Large vessel vasculitis (giant cell arteritis, Takayasu arteritis)

Combined Spinal-Epidural Anaesthesia for Caesarean Delivery in Takayasu's Arteritis: A Viable Alternative

Takayasu's arteritis (TA), also known as “pulseless disease”, is a nonspecific inflammatory arteritis of large and medium caliber arteries of unknown aetiology with a predilection for young women of childbearing age. Although the evolution of the disease is not affected during pregnancy, it can result in uncontrolled hypertension, multiple organ dysfunction, and stenosis that hinder regional blood flow. Associated pregnancy, therefore, poses an increased risk to the mother and foetus due to the many cardiovascular complications that can occur in the course of the disease, making anaesthesia for caesarean delivery especially challenging to the anaesthesiologist. We report the successful anaesthetic management of a case of TA undergoing caesarean section in view of a previous caesarean delivery. We also engage in a brief review of the related literature.

Takayasu's Arteritis in Pregnancy: A Rare Case Report from a Tertiary Care Infirmary in India

Background. Takayasu's arteritis (TA) is a rare, chronic, inflammatory, progressive, idiopathic arteriopathy, afflicting young women of reproductive age group, causing narrowing, occlusion, and aneurysms of systemic and pulmonary arteries, especially the aorta and its branches. During pregnancy, such patients warrant special attention. An interdisciplinary collaboration of obstetricians, cardiologists, and neurologists is necessary to improve maternal and fetal prognosis. Here a case is reported where a patient with diagnosis of TA, complicated by neurological sequelae, successfully fought the vagaries of the condition twice to deliver uneventfully. Case. 25-year-old G2P1L1 presented at 34 weeks of gestation, with chronic hypertension, with TA, with epilepsy, and with late-onset severe IUGR. Following a multidisciplinary approach, she delivered an alive born low birth weight baby (following induction). Her postpartum course remained uneventful. Conclusion. Pregnancy with TA poses a stringent challenge to an obstetrician. Despite advancements in cardiovascular management and advent of new-fangled drugs, the optimal management for pregnant patients with this disease still remains elusive.

Updates in Pathophysiology, Diagnosis and Management of Takayasu Arteritis

BACKGROUND

Takayasu arteritis (TA) is a rare, systemic, inflammatory vasculitis of granulomatous nature, and still of unknown etiology. It mainly involves the aorta and its major branches and is more commonly seen in women of childbearing age and Asians. TA leads to stenosis, occlusion, or aneurysmal degeneration of large arteries, and its pathogenesis seems to be mainly due to an abnormal cell-mediated immunity, although other molecular and genetic abnormalities may contribute. The diagnosis and treatments lie on clinical and arteriographic findings. Because of its fluctuating course, both clinical scores and biomarkers are currently evaluated. The aim of this review is to report a comprehensive and methodologically robust state of the art about Takayasu arteritis, including the latest data and evidences in the definition, epidemiology, pathogenesis and etiology, clinical manifestations and classification, diagnosis, assessment of disease activity and progression, biomarkers, and treatment.

METHODS

We searched all publications addressing definition, epidemiology, pathogenesis, etiology, classification, diagnosis, biomarkers, and treatment of TA. Randomized trials, cohort studies, and reviews were contemplated to give a breadth of clinical data. PubMed and Scopus were searched from August 2010 to November 2015.

RESULTS

Of the 3,056 records found, 267 matched our inclusion criteria. After reading the full-text articles, we decided to exclude 169 articles because of the following reasons: (1) no innovative or important content; (2) no multivariable analysis; (3) insufficient data; (4) no clear potential biases or strategies to solve them; (5) no clear end-points; and (6) inconsistent or arbitrary conclusions. The final set included 98 articles.

CONCLUSIONS

This review presents the last updates in all fields of Takayasu arteritis. Still today, large areas of TA pathogenesis and disease-activity assessment need to be further investigated to better treat patients with TA.

Sudden death due to isolated segmentary coronary vasculitis

Coronary vasculitis is a group of conditions occurring either independently or associated with another diseases characterized by an inflammation of the blood vessel's wall and subsequent fibrinoid necrosis, occlusion, stenosis, or aneurismal dilatations. Coronary vasculitis leading to sudden cardiac death has rarely been described in the scientific literature.We present the case of an 18-year-old football player who collapsed when playing football. The patient remained in a deep coma (glasgow coma scale = 3) in the hospital for another 4 hours before dying. During hospitalization, he was diagnosed with acute anterolateral myocardial infarction with ST elevation. An autopsy was performed the next day, and on the coronary vessels were identified a dilatation with luminal extension, which, based on clinical and pathological criteria, was considered to be an isolated, coronary polyarteritis nodosa.

Application of cerebral oximetry for a parturient with Takayasu's arteritis undergoing cesarean section -a case report-

Takayasu's arteritis (TA) is a chronic inflammatory disease involving the aorta. Because TA sometimes involves cerebral arteries, anesthetic debates focus on cerebral monitoring. There is limited evidence as to which cerebral monitoring method is most adequate. Furthermore, there is insufficient evidence to determine which anesthetic technique is better for TA parturients. We experienced the case of a TA parturient who developed transient cerebral ischemia during cesarean section. The patient's TA involved her cerebral arteries, and her regional cerebral oxygen saturation (rSO₂) was lower in the left side than in the right side. She complained of speech impairment, tinnitus, and stiffness of the posterior neck when the rSO₂ levels dropped. The FloTrac/Vigileo™ system did not correlate with clinical symptoms, but the cerebral oximeter displayed the low oxygen saturation. We recommend the cerebral oximetry for cerebral monitoring in TA parturients who undergo cesarean sections, especially in hemodynamically unstable patients under regional anesthesia or unconscious patients under general anesthesia.

Takayasus's arteritis in pregnancy. Case report and literature review

BACKGROUND AND OBJECTIVES

Takayasus's Arteritis (TA) is a chronic, inflammatory, progressive, idiopathic disease that causes narrowing, occlusion, and aneurysms of systemic and pulmonary arteries affecting especially the aorta and its branches. During pregnancy, one should pay special attention to these patients. The objective of this report was to present the peripartum anesthetic care of a patient with TA and a review of the literature.

CASE REPORT

This is a 31-year old gravida who underwent exchange of the aortic arch and placement of a metallic aortic valve for TA four years ago. She had no complications during pregnancy, and she was admitted at 34 weeks of pregnancy for anticoagulation management. Elective cesarean section was performed at 39 weeks with continuous epidural anesthesia. Fractionated doses of local anesthetic were administered to guarantee slow installation of the blockade. The patient remained hemodynamically stable and was transferred to the ICU in the postoperative period.

CONCLUSIONS

Several complications can affect gravidas with TA. Careful patient evaluation, treatment of TA complications, and anestheticsurgical planning are fundamental. Maintenance of perfusion is the main concern in these patients, and neuraxial blocks may be used without harming the mother and fetus. In patients with compensated TA complications, monitoring does not differ from that routinely used in cesarean sections. Continuous epidural anesthesia with slow installation maintains hemodynamic stability and allows monitoring cerebral perfusion through the level of consciousness. To avoid postoperative hypoperfusion or hypertensive complications patients should be monitored in an intensive or semi-intensive care unit for 24 hours.

Risk factors for early visual deterioration in temporal arteritis

BACKGROUND

Despite corticosteroid treatment, patients with temporal arteritis may continue to lose vision. However, predictors of progressive visual loss are not known.

METHODS

We retrospectively reviewed 341 consecutive patients with suspected temporal arteritis who underwent temporal artery biopsy. 90 patients with biopsy proven temporal arteritis were included in our study.

RESULTS

Twenty-one patients (23%) experienced continuous visual symptoms despite steroid therapy and 14 among these suffered persistent visual deterioration. Based on univariate analysis, visual loss on presentation was associated with disc swelling and a history of hypertension. Risk factors for progressive visual loss included older age, elevated C reactive protein and disc swelling.

CONCLUSION

Although corticosteroid therapy improves the visual prognosis in temporal arteritis, steroids may not stop the progression of visual loss. Our study reliably establishes the risk factors for visual loss in this serious condition. Whether addressing these risk factors early in their presentation can alter the visual outcome remains unknown. Individual risk anticipating treatment regimens and strategies might improve the visual prognosis in temporal arteritis in the future.

The Clinical Spectrum of Primary Renal Vasculitis

BACKGROUND AND OBJECTIVES

The vasculitides are potentially severe and often difficult to diagnose syndromes. Many forms of vasculitis may involve the kidneys. This review will focus on the clinical and histopathological aspects of renal involvement in the systemic vasculitides.

METHODS

We searched the MEDLINE database using as key terms the MeSH terms and textwords for different forms of vasculitis and for renal involvement, creating a database of more than 2200 relevant references.

RESULTS

The frequency of renal involvement in vasculitis varies among different syndromes. It is more frequent in Wegener's granulomatosis and microscopic polyarteritis, while it is uncommon to rare in other forms of vasculitis such as Behçet's disease and relapsing polychondritis. The vessels affected include the renal artery in Takayasu arteritis, medium-size renal parenchymal artery in classic polyarteritis nodosa, and glomerular involvement in Wegener's granulomatosis and microscopic polyarteritis. The clinical expression of renal vasculitis depends on the size of the affected vessels and includes renovascular hypertension, isolated nonnephrotic proteinuria, interstitial nephritis, and glomerulonephritis, which can be rapidly progressive. Diagnosis is established by a combination of history, clinical manifestations, laboratory findings (eg, urine sediment, urine protein, antineutrophil cytoplasmic antibodies), imaging techniques (renal angiography, especially when there is a suspicion of medium-to-large vessel disease, and chest radiograph), and finally, renal biopsy. Prognosis varies from unfavorable in the rapidly progressive glomerulonephritis of microscopic polyarteritis, which can lead to renal failure, chronic dialysis, and renal transplantation, to benign, as in the case of Henoch Schonlein purpura, in which the majority of patients recover.

CONCLUSIONS

The manifestations and prognosis of renal vasculitis range widely. Renal involvement greatly influences prognosis and dictates the need for early and prompt immunosuppressive therapy. Thus, the clinician should be alert for the timely diagnosis and treatment of renal vasculitis.

Occlusive thromboaortopathy (Takayasu disease): clinical and angiographic features and a brief review of literature

The aim of this study was to evaluate the diagnostic criteria and angiographic classifications of Takayasu arteritis by presenting the clinical, angiographic, and prognostic findings and a prospective follow-up of 78 patients. Occlusