. The wider use of combined immunosuppression and the introduction of biologic therapy for refractory TA may reduce future requirements for surgical intervention.

Concomitant Hybrid Arch Vessel Reconstruction and Intracranial Clot Retrieval in Takayasu's Arteritis Presenting with Acute Cerebral Ischemia: A Case Report

BACKGROUND

Type 1 Takayasu's arteritis (TA) predominantly affects the supra-aortic branches. Occlusive disease can cause catastrophic complications such as stroke and death. Open and endovascular techniques of revascularization are described for extracranial disease. There is currently no default choice of surgical intervention. Furthermore, the management of distal intracranial complications has not been described.

METHODS

A 25-year-old woman with known TA on immunosuppression was presented with acute left middle cerebral artery (MCA) stroke. Computed tomography angiogram and formal cerebral digital subtraction angiography demonstrated critical stenoses or occlusion of all arch vessels except for the left subclavian artery (SCA), which was also stenosed at the origin. The left vertebral artery was the sole inflow to the brain. Furthermore, there was acute embolus in M1 of MCA and A1 of the anterior cerebral artery (ACA). Surgical access was achieved by bilateral common carotid artery (CCA) and left SCA exposures. Extracranial revascularization was performed using a hybrid technique: (i) left SCA covered stent; (ii) left SCA to right CCA bypass; (iii) left CCA thrombectomy; (iv) left CCA covered stent; and (v) left CCA interposition bypass. This was immediately followed by clot retrieval in the MCA and ACA territory for intracranial revascularization.

RESULTS

There were no major postoperative complications and the patient made an excellent neurologic recovery.

CONCLUSIONS

Hybrid vascular reconstruction for extracranial disease with concomitant clot retrieval for intracranial disease is a novel approach to achieving emergency revascularization in active TA.

Factors Associated With Need for Revascularisation in Non-coronary Arterial Occlusive Lesions Secondary to Takayasu's Arteritis

OBJECTIVE/BACKGROUND

Takayasu's arteritis (TA) is rare inflammatory large vessel form of vasculitis. The objective of this study was to evaluate experience in the management of TA patients and to identify the influence of inflammatory markers and clinical variables associated with disease progression, worsening ischaemic symptoms, and the need for interventions.

METHODS

Demographics, and laboratory and clinical variables in patients that required revascularisation procedures were compared with those who had adequate symptomatic control with medical management. Categorical data were analysed with Fisher's exact test, continuous variables with two-sample t test, and a life table analysis was used to study the recurrence of symptoms in intervened patients.

RESULTS

From January 1995 to May 2016, 47 patients (mean age 30 years; range 14-59 years) were managed; 44 (94%) were female. During the mean follow-up period of 120 months, 21 (45%) underwent 23 procedures (17 of these [74%] open, six [26%] endovascular). From the intervened group, eight (38%) patients presented with transient ischaemic attacks, five (24%) with renovascular hypertension, and four (19%) with upper extremity and four (19%) lower extremity claudication. Comparative analysis demonstrated that elevation of erythrocyte sedimentation rate (ESR) at the time of the diagnosis (revascularisation group: median value 28 mm/hour; medical management group: median value 15 mm/hour) was associated with progression of the disease, worsening symptoms, and subsequent need for intervention (p = .04). Active smoking was a factor connected with the need for revascularisation (p = .05). Immediate symptomatic improvement occurred in 19 (90%) patients that underwent surgical or endovascular revascularisation.

CONCLUSION

Patients with TA who underwent interventions had higher ESR at the time of diagnosis; this factor and active smoking were associated with progression of the disease and worsening ischaemic symptoms despite medical therapy. Revascularisation procedures are effective at relieving symptoms; lifelong surveillance is necessary.

Open and Endovascular Management of Severe Cerebral Ischemia in Takayasu's Arteritis

BACKGROUND

Severe cerebral ischemia in patients with Takayasu's arteries was caused by occlusion of most supra-aortic arteries. Arterial revascularization is necessary to decrease the incidence of stroke and improve the quality of life but may be complicated with multiple occlusive lesions and inflammation condition of this disease. This study was to assess options and long-term outcomes of surgical and endovascular treatment.

