Long-term outcome after surgical treatment of arterial lesions in Behçet disease

Recommendations for the management of the vascular involvement in Behçet's disease by the Japanese National Research Committee for Behçet's disease-secondary publication

OBJECTIVES

This study aimed to develop clinical guidelines for the management of vascular Behçet's disease (BD) by the Behçet's Disease Research Committee of the Ministry of Health, Labour and Welfare of the Japanese Government.

METHODS

A task force proposed clinical questions (CQs) concerning vascular BD based on a literature search. After screening, draft recommendations were developed for each CQ and brushed up in three blinded Delphi rounds, leading to the final recommendations.

RESULTS

This study provides recommendations for 17 CQs concerning diagnosis and differential diagnoses, assessment of disease activity, and treatment. The guidelines recommend immunosuppressive treatments, for both arterial and venous involvement with active inflammation. Anticoagulation is also recommended for deep vein thrombosis except in high-risk patients. Surgical and endovascular therapies can be optional, particularly in patients with urgent arterial lesions undergoing immunosuppression. In addition, two sets of algorithms for diagnosis and treatment are shown for arterial and venous involvement.

CONCLUSIONS

These recommendations are expected to serve as useful tools in the daily clinical practice of BD. This content has already been published in Japanese in the Guideline for the Management of Behçet's Disease 2020 and is submitted with permission from both the primary and secondary publishers.

Hybrid surgery management challenges of a Behcet's disease patient with recurrence of aortic aneurysms: a case report

Background

Behcet's disease is a vasculitis of unknown origin that can involve multiple organs or tissues. Aneurysm or pseudoaneurysm, also one of the complications of Behcet's disease, is usually accompanied by a poor prognosis. Surgery is usually accompanied by a high risk of complications, such as the recurrence of anastomotic pseudoaneurysms and blockage of the target vessel. Using hybrid surgery, we successfully treated a complex and recurrent abdominal aortic pseudoaneurysm in a patient with BD.

Methods

We report a 32-year-old female diagnosed with Behcet's disease with recurrent thoracoabdominal aortic aneurysm. Adequate immunotherapy was given during the perioperative period. The splanchnic artery branches were reconstructed, and the aneurysm was sequestered with endovascular repair. The patient recovered uneventfully and was discharged from the hospital 8 days after hybrid surgery. At the 60-month follow-up, no aneurysm was observed, the stent had no displacement or internal leakage, and the reconstructed blood vessels were unobstructed.

Conclusion

Hybrid surgery could be a feasible and effective strategy for BD aneurysms. Adequate preoperative and postoperative immunotherapy with arterial anastomosis away from the diseased artery may be the key to success.

Aortic sinus aneurysm invading ventricular septum and dissection caused by Behcet's disease: a case report and literature review

Few case reports have mentioned the aortic sinus aneurysm invading ventricular septum and dissection caused by Behcet's disease. Here, we reported a 36-year-old male patient with an aortic sinus aneurysm invading the ventricular septum and dissection caused by Behcet's disease, who manifested as recurrent chest tightness and shortness of breath. Cardiac ultrasound showed the rupture of the right aortic sinus and the formation of ventricular septal dissection. Ascending aortic valve prosthesis replacement, mitral valvuloplasty with ring implantation and tricuspid valvuloplasty were performed. Postoperatively, he was treated with hormones, hydroxychloroquine sulfate, mycophenolate mofetil tablets, thalidomide and warfarin, and his symptoms were relieved. This is a rare case easily being misdiagnosed and missed, early diagnosis and in-time treatment are crucial to avoid surgical complications. The diagnostic and therapeutic approaches of this patient were reported and related literature was reviewed in this case report.

Long-term outcomes of endovascular treatment for aortic pseudoaneurysm in patients with Behçet's disease

OBJECTIVES

Behçet's disease (BD) is a multisystem inflammatory disorder with unknown etiology, and its aneurysmal lesions are associated with high mortality due to the high risk of rupture. This study intended to further explore the long-term safety and efficacy of endovascular therapy for BD-related aortic pseudoaneurysm (BAP).

METHODS

From January 2009 to May 2021, 17 BAP patients who underwent endovascular repair were retrospectively identified and enrolled. Adequate immunosuppressive treatment was instituted before and after endovascular treatment unless emergency surgery was required. The patients were followed up at 3, 6, and 12 months and yearly after the primary endovascular intervention by computed tomography angiography (CTA) examination.

RESULTS

Nineteen BAPs were identified among 17 patients. BAPs located at the aortic arch were found in three patients (17.6%), descending thoracic aorta in 5 (29.4%), and abdominal aorta in 10 (58.8%; suprarenal abdominal aorta in 2 [11.8%], and infrarenal abdominal aorta in 8 [47.1%]). The mean ESR during admission was 56.5 ± 24.9 mm/h (range = 30.0-120.0 mm/h), which fell to 22.7 ± 18.4 mm/h (range = 2.0-74.0 mm/h) before the endovascular intervention (p < 0.001). The rate of favorable immunosuppressive control before intervention is 76.5% (13/17). Technical success was achieved in all patients. Median follow-up time was 57.0 months (interquartile range [IQR] = 21.3-67.3 months). Pseudoaneurysm recurrence was observed in four patients, type I endoleak in one, pseudoaneurysms sac dilation in one, and external iliac artery occlusion in 1. Two patients died of pseudoaneurysm rupture. Five-year accumulated overall rate, recurrence-free rate, and reintervention-free survival rate of BAP patients were 92.8%, 75.4%, and 71.8%, respectively.

