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

Development and validation of a risk prediction model for valve regurgitation in Behçet's disease

BACKGROUND

In Behçet's disease (BD), mild-to-severe valvular regurgitation (VR) poses a serious complication that contributes significantly to heart failure and eventually death. The accurate prediction of VR is crucial in the early stages of BD subjects for improved prognosis. Accordingly, this study aimed to develop a nomogram that can detect VR early in the course of BD.

METHODS

One hundred seventy-two patients diagnosed with Behçet's disease (BD) were conducted to assess cardiac valve regurgitation as the primary outcome. The severity of regurgitation was classified as mild, moderate, or severe. The parameters related to the diagnostic criteria were used to develop model 1. The combination of stepAIC, best subset, and random forest approaches was employed to identify the independent predictors of VR and thus establish model 2 and create a nomogram for predicting the probability of VR in BD. Receiver operating characteristics (ROC) and decision curve analysis (DCA) were used to evaluate the model performance.

RESULTS

Thirty-four patients experienced mild-to-severe VR events. Model 2 was established using five variables, including arterial involvement, sex, age at hospitalization, mean arterial pressure, and skin lesions. In comparison with model 1 (0.635, 95% CI: 0.512-0.757), the ROC of model 2 (0.879, 95% CI: 0.793-0.966) was improved significantly. DCA suggested that model 2 was more feasible and clinically applicable than model 1.

CONCLUSION

A predictive model and a nomogram for predicting the VR of patients with Behçet's disease were developed. The good performance of this model can help us identify potential high-risk groups for heart failure. Key Points • In this study, the predictors of VR in BD were evaluated, and a risk prediction model was developed for the early prediction of the occurrence of VR in patients with BD. • The VR prediction model included the following indexes: arterial involvement, sex, age at hospitalization, mean arterial pressure, and skin lesions. • The risk model that we developed was better and more optimized than the models built with diagnostic criteria parameters, and visualizing and personalizing the model, a nomogram, provided clinicians with an easy and intuitive tool for practical prediction.

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.

Zone 2/3 lesion and emergency repair as potential mortality predictors of TEVAR for thoracic aortic pseudoaneurysm

OBJECTIVE

Thoracic aortic pseudoaneurysm (TAP) is an uncommon but life-threatening condition. The present study aimed to investigate the early and midterm clinical outcome of TAP patients following TEVAR and identify potential mortality predictors.

METHODS

We retrospectively reviewed a series of 37 eligible patients with TAP admitted to our hospital from July 2010 to July 2020. We explored their baseline, perioperative and follow-up data. Fisher exact test and Kaplan-Meier method were applied for comparing difference between groups.

RESULTS

There were 29 men and 12 women, with the mean age as 59.5 ± 13.0 years (range 30-82). The mean follow-up period was 30.7 ± 28.3 months (range 1-89). For early outcome (≤ 30 days), mortality happened in 3 (8.1%) zone 3 TAP patients versus 0 in zone 4 (p = 0.028); postoperative acute arterial embolism of lower extremity and type II endoleak respectively occurred in 1(2.7%) case. For midterm outcome, survival at 3 months, 1 year and 5 years was 88.8%, 75.9% and 68.3%, which showed significant difference between zone 2/3 versus zone 4 group (56.3% vs. 72.9%, p = 0.013) and emergent versus elective TEVAR group (0.0% versus 80.1%, p = 0.049). Previous stent grafting or esophageal foreign body with Aortoesophageal fistula (AEF), and systemic vasculitis, as etiologies, resulted in encouraging immediate outcome but worse midterm prognosis.

CONCLUSION

TAP lesions at zone 2/3 and emergent TEVAR predict worse midterm outcomes compared to zone 4 lesions and elective TEVAR. The outcomes are also mainly restricted by the etiology of the TAP.

Long Term Outcomes and Potential Risk Factors for Endovascular Repair of Aortic Pseudoaneurysms in Vascular Behçet's Disease

OBJECTIVE

This study aimed to analyse long term outcomes and risk factors for endovascular repair of aortic pseudoaneurysms in patients with vascular Behçet's disease (BD).

METHODS

Medical records of 26 aortic vascular BD patients who underwent endovascular treatment at the vascular department of Peking Union Medical College Hospital between January 2002 and December 2021 were reviewed retrospectively. Erythrocyte sedimentation rate (ESR) and C reactive protein were used to assess BD activity. Computed tomography angiography (CTA) was obtained pre- and post-operatively for almost all patients. Univariable logistic regression analysis was used to analyse risk factors for endovascular repair, such as inflammatory indicators, drug usage, and stent graft parameters.

RESULTS

The abdominal aorta (n = 17) was the most common site of 27 vascular BD pseudoaneurysms in this study. CTA also revealed one aortic arch pseudoaneurysm, seven descending thoracic aortic pseudoaneurysms, one thoraco-abdominal aortic pseudoaneurysm, and one pseudoaneurysm at the aortic bifurcation. Most of the pseudoaneurysms were treated with covered stent grafts. The technical success rate was 96% and no deaths occurred during hospital stay. The mean follow up was 5.8 ± 5.5 years and 31% (8/26) experienced post-operative complications. Overall one, three, and five year event free survival rates were 87%, 78%, and 74%, respectively. Univariable logistic regression analysis revealed that pre-operative ESR ≥ 16.0 mm/h (p = .040), pre-operative glucocorticoid (GC) use ≤ 11.5 days (p = .024), pre-operative immunosuppressant use ≤ 15.5 days (p = .028), and length of proximal landing zone ≤ 1.95 cm (p = .034) were associated with a worse prognoses following endovascular treatment. Proximal oversize ≥ 9.5% (p = .074) was also regarded as a risk factor, although not statistically significant.

CONCLUSION

This study further confirmed the feasibility of endovascular repair for aortic vascular BD patients. Risk factors predicting poor prognoses included elevated pre-operative ESR, insufficient pre-operative GC use or immunosuppressant use, inadequate proximal landing zone, and larger proximal oversize percentage.

[Vascular manifestations of Behcet's disease]

Behçet disease is a multi-systemic complex vasculitis with unknown etiology characterized by different clinical involvements, including mucocutaneous, ocular, vascular, articular, neurological and gastrointestinal manifestations. Growing evidence supports that different phenotypes, characterized by clusters of co-existing involvements, can be distinguished. Namely, the vascular phenotype identifies a specific group of patients who suffer from recurrent inflammatory thrombosis and arterial involvement. Vascular disease develops in up to 40% with a definite male preponderance and is usually an early manifestation. It is one of the main causes of death in Behçet's disease. Venous involvement is significantly more common than arterial disease and lower extremity deep vein thrombosis is its most frequent manifestation. Arterial disease involves mostly pulmonary arteries and aorta and manifests mainly in the form of aneurysms. Glucocorticoids and immunosuppressant's are the recommended first-line treatments in vasculo-Behçet. Furthermore, randomized controlled trials are still needed to assess the role of adding anticoagulation to current standard therapy in venous thrombosis in Behçet's disease and to assess the role of anti-TNF alpha therapy in vasculo-Behçet.

Early and Midterm Outcomes of Endovascular Treatment in Arterial Manifestations of Vascular Behcet Disease

BACKGROUND

Behcet's disease (BD), originally described by Hulusi Behcet in 1937, is a chronic relapsing inflammatory process of an immunologic syndrome and the involvement of the vascular system is called Vasculo-Behcet disease (VBD). This is a retrospective study evaluating 21 patients diagnosed with VBD who underwent endovascular treatment.

METHODS

This single-center study was conducted between January 2016 and January 2022. Early and mid-term endovascular outcomes of a total of 21 patients (16 males, 5 females with a median age of 42 years; range, 31 to 46 years), with a diagnosis of VBD, who underwent endovascular arterial repair in our hospital, were retrospectively analyzed. Follow-ups were scheduled for the first and sixth postoperative months and every 6 months thereafter. For symptomatic patients, imaging studies and additional interventions were planned. The primary outcomes were a procedural success and a requirement for reintervention. Secondary outcomes were complications and all causes of mortality.

RESULTS

Twenty-one patients underwent endovascular repair. In this study, 1 balloon-expandable stent for brachial artery aneurysm (4,8%), 1 viabahn graft for femoral artery aneurysm (4,8%), 2 tube endograft for ruptured iliac artery aneurysm (9,5%), 1 tube endograft (Thoracic endovascular aortic repair [TEVAR]) insertion at the aortic bifurcation for infrarenal abdominal aortic occlusion (4,8%), 1 chimney-TEVAR for saccular arcus thoracic aortic aneurysm (TAA) (4,8%) and 7 TEVAR for saccular TAA (33,3%), 1 EVAR for an intact and symptomatic infrarenal abdominal aortic aneurysm (AAA) (4,8%), 1 EVAR (aorto-uniiliac) for ruptured iliac artery aneurysm (4,8%), and 6 EVAR for ruptured AAA (28,5%) were deployed. The technical success rate was 100% with a mean follow-up period of 50. 4 ± 10.7 months (8-66 months). The mean aneurysm diameter was 10,7 ± 53 mm. In the follow-up period, 3 patients presented with a hematoma at the insertion site of the sheath (14.3%). There were no early mortalities. Three patients required reintervention (14,3%); 1 of these underwent open surgical repair due to a pseudoaneurysm of the access site (4,8%). The Kaplan-Meier analysis revealed freedom from reintervention rate as 94,1 ± 5,7% at 1 year, 85,6 ± 9,7% at 3 years, and 68,4 ± 17,1% at 5 years.

CONCLUSIONS

Awareness of the BD especially for vascular involvements in young ages is lifesaving. Endovascular therapy with proper medical treatment seems to be the treatment of choice according to the early and midterm successful results with low morbidity and mortality.

Vascular complications of Behçet disease

Behçet disease is a multi-systemic complex vasculitis with unknown etiology characterized by different clinical involvements, including mucocutaneous, ocular, vascular, articular, neurological, and gastrointestinal manifestations. Growing evidence supports that different phenotypes, characterized by clusters of co-existing involvements, can be distinguished. Namely, the vascular phenotype identifies a specific group of patients who suffer from recurrent inflammatory thrombosis and arterial involvement. Vascular disease develops in up to 40% with a definite male preponderance and is usually an early manifestation. Venous involvement is significantly more common than arterial disease, and lower extremity deep vein thrombosis is its most frequent manifestation. Arterial disease involves mostly pulmonary arteries and aorta and manifests mainly in the form of aneurysms. Glucocorticoids and immunosuppressants are the recommended first-line treatments in vasculo-Behçet. Furthermore, controlled trials are still needed to assess the role of adding anticoagulation to the treatment regimen, with an accent on new oral anticoagulants. Treatment with anti-TNF alpha agents seems promising, but the management strategies are not clear yet.

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.

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.

Short-term outcome of primary stent graft for peripheral artery aneurysm in patients with Behçet disease

OBJECTIVE

Endovascular treatment of peripheral artery aneurysms (PAAs) in patients with Behçet disease is controversial. We report a single-institution experience of primary stent graft repair of PAAs in Behçet patients.

METHODS

Behçet patients who had endovascular stent graft repair of PAAs at a single center between January 2012 and December 2018 were identified. Demographics, past medical history, cardiovascular risk profile, and perioperative details were analyzed.

RESULTS

Twenty-two patients (mean age, 38 ± 7 years; 100% male) were included. The distribution of PAAs was external iliac artery in 2 (9%) patients, common femoral artery in 4 (18%) patients, superficial femoral artery in 15 (68%) patients, and above-knee popliteal artery in 1 (5%) patient. Pseudoaneurysm was diagnosed in five (23%) patients. We used antegrade access in the majority of patients (16 [73%]). Technical success was achieved in 21 (95%) patients. The mean hospital stay was 3 ± 2 days. There were no deaths or serious complications, and five (23%) patients experienced access site complications. The mean follow-up was 23 ± 11 months. The early primary and assisted primary patency rate was 91%. However, follow-up computed tomography angiography detected stent graft occlusion in six patients (27%).