METHODS

Twenty-nine patients with severe cerebral ischemic symptoms underwent surgical or endovascular treatment from January 1991 to July 2015. Demographic characteristics, surgical and endovascular procedures, and follow-up outcomes were reviewed. Risk factors associated with primary patency of surgical treatment and assisted primary patency of endovascular treatment was identified by Cox regression analyses.

RESULTS

There were 29 patients with a median age of 24 (range 9-37 years), 9 in active and 20 in inactive phase. Seventeen patients underwent a variety of bypass procedures. Fourteen endovascular procedures were performed in 12 patients. No death occurred within 30 days after both procedures. Complications within 30 days after bypass included stroke in 1 patient, infection in 2 patients, and heart failure in 1 patient. Nine patients developed brain hyperperfusion after bypass. Transient hemiplegic paralysis occurred in 1 patient during dilation of the carotid artery. During a median follow-up time of 41 months, primary and secondary patency rate of bypass at 1 and 3 years was 93.75% and 100% and 87.5% and 100%, respectively. Assisted primary and secondary patency rate of endovascular treatment at 1 and 3 years was 85.71% and 92.86% and 68.18% and 75.66%, respectively. There was no independent risk factor associated with either primary patency of surgical treatment or assisted primary patency of endovascular treatment. Disease activity was independent risk factor associated with combined rate of primary patency of surgical treatment and assisted primary patency of endovascular treatment (HR: 0.17, 95% CI: 0.03-0.93, P = 0.04).

CONCLUSIONS

Bypass is the preferred treatment in majority of patients with good long-term patency, even has a higher propensity for postoperative complications. Endovascular treatment should be preserved for short lesions in inappropriate or high-risk surgical patients but needs more reintervention and close monitoring of lesion for better outcomes. Long-term patency of surgical and endovascular treatment is related with disease activity. Combination of surgical or endovascular treatment and medical therapy may improve the efficacy of interventions.

How to Clamp and Bypass if There Is Single Artery Supply to the Head and That Contains Severe Stenosis?

Takayasu arteritis manifests with arterial occlusions and aneurysms. Revascularization is sometimes challenging, especially when carotid arteries are affected. In this report, we present a carotid artery revascularization technique in a patient who was admitted with orthostatic and postprandial transient ischemic attacks, resulting in a diagnosis of bilaterally occluded subclavian and vertebral arteries, occluded left common carotid artery, and severely stenosed right common carotid artery. Clamping of the right carotid artery was a challenge; however, our technique provides a neurologically safe revascularization.

Left subclavian-carotid bypass in a 38-year old female with brain ischemic symptoms secondary to Takayasu's arteritis: A case report

Introduction

Takayasu’s arteritis (TA) is a rare form of vasculitis that affects the aorta, its branches and pulmonary arteries. TA is primarily treated by pharmacologic therapy; however revascularization procedures may be required to treat organ ischemia. Evidence-based consensus regarding the indications for surgical or endovascular therapy for patients with supra-aortic vessels lesions remains unclear.

Presentation of case

We herein present a female patient with known TA since 2000, who experienced progressive and frequent episodes of amaurosis fugax in the left eye for 4 months. Computed tomography angiography (CTA) revealed focal stenotic segments in the right common carotid artery (CCA) and internal carotid artery (ICA) and near occlusion of the proximal left CCA. We opted to treat the left side first with open revascularization, and a subclavian-carotid bypass was performed using a 6 millimeters (mm) externally supported ePTFE graft. Patient recovered well from the surgery, her neurological exam was normal and she was discharged home in stable condition in postoperative day three. At three months she remains symptoms-free and her bypass is patent.

Discussion/Conclusion

This case illustrates the clinical presentation of TA affecting both carotid arteries; open revascularization via carotid subclavian bypass grafting was successfully performed with minimal morbidity, complete resolution of symptoms and improvement of the patient’s quality of life. Revascularization procedures when indicated should be performed while the disease is inactive and close surveillance is mandatory.