CONCLUSION

Endovascular treatment in BAP patients seemed to be associated with long-term safety and efficacy with a 5-year overall survival rate of 92.8%. Adequate immunosuppressive treatment was essential for BAP patients to prevent aortic pseudoaneurysm recurrence and improve the prognosis.

Adjunctive proximal aortic and aortodistal prosthetic wrapping of vascular anastomoses for Adamantiadis-Behçet's aortic/aortoiliac aneurysms: A revisit

BACKGROUND

We described our local experiences with a single-layer wrapping technique for the vascular anastomoses in patients with Adamantiadis-Behçet's aortic/aortoiliac aneurysms using InterGard Silver-impregnated Dacron® patch prosthesis.

METHODS

Between January 2013 to December 2019, we retrospectively reviewed 20 patients presented with Adamantiadis-Behçet's aortic/aortoiliac aneurysms. All patients presented with Adamantiadis-Behçet's aortic/aortoiliac aneurysms. Two groups were analyzed, Group I, considered as a control group (n = 20). While group II (n = 20), of which prosthetic wrapping was performed. Follow up took place for a maximum of 24 months.

RESULTS

during a six-year retrospective study period, 20 patients were recruited. They included 15 males and five females (ratio 3:1). The median age was 30.5 ± 4.2 years. Anastomotic pseudoaneurysms were reported in group I (control, [non-wrapping group]). While group II doesn't (wrapping group). Paired samples t test revealed a significant difference between those underwent wrapping and those with non-wrapping (p = .019 and .038). False aneurysms were reported in 80% of the non-wrapping group as estimated by the Kaplan-Meier curves. While Log-rank test results revealed a significant difference between both the studied groups (p < .008). Primary graft patency was 90% at 24 months as reported by the Kaplan-Meier survival method.

CONCLUSIONS

adjunctive wrapping for vascular anastomoses using Intergard Silver-impregnated Dacron® patch in patients with Adamantiadis-Behçet's aortic/aortoiliac aneurysms is an applicable, simple, and reliable technique. It was associated with low morbidity and mortality rates. Moreover, we discussed a relatively old technique aiming to explore its success and safety in treating arterial aneurysms in Adamantiadis-Behçet's disease patients.

Specific Features of Patients Under 40 Years Old With Small-to-Medium-Sized Arterial Deterioration

Background

Arterial deterioration is mostly caused by atherosclerosis, which progresses with age. However, we have observed serious backgrounds or etiologies in younger patients with non-atherosclerotic diseases and deterioration of small-to-medium-sized arterial lesions. Therefore, we aimed to identify the specific features of patients aged <40 years with deterioration of small-to-medium-sized arteries.

Methods

We selected patients who were admitted to our department from 1995 to 2019 with deterioration of small-to-medium-sized arteries (aneurysms, dissection, rupture, or arterial injury/damage) and focused on the cohort aged <40 years. We examined the backgrounds or etiologies of the patients including genetic and inflammatory diseases, which might have caused the arterial deterioration.

Results

Consequently, more than half (54.1%) of the patients aged <40 years had non-atherosclerotic comorbid diseases. However, the number of deteriorated arterial lesions was higher in patients aged <40 years than in patients aged ≥40 years (3.13 vs. 1.33 lesion/patient; P = 0.011). Furthermore, the data analysis of patients with multiple arterial lesions (≥3) revealed that the younger population tended to have more specific backgrounds or etiologies, notably Ehlers-Danlos syndrome and Behçet's disease. There were no differences in the all-cause mortality and cardiovascular disease-related mortality between patients aged <40 and ≥40 years (P = 0.89 and 0.29, respectively).

Conclusions

Over 50% of patients aged <40 years with deterioration of small-to-medium-sized arteries had non-atherosclerotic, specific clinical backgrounds or etiologies, including genetic and inflammatory diseases. In addition, they exhibited more arterial lesions than older patients.

Combined medical therapy and neurosurgical revascularization preventing stroke in post-varicella angiopathy: Case report and review of literature

BACKGROUND

Post varicella angiopathy (PVA) is an underdiagnosed but potentially severe disease in both pediatric and adult settings. No guidelines are available for the medical and neurosurgical management of this condition. We report the first pediatric case with headache and PVA who was treated with surgical revascularization before the onset of ischemic events.

METHODS

This case report was conducted via retrospective chart review. A literature review was also completed, in order to identify previously described PVA undergone to revascularization.

RESULTS

We report on a 9-year-old boy presenting with a long history of headache and PVA involving the distal left middle cerebral artery. The arterial lesion rapidly worsened over a 10 months' period with formation of focal moyamoya-like collaterals, despite an adequate intravenous antiviral treatment. The pattern of headaches significantly changed with a clear left-side lateralization and a "re-build-up" phenomenon on EEG. The patient was treated with left superficial temporal artery - middle cerebral artery (STA-MCA) bypass and encephalo-duro-arterio-myo-pericranial-synangiosis. This combined treatment resulted in an immediate and persistent improvement of brain perfusion, accompanied by prompt resolution of neurological symptoms. Two cases who presented with Suzuki stage III (unilateral or bilateral) moyamoya PVA and recurrent strokes or transient ischemic attacks despite adequate pharmacological prophylaxis have been surgically treated using both indirect and direct revascularization technique. The outcome was good in both cases.