CONCLUSIONS

Stent graft for PAA in patients with Behçet disease had a high early patency rate and minimal morbidity. However, the complication and reintervention rates were high during follow-up, with low surgical conversion.

Behcet's disease involved the root of aorta in the treatment with modified Bentall procedure: a case report

Background

Behcet’s disease (BD) is a multisystemic vasculitis of unknown etiology, the incidence of cardiovascular system involvement is rare, about1–5% (Sakane et al., N Engl J Med 341:1284–91, 1999). BD combined with aortic pseudoaneurysm and aortic valve regurgitation is usually need surgical treatment, but there is controversy about which surgical method to choose.

Case presentation

We report a case of BD combined with severe aortic valve regurgitation and two giant pseudoaneurysms of the aortic sinus. The patient underwent modified Bentall procedure (MBP) and use oral immunosuppressive as well as corticosteroid strictly, after 8 months follow-up, the patient recovered well.

Conclusion

For patient with aortic valve regurgitation and ascend aortic pseudoaneurysm caused by BD, we recommend modified Bentall procedure when rheumatism in a stable period. Corticosteroids and immunosuppressive drugs should be used before and after surgery.

Coronary Involvement in Behçet's Disease: what are its Risks and Prognosis? (Rare Cases and Literature Review)

Objective

In our clinic, we aimed to investigate the effect of preoperative risk factors and postoperative complications on reoperation and mortality in cases with Behçet's disease which presents very rare coronary artery involvement.

Methods

Thirteen patients with Behçet's Disease who had undergone coronary artery bypass grafting in our center between 2003 and 2015 were analyzed. We evaluated the clinical and laboratory findings, complications and mortality rates of our patients in light of the literature.

Results

The mean age was 38.5 (30-55; 3 women). The mean time from onset of Behçet's disease to coronary artery disease was 4,7 (3-11) years. Fifty-four percent of the patients were asymptomatic. Coronary artery disease of these was exposed while peripheral vascular surgery was planned due to complications of Behçet's disease. Symptomatic patients presented angina pectoris (31%), acute coronary syndrome (8%) and arrhythmia (8%). In coronary pathology of patients, distal type obstruction (31%), aneurysm and pseudoaneurysm (31%), proximal segment thrombus (15%), chronic type stenosis and occlusions (31%) were present. Early mortality (15%) was due to acute myocardial infarction while the late mortality (15%) was due to cerebral and gastrointestinal bleeding. Reoperation was due to bleeding in one case on the 1st postoperative day and due to acute pulmonary embolism in another case in the 3^rdpostoperative year.

Conclusion

In Behçet's disease, coronary artery bypass grafting is a procedure with high mortality, especially in the acute period. The on-pump surgery technique in these cases can be safely performed for multiple bypasses and in patients above 40 years old.

Behçet Syndrome and Crohn's Disease: What Are the Differences?

Behçet syndrome (BS) is a variable vessel vasculitis that has pleiotropic manifestations. A 43-year-old male with a previous diagnosis of Crohn’s disease (CD) presented with deep venous thrombosis and bilateral superficial femoral artery aneurysms. A diagnosis of BS was made, and the patient was treated aggressively with immunosuppressive therapy and bilateral bypass surgery, attaining a favourable outcome. CD has many features that overlap with BS, and it may be challenging to distinguish between these two conditions, as our case illustrates. Nonetheless, the combination of venous thrombosis and arterial aneurysms should point the clinician towards a diagnosis of BS.

Surgical Outcomes in Behcet's Disease Patients With Severe Aortic Regurgitation

BACKGROUND

An optimal treatment for aortic regurgitation in Behcet's disease has not been established. We investigated the effect of operative technique, prosthetic material, and immunomodulation therapy on surgical outcomes.

METHODS

In this study, 23 patients with Behcet's disease surgically treated for aortic regurgitation were assessed. Significant postoperative events were defined as death, aortic valve or graft-related problem(s), infective endocarditis, disabling stroke, and aortic valve or root reoperation. Surgical procedures were classified as isolated aortic valve replacement, bioprosthetic root replacement, and mechanical root replacement. Allograft root replacements were included in the bioprosthetic root replacement group.