CONCLUSION

Surgical revascularization may have a role in the treatment of PVA and may prevent stroke. Given the lack of standardized treatment algorithms, individualized regimens should be formulated on a case-specific basis.

Angiographic patterns and temporal changes of arterial lesions in Behcet's disease

BACKGROUND

Behcet's disease (BD) can entail vascular involvement in various forms including aneurysm. We evaluated the angiographic patterns and changes in arterial lesions over time in BD patients with arterial involvement.

METHODS

We reviewed the medical records of BD patients diagnosed with arterial lesions between 1995 and 2018. Angiographic patterns were categorized as stenosis, occlusion, dilatation, or aneurysm. Patients were divided according to symptom duration (<5, 5-10, >10 years). Cox proportional-hazards model was used to evaluate the risk factors for vascular progression.

RESULTS

47 BD patients had arterial involvement in the following patterns: aneurysm (n = 31), stenosis (n = 17), dilatation (n = 13), and occlusion (n = 8). Aneurysm (70.8%) was the most common pattern in 24 patients with short (<5 years) symptom duration. Stenosis was more common (50.0%) in 12 patients with longer symptom durations (>10 years). In 23 patients with follow-up imaging (median, 5.7 years), eight (34.8%) developed 11 new lesions: stenosis (n = 5), dilatation (n = 1), and aneurysm (n = 5). One stenotic lesion progressed to occlusion, and two dilated lesions progressed to aneurysms. Lower extremity involvement and methotrexate use were associated with arterial progression, with hazard ratios of 5.716 (p = 0.029) and 0.101 (p = 0.049), respectively.

CONCLUSION

In BD patients with arterial involvement, aneurysm was the most common pattern in earlier stages of BD, while stenosis was more common in later stages of BD. Methotrexate use was associated with lower risk of arterial lesion progression.

Association of Large Vessel Aneurysm/Pseudo-Aneurysm/Aortitis and Deep Vein Thrombosis in Patients with Behçet's Disease: A Case Report

BACKGROUND

Behçet's disease (BD) is a complex vasculitis with some vascular manifestations including venous thrombosis, arterial thrombosis/aneurysm/pseudoaneurysm, and co-associated venous thrombosis and arterial lesions. We present two patients with Behçet's disease came with progressive both arterial and venous involvement.

CASE PRESENTATION

The first patient was a young man with recurrent oral aphthosis and skin folliculitis and referred with complaint of new abdominal pain and 2 months severe headache. He had not referred to a physician due to COVID-19 pandemic until that time. In addition, he gradually developed a lower extremity edema and eventually was diagnosed with BD complicated with brain sagittal sinus vein thrombosis, abdominal aortic aneurysms and aortitis and deep vein thrombosis (DVT) of femoral vein. The second patient was a young woman with previous history of uveitis, DVT and recurrent oral and genital aphthosis presented with a large inguinal mass due to large iliac artery pseudoaneurysm impending to rupture, and after the operation, due to poor follow-up, developed a new femoral DVT.

CONCLUSION

It seems the same inflammatory process is responsible for arterial and venous involvement in patients with BD, so it should be considered that involvement in one side (venous/arterial) can be a risk factor for the other side (venous/arterial) and early immunosuppressive treatment should always be considered to improve the prognosis.

Subclavian artery pseudoaneurysm in vascular Behcet's disease repaired using endovascular treatment: A case report of the clinical course over 10 years

The vascular involvement in patients with Behcet's disease is defined as vascular Behcet's disease, which can greatly influence the prognosis. However, there are few reports on endovascular treatment (EVT) for subclavian pseudoaneurysms with long-term prognosis over 10 years. We present the case of a 42-year-old man with left subclavian artery pseudoaneurysm due to vascular Behcet's disease who was treated with EVT along with immunosuppressive therapies. Subsequently, 8 years after, the aneurysm recurred in the stent with stent fracture. Therefore, additional EVT was performed. We present the details of the patient's clinical course over 10 years after the EVT. <Learning objective: Vascular Behcet's disease can greatly influence the prognosis. Therefore, understanding its treatment and management is important. There are few reports on endovascular treatment (EVT) for subclavian pseudoaneurysms with long-term prognosis over 10 years. Long-term management and recurrence monitoring are required for vascular Behcet's disease even after EVT.>.

Late Vascular Injury at Both Edges of the VIABAHN Stent Graft after Endovascular Repair for Idiopathic Superficial Femoral Artery Rupture

The VIABAHN stent graft is often used for traumatic and iatrogenic vascular injuries. In this case, vascular injury at both edges of the VIABAHN stent graft was noted 4 months after endovascular repair for idiopathic superficial femoral artery (SFA) rupture. The longitudinal compression of the SFA with a decrease in hematoma size was assumed to exceed the flexibility of the stent graft. Thus, the use of stent grafts for vascular injuries with giant pseudoaneurysms may result in late vascular injuries at both edges of the stent graft. Therefore, cautious assessment of its indications and strict surveillance are required.

One-year results of stent graft repair for carotid artery pseudo-aneurysm in patients with Behcet's disease

OBJECTIVES

Behcet's disease is a multisystem disorder of unknown etiology with vascular complications. This study reviewed the mid-term outcome of Behcet's disease patients with carotid artery pseudo-aneurysms treated by endovascular stent-graft repair at our unit.

METHODS

During a period of 11 years, six cases were included. Postoperative ultrasound duplex results were recorded along with computed tomography angiography report done a year after intervention.

RESULTS

The mean age (±SD) was 38 (±5.2) years. The mean (±SD) pseudo-aneurysm size was 33 (±12.2) mm. Technical success was 83%; failed cannulation of the internal carotid artery was encountered in one case. On day 2 post-operative, a duplex ultrasound revealed complete exclusion and thrombosis of the false aneurysm in all cases. A year later, a computed tomography angiography revealed a primary patency rate of 80%, and only one case had a recurrent pseudo-aneurysm at the distal margin of the stent graft. All cases, however, had complete thrombosis in the pseudo-aneurysms lumen with a mean (±SD) regression in size of 18 (±6) mm. The mean (±SD) percentage of in-stent stenosis was 34.5% (±11.73%).

CONCLUSIONS

Stent graft repair for carotid artery pseudo-aneurysm in Behcet's disease patients might be the preferable first line of treatment since it had a high technical success and mid-term primary patency rates, with additional fact that it obviously avoids the hazardous complications of surgery.

Usefulness of duplex ultrasonography to detect collagen sponge misplacement into the arterial lumen during the use of Angio-Seal: A case report

A 76-year-old man who had undergone percutaneous coronary intervention suffered intermittent claudication. Duplex ultrasonography revealed superficial femoral artery stenosis with an intraluminal heterogeneous echogenic mass. We suspected that stenosis was caused by the puncture procedure of the Angio-Seal. Open surgery revealed that a collagen sponge that should have been outside the arterial wall was misplaced in the wall with massive granulation, and atherectomy with patchplasty was performed. Vessel deterioration was considered due to several factors, including inappropriate access site, arterial wall calcification, and comorbidities like Behçet's disease. Ultrasonography is a convenient and useful method to evaluate arterial lesions.

Endovascular Repair of a Common Carotid Pseudoaneurysm in a Patient with Behçet's Disease: A Case Report and Review of Literature

Behçet’s disease (BD) is a multisystem inflammatory disorder. Physicians should be alerted to the possibility of BD in a patient with a carotid artery pseudoaneurysm and no clear predisposing factor such as neck trauma or surgery. Endovascular repair of carotid pseudoaneurysms is technically feasible with excellent midterm follow-up results. Administration of immunosuppressive therapy before endovascular intervention is mandatory to reduce the chance of vascular complications accompanied by BD.

A 40-year-old man presented with a painful and pulsatile neck mass with 2 episodes of transient ischemic attacks. The patient also complained of recurrent urogenital ulcers and aphthous lesions together with painful rashes. Ultrasonography and computed tomography angiography revealed 2 aneurysmal dilations in the left common carotid artery at the bifurcation level. He was referred to a rheumatologist, who made the diagnosis of BD. High-dose corticosteroids and cyclophosphamide were commenced. One week later, 2 overlapping self-expanding stent grafts were deployed. The final angiogram showed no residual endoleak, and the flow of the carotid and cerebral arteries was satisfactory. The patient was discharged with no neurological complications. Follow-up ultrasonography and computed tomography angiography 6 months later showed no endoleak, as well as significant shrinkage of the aneurysm sac.

Clinical characteristics and factors influencing the prognosis of Behçet’s disease complicated with vascular involvement

Summary: Background: Vascular Behçet's disease (VBD) might involve all sizes of arterial and venous vessels. Major vascular involvement caused the primary death in Behçet's syndrome (BS). We aimed to investigate the clinical characteristics and factors influencing the prognosis of VBD. Patients and methods: A retrospective analysis of the prospectively collected data of the Shanghai BS database from October 2012 to October 2018 was conducted. Patients who were diagnosed with BS and merged with venous thrombosis, arterial aneurysms, and arterial stenosis/occlusions were enrolled. Results: There were 47 patients with vascular involvement among 836 BS patients, 38 males and 9 females. The numbers of patients with venous thrombosis, arterial aneurysm, and arterial stenosis/occlusion were 25 (53.2 %), 21 (44.7 %), and 12 (25.5 %), respectively. Nearly half of the venous thromboses were located in limbs (n = 22, 46.8 %). Arterial aneurysm was the main form of arterial lesion. Most of the patients (93.6 %) were treated with corticosteroids and immunosuppressants. Late onset of BS or with arterial involvement had lower treatment response. Therapy with biological agents had significantly better results than that in the group without biological treatment (94.1 % vs. 80 %, P = 0.005). Conclusions: VBD showed a male preponderance and more than half of the patients presented with venous thrombosis. Late onset and arterial involvement were associated with poor prognosis. Therapy with biological agents is a viable alternative treatment to improve the prognosis.

Prophylactic prosthetic wrapping for vascular anastomosis in patients with Behçet's aortic aneurysms: an experience from a resource-challenged setting

BACKGROUND

The objectives of the current study were to evaluate our technical and clinical results of surgical treatment of infrarenal Behçet's abdominal aortic aneurysm (AAA). In addition to the prosthetic wrapping of the constructed anastomosis as a prophylactic measure for patients with vasculo-Behçet's disease, together with the administration of per- and postoperative immunosuppressive therapy.

METHODS

A single-center retrospective case series included 16 patients with vasculo-Behçet's AAA who treated with open surgical repair, between January 2005 and December 2013. The administration of immunosuppressive treatment was done preoperatively to achieve complete remission of the disease activity before starting the surgical repair. Patients' data were retrieved and analyzed emphasizing the diagnostic procedures, the used surgical techniques, and suitable graft selection, as well as, graft-related complications. The patients were followed up for one month to a maximum of 72 months. The median follow-up period was 24.83±9.4 months.

RESULTS

This study included 16 patients, 10 (63%) males, and 6 (37%) females, with the median age of (30.50 years, range: 21-37 years). Moreover, all patients were anticoagulated and discharged on warfarin and aspirin therapy. All surgical procedures were done on an elective basis except for only one emergency laparotomy, which was performed for a life-threatening ruptured aneurysm. The vascular anastomoses were performed using either interposition tube graft (for isolated AAA), or Y-shaped graft (for concomitant aorto-iliac aneurysms). Furthermore, prophylactic prosthetic wrapping was applied encircling the graft to the host artery. In addition, all patients received systemic immunosuppressive therapy post-surgical intervention to prevent anastomotic site complications. Technical success was obtained in 100% of cases. Moreover, the patients were followed up for a period of 12-72 months. Two anastomotic pseudoaneurysms were developed postoperatively. More interesting is that both were infected (one low-virulent that was conservatively treated and one overt that was surgically repaired). Furthermore, there was no aneurysm-related mortality.

CONCLUSIONS

Prophylactic prosthetic wrapping of vascular anastomosis in patients with Behçet's AAA in resource-challenged settings, where the proximal anastomoses were all end-to-end with wrapping, is an affordable, simple, reliable, and feasible technique, and commonly associated with a lower incidence of anastomotic site false aneurysms and different complications related to the implanted graft, where endovascular procedures might not be applicable. Moreover, the proper preoperative medical preparation for controlling the activity of Behçet's disease, with the administration of immunosuppressive agents, followed by immediate postoperative therapy, may have a good impact on the operative technical success and the prevention of the development of serious postoperative complications; especially anastomotic pseudoaneurysms (which may be complicated by fatal hemorrhage), as well as other graft-related complications.

Vascular suture line wrapping for Aortoiliac anastomoses following open surgical repair of Infrarenal Behçet's Aortoiliac aneurysms

Background

This study was conducted to evaluate our local experiences of adjunctive mechanical prosthetic wrapping for aortoiliac vascular anastomoses as a prophylactic measure following surgical repair of Behçet’s aortoiliac aneurysms. The goal of prosthetic wrapping to reinforce the vascular anastomoses by mechanical protection to reduce the bleeding complications, and consequently pseudoaneurysm formation. This was aided by the administration of pre- and postoperative immunosuppressive therapy as an adjuvant treatment.

Methods

A seven-year retrospective study was conducted between January 2006 and December 2012, retrieving data of patients with Behçet’s aortoiliac aneurysms. All patients underwent open surgical repair using a heparin-bonded synthetic Dacron® graft. Data for all patients were retrieved and analyzed for diagnostic procedures, graft selection, as well as, different methods of surgical repair. Graft-related complications such as anastomotic pseudoaneurysms, occlusion, and thrombosis were also reported.

Results

Sixteen patients were recruited in this study. There were  11 (69%) males and 5 (31%) females with the male to female ratio 2:1. The patients’ age ranged between 25 and 47 years with the mean of 36.4 ± 7.3. All Behçet’s aortic/aortoiliac aneurysms were repaired by the application of heparin-bonded Dacron® tube and bifurcated grafts. The anastomotic wrapping technique was performed for both the proximal and the distal vascular anastomoses. The technical success of aortoiliac aneurysm and wrapping techniques was achieved in 100% of patients. All patients were given pre- and postoperative systemic immunosuppressive therapy. No graft-related complications were reported except for only one anastomotic pseudoaneurysm that developed at one of the right iliac anastomoses, that developed within 24 months after follow up.

Conclusions

Mechanical prosthetic wrapping for vascular anastomoses in patients with Behçet’s aortic/aortoiliac aneurysms is a feasible, simple, and reliable technique with low morbidity and mortality. It was performed as a prophylactic measure to avoid the development of postoperative anastomotic pseudoaneurysms. It must be performed for all patients with Behçet’s arterial aneurysms whenever possible. Furthermore, the supplemental administration of pre- and postoperative systemic immunosuppressive therapy should be considered as an important factor for the prophylaxis and prevention of anastomotic pseudoaneurysms and other graft-related complications.

Pulmonary manifestations of large, medium, and variable vessel vasculitis

The hallmark of vasculitis is autoimmune inflammation of blood vessels and surrounding tissues, resulting in an array of constitutional symptoms and organ damage. The lung is commonly targeted in the more familiar ANCA-associated small vessel vasculitidies, but large and medium vessel vasculitides, including Takayasu arteritis, giant cell arteritis, polyarteritis nodosa, Behcet's disease, and necrotizing sarcoid granulomatosis, may also feature prominent pulmonary involvement. Pulmonary manifestations of these conditions include pulmonary arterial aneurysms, pulmonary hypertension, diffuse alveolar hemorrhage, pulmonary nodules, and parenchymal infiltrates. An understanding of the diverse manifestations of vasculitis and a high index of clinical suspicion are essential to avoid delays in disease recognition that may result in permanent or life threatening morbidity. In this review, we outline the general clinical manifestations, pulmonary manifestations, diagnostic workup, imaging findings, and treatment of medium, large, and variable vessel vasculitides.

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.

Successful management of a giant dissecting aortic aneurysm in a patient with Behcet's disease

Thoracic aortic aneurysm with subsequent dissection is a very rare but dangerous complication of Behcet's disease, which is a systemic syndrome that can involve blood vessels of all sizes. Surgical experience in dealing with this complication in patients with Behcet's disease has been limited. We report a 20-year-old patient with Behcet's disease who presented with a giant dissecting thoracic aortic aneurysm. The patient was successfully treated with an aortic root and arch replacement using a frozen elephant trunk technique. Timely surgical intervention and appropriate long-term medical management are important for these patients.

Tratamento endovascular de aneurisma de aorta abdominal com erosão de vértebra lombar associada à doença de Behçet: relato de caso

A doença de Behçet é uma doença sistêmica, multifatorial e autoimune com diversas manifestações clínicas, entre elas o acometimento vascular. Aneurisma de aorta associado a erosão de vértebra lombar é condição rara na literatura, existindo apenas quatro relatos de caso nas bases de dados da PubMed. O presente artigo relata o caso de paciente do sexo feminino com diagnóstico de Doença de Behçet de longa data e aneurisma sacular de aorta abdominal infrarrenal com erosão de vértebra lombar. O caso foi tratado por meio de técnica endovascular com colocação de endoprótese monoilíaca e enxerto fêmoro-femoral cruzado, devido a limitações anatômicas da bifurcação aórtica. O artigo aborda a raridade desse tipo de apresentação da doença e o desfecho do tratamento e apresenta revisão da literatura sobre esse tema.

Behcet's disease

Behçet's disease (BD) is a chronic relapsing and remitting vasculitis of unknown aetiology. It has the capacity to affect almost all organ systems because of its potential to involve both arteries and veins of all sizes, resulting in significant organ-threatening morbidity and mortality. Traditionally known as the 'silk road' disease, it has a worldwide occurrence. The aetiopathological mechanisms of disease development in BD remain poorly understood, but genome wide studies show human leukocyte antigen and non-human leukocyte antigen associations. Environmental influences and genetic factors may have a role in the aetiopathogenetic mechanisms that lead to development of the disease, indicating the autoimmune and auto-inflammatory nature of BD. The evidence base for treatment is limited but new knowledge is emerging and current treatment options range from symptomatic treatment, through to non-biological and biological immunosuppressive drugs, to cover the spectrum of clinical manifestations.

Characteristics of Abdominal Aortic Aneurysm in Japanese Patients Aged 50 Years or Younger

Objective: We investigated the characteristics and surgical outcomes of abdominal aortic aneurysm (AAA), which typically occurs in elderly persons, in Japanese patients aged 50 years or younger.

Materials and Methods: Clinical records of 999 patients who underwent open or endovascular repair for AAA at our hospital between 2007 and 2015 were reviewed to identify the clinical characteristics and surgical outcomes of young patients with AAA. The cohort included 14 patients aged 50 years or younger (mean, 40.4 years; young group) and 985 patients aged older than 50 years (mean, 72.8 years; old group).

Results: Marfan syndrome, prior aortic dissection, and a history of aortic surgery were more prevalent in the young group, and 50% of the patients in the young group had dissecting aneurysms. All patients in the young group underwent open repair. Overall in-hospital mortality rates were 7.1% (1/14) and 1.9% (19/985) in the young and old groups, respectively (P=0.67). Seven-year survival and aortic event-free survival rates in the young group were 82.5%±11.5%, and 71.2±14.5%, respectively.

Conclusion: AAA in patients aged 50 years or younger tended to be associated with Marfan syndrome, a history of aortic surgery, and prior aortic dissection. Early outcomes of AAA among young patients are acceptable, but close postoperative monitoring is important.

Outcomes of surgery for patients with Behcet's disease causing aortic pseudoaneurysm: a shift from open surgery to endovascular repair

OBJECTIVES

Behcet's disease is a form of systematic vasculitis that affects vessels of various sizes. Aortic pseudoaneurysm is one of the most important causes of death among patients with Behcet's disease due to its high risk of rupture and associated mortality. Our study aimed to investigate the outcomes of Behcet's disease patients with aortic pseudoaneurysms undergoing open surgery and endovascular aortic repair.

METHODS

From January 2003 to September 2014, ten consecutive patients undergoing surgery for aortic pseudoaneurysm met the diagnostic criteria for Behcet's disease. Endovascular repair was the preferred modality and open surgery was performed as an alternative. Systemic immunosuppressive medication was administered after Behcet's disease was definitively diagnosed.

RESULTS

Eight patients initially underwent endovascular repair and two patients initially underwent open surgery. The overall success rate was 90% and the only failed case involved the use of the chimney technique to reach a suprarenal location. The median follow-up duration was 23 months. There were 7 recurrences in 5 patients. The median interval between operation and recurrence was 13 months. No significant risk factors for recurrence were identified, but a difference in recurrence between treatment and non-treatment with preoperative immunosuppressive medication preoperatively was notable. Four aneurysm-related deaths occurred within the follow-up period. The overall 1-year, 3-year and 5-year survival rates were 80%, 64% and 48%, respectively.

CONCLUSIONS

Both open surgery and endovascular repair are safe and effective for treating aortic pseudoaneurysm in Behcet's disease patients. The results from our retrospective study indicated that immunosuppressive medication was essential to defer the occurrence and development of recurrent aneurysms.

Endovascular Treatment of Behcet Disease With Recurrent Infrainguinal Arterial Pseudoaneurysms: A Case Report and Literature Review

Aneurysm or pseudoaneurysm formation is one of the vascular complications of Behcet disease. At present, the optimal treatment for the disease has not been established.The authors report a case of vasculo-Behcet disease (v-BD) with recurrent pseudoaneurysms in the left infrainguinal arteries (common femoral artery, superficial femoral artery, and popliteal artery), as well as thrombosis in the popliteal vein and posterior tibial vein. The patient underwent 3 rounds of surgery, but developed a new pseudoaneurysm several months after each surgery. Eventually, the patient was successfully treated with a combination of endovascular repair, using a fully covered stent graft, and prednisone. The pseudoaneurysm regressed without recurrence for more than 1 year.For v-BD, treatment with immunosuppressive therapy alone may not be sufficient to prevent the recurrence of pseudoaneurysms. For the endovascular treatment of pseudoaneurysms affecting the infrainguinal arteries in v-BD, a fully covered stent graft without oversizing is essential to prevent the recurrence of pseudoaneurysms.

Endovascular Treatment of a Ruptured Innominate Artery Aneurysm in Behcet Disease

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

[Aortitis and surgery]

Non-infectious aortitis are usually due to giant cell arteritis (temporal arteritis), Takayasu and Behçet's diseases. Aortitis should be suspected in the presence of aortic wall thickening or of aneurysm or occlusion of the aorta and its branches in the absence of characteristic cardiovascular risk factors. Surgery is required in case of severe damage. But the quiescence of the inflammatory disease must be obtained before endovascular or surgical treatment to prevent complications such as anastomotic false aneurysm or stent thrombosis, especially common in this disease. The frequency of aortic aneurysms (in particular of ascending aorta) in giant cell arteritis encourages its systematic screening, as well as regular monitoring of the entire aorta during the follow-up. Behçet's and Takayasu diseases require the greatest control of inflammation and the knowledge of some surgical tricks to avoid the risk of recurrence. The literature review shows that endovascular treatment could reduce perioperative morbidity but did not allow reducing long-term complications.

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

BACKGROUND

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Acute myocardial infarction and subclavian artery occlusion in a 41-year-old woman with Behçet's disease: coronary and large vessel arteritis

We report the case of a 41-year-old Chinese woman with Behçet's disease (BD) complicated by acute myocardial infarction, requiring inotropic and ventilatory support. Angiography showed critical left anterior descending coronary artery stenosis, a blocked left subclavian artery and left carotid artery stenosis. The patient was successfully treated with a high dose of immunosuppressants, standard anti-ischaemic therapy and percutaneous coronary intervention. Although life-threatening, coronary arteritis is a treatable manifestation of BD. We suggest that the diagnosis of coronary arteritis be considered in patients with BD who present with chest pain. Involvement of other arteries should also be looked out for in these patients.

Spontaneous Intra-Abdominal Hemorrhage Due to Rupture of Jejunal Artery Aneurysm in Behcet Disease: Case Report and Literature Review

Rupture of jejunal artery aneurysm is a very rare event resulting in life-threatening hemorrhage in Behcet disease (BD). We report a case of ruptured jejunal artery aneurysm in a 35-year-old patient with BD. The patient had a 1-year history of intermittent abdominal pain caused by superior mesenteric artery aneurysm with thrombosis. Anticoagulation treatment showed a good response. Past surgical history included stenting for aortic pseudoaneurysm. On admission, the patient underwent an urgent operation due to sudden hemorrhagic shock. Resection was performed for jejunal artery aneurysm and partial ischemia of intestine. The patient was diagnosed with BD, based on a history of recurrent oral and skin lesions over the past 6 years. Treatment with anti-inflammatory medications showed a good response during the 8-month follow-up.An increased awareness of BD and its vascular complications is essential. Aneurysms in BD involving jejunal artery are rare, neglected and require proper management to prevent rupture and death. To our knowledge, this is the first reported case of jejunal artery aneurysm caused by BD.

Endovascular Treatment of Left Subclavian Artery Pseudoaneurysm after Clavicle Fracture in an Elderly Adult with a 40-Year History of Behçet's Disease

Behçet's disease (BD) is a rare chronic systemic vasculitis of unknown etiology that presents in young adults. We report a very rare case of a left subclavian artery pseudoaneurysm identified after a left clavicle fracture in a 70-year-old man with a 40-year history of intestinal BD. The patient received fixation by banding to treat a fracture after falling from a bed about 5 months previously, and he was referred to our hospital due to the finding of a left subclavian pulsatile mass. As enhanced computed tomography showed a left subclavian artery pseudoaneurysm, it was repaired using an endovascular stent graft.

Cogan and Behcet syndromes

Cogan and Behcet syndromes are considered large vessel vasculitides. Both are rare diseases, with varied clinical manifestations affecting multiple organ systems. Although both have hallmark symptoms (ocular and vestibuloauditory inflammation in Cogan syndrome and aphthous ulcers in Behcet syndrome), neither has confirmatory diagnostic testing. Delayed diagnosis can result in poor outcomes. In both syndromes, large vessel arterial inflammation may result in severe morbidity and mortality. Treatment strategies in both syndromes vary based on organ system involvement and severity of manifestations. In this article, the epidemiology, proposed pathogenesis, manifestations, and the most current treatment paradigms for these syndromes are reviewed.

Effectiveness and tuberculosis-related safety profile of interleukin-1 blocking agents in the management of Behçet's disease

Behçet's disease (BD) is a multi-systemic disorder of unknown etiology characterized by relapsing oral-genital ulcers, uveitis, and involvement of the articular, gastrointestinal, neurologic, and vascular systems. Although the primum movens of this condition remains unknown, a tangled plot combining autoimmune and autoinflammatory pathways has been hypothesized to explain its start and recurrence. In-depth analysis of BD pathogenetic mechanisms, involving dysfunction of multiple proinflammatory molecules, has opened new modalities of treatment: different agents targeting interleukin-1 have been studied in recent years to manage the most difficult and multi-resistant cases of BD. Growing experience with anakinra, canakinumab and gevokizumab is discussed in this review, highlighting the relative efficacy of each drug upon the protean BD clinical manifestations. Safety and tolerability of interleukin-1 antagonists in different doses have been confirmed by numerous observational studies on both large and small cohorts of patients with BD. In particular, the potential for Mycobacterium tuberculosis reactivation and tuberculosis development appears to be significantly lower with interleukin-1 blockers compared to tumor necrosis factor-α inhibitors, thus increasing the beneficial profile of this approach.

Single-Stage Endovascular Treatment Performed on Multiple Aortic Aneurysms in a Patient with Behçet's Disease-Report of a Case

A 50-year-old male diagnosed with Behçet's disease was referred to our department for stent graft treatment because of thoracic, abdominal, and right common iliac artery (CIA) aneurysms. He had a superior mesenteric artery aneurysm in 2005 that was treated with resection and bypass surgery through the radial artery. He later underwent four abdominal surgical procedures for conditions such as intestinal perforation and ileus. Stent graft treatment was performed. The postoperative course was uneventful; postoperative computed tomography (CT) showed no apparent endoleak, while that performed at 3 years post-discharge showed that the aneurysms had decreased in size.

Outcomes of endovascular treatment for aortic pseudoaneurysm in Behcet's disease

OBJECTIVE

To evaluate the effectiveness of endovascular stent grafting for surgical management of aortic pseudoaneurysm in patients with Behcet's disease (BD).

METHODS

We present a single-institution retrospective cohort of patients with aortic pseudoaneurysm and BD treated with aortic stent grafting. Computed tomography imaging was obtained preoperatively in all patients and once within 2 weeks postoperatively, and then annually. Clinical follow-up and erythrocyte sedimentation rate were used to follow BD activity. Immunosuppressant therapy was instituted prior to endovascular treatment unless a contraindication existed.

RESULTS

From 1998 to 2012, 10 patients (eight male, two female; median age, 39) with BD and aortic pseudoaneurysm were treated with endovascular stent grafting at this institution. Ninety percent of these patients received immunosuppressive therapy before and after surgical treatment. The median follow-up period was 57 months (interquartile range, 43-72). The locations of the 12 pseudoaneurysms treated in this cohort were infrarenal abdominal aorta (seven), descending thoracic aorta (four), and aortic arch (one). Median pseudoaneurysm size was 4.5 cm (interquartile range, 3.4-5.9). At long-term follow-up, complete resolution of the aortic pseudoaneurysm was noted in all patients. No endoleaks occurred. Newly developed pseudoaneurysm at the distal margin of the stent graft was noted in one patient 17 months after the stent graft procedure. One patient required a subsequent stent graft placement for an expanding pseudoaneurysm of the subclavian artery. No patient deaths occurred during the follow-up period.

CONCLUSIONS

Endovascular treatment of aortic pseudoaneurysm with stent-grafting in patients with BD is safe and effective with long-term durability.

Sutureless surgical techniques for arch aneurysm repair in a patient with Behçet's disease

In patients with vasculo-Behçet's disease, endovascular stent graft is a reasonable treatment from the viewpoint of prevention of an anastomotic pseudo-aneurysm. We report a case of total arch replacement combined with open stent grafting technique to the downstream aorta and graft inclusion into sino-tubular junction as sutureless surgical techniques for an arch aneurysm in a 42-year-old woman with Behçet's disease. Postoperative computed tomography (CT) showed that the aortic aneurysm had completely disappeared in 11 months after the operation. Open stent grafting technique was effective to prevent anastomotic pseudo-aneurysm formation.

Differential diagnosis and management of Behçet syndrome

Behçet syndrome (also known as Behçet disease) is a rare condition that is associated with considerable morbidity. Cases of Behçet syndrome have been reported worldwide, but the highest prevalence occurs in countries that border the ancient Silk Route, such as Turkey and Iran. Although oral ulceration, genital ulceration and eye disease are the classic triad of manifestations, the cardiovascular, gastrointestinal, musculoskeletal and central nervous systems can also be affected. The syndrome is chronic and relapsing with some patients having benign episodes whereas others have more serious complications, including blindness or the rupture of a pulmonary arterial aneurysm. Diagnosing Behçet syndrome, particularly outside of endemic regions, often incurs a considerable delay owing to the rarity of this condition. Furthermore, a paucity exists of data from randomized controlled trials on the optimal therapeutic approaches to use in patients, as well as a lack of informative laboratory surrogate markers to monitor disease progression. This Review discusses the issues surrounding the diagnosis and differential diagnosis of Behçet syndrome and presents the current approaches to managing patients with this complex group of disorders.