RESULTS

A total of 40 operations, including 39 aortic valve or root surgeries and 1 orthotopic heart transplantation, were performed on patients confirmed with Behcet's disease. However, the study only reviewed 35 of the 40 cases (4 cases with inadequately documented medical records and 1 heart transplantation case were excluded). Significant adverse events occurred in 8 of 11 (73%) isolated aortic valve replacement, 9 of 12 (75%) bioprosthetic root replacement (5 xenografts and 7 allografts), and 4 of 12 (33%) mechanical root replacement cases. Multivariate analysis revealed that the 1-month postdischarge C-reactive protein level and operative age were independent predictive factors for postoperative event-free survival. Mechanical root replacement was identified as the most significant predictive factor leading to positive outcomes (hazard ratio, 0.147; 95% confidence interval, 0.028 to 0.766; p = 0.023).

CONCLUSIONS

The findings suggest that mechanical root replacement combined with a low postoperative C-reactive protein level maintained through adjunctive immunomodulation therapy may lead to optimal surgical outcomes in Behcet's disease associated with severe aortic regurgitation.

Serum uric acid could be served as an independent marker for increased risk and severity of ascending aortic dilatation in Behçet's disease patients

OBJECTIVE

This study aimed to investigate the correlation of serum uric acid (SUA) with risk and dilatation diameter of ascending aortic dilatation (AAD) in Behçet's disease (BD) patients.

METHODS

Seventeen BD patients complicated with AAD and 20 BD patients without AAD were consecutively enrolled and categorized into AAD group and control group, respectively. Ascending aortic dilatation was determined by two-dimensional doppler echocardiographic examination, and AAD was defined as a diameter of ascending aorta ≥3.8 and <4.4 cm. SUA was detected by quantitative immunoassay method.

RESULTS

Ascending aortic dilatation patients presented with higher proportion of male patients (P = 0.003), hypertension occurrence (P = 0.036) and increased diameter of ascending aorta (P < 0.001) compared to controls. SUA was elevated in AAD patients compared to controls (P = 0.002), and receiver operating characteristic curve displayed that SUA presented with great predictive value for AAD risk in BD patients with area under curve (AUC) 0.821 (95% CI 0.675-0.966). Pearson's analysis also disclosed that SUA was positively correlated with ascending aortic diameter in total BD patients. However, no difference of CRP (P = 0.219) or ESR (P = 0.320) between AAD patients and controls was observed, and no correlation of CRP (R = -0.150, P = 0.377) or ESR (R = 0.067, P = 0.692) with ascending aortic diameter in total BD patients was discovered either. Further multivariate logistic regression illuminated that SUA was an independent factor predicting AAD risk in BD patients (P = 0.031).

CONCLUSIONS

Serum uric acid could be served as an independent marker for increased risk and severity of AAD in BD patients.

Management of tibioperoneal trunk aneurysm in a patient with Behçet disease

Only a few cases of infrapopliteal aneurysms are reported in the literature. These are commonly associated with trauma, infection, and iatrogenic injuries and mostly present as pseudoaneurysms. We report the case of a 44-year-old man with Behçet disease and an 8-cm tibioperoneal trunk aneurysm and discuss the management options of these aneurysms.

Behcet's disease with recurrent thoracic aortic aneurysm combined with femoral artery aneurysm: a case report and literature review

Background

Aneurysm or pseudoaneurysm is the main vascular complication of Behcet’s disease. Most hospitals adopt endovascular treatment.

Case presentation

We report a case of Behcet’s disease with recurrent thoracic aortic aneurysm combined with femoral artery aneurysm. The patient underwent two rounds of endovascular surgery, but developed new aneurysms immediately after surgery. Eventually, the patient died due to rupture of recurrent aneurysm.

Conclusions

For vasculo-Behcet’s disease, we suggest performing the operation during the stable period. At the same time, glucocorticoids could be used with immunosuppressants preoperatively and postoperatively.

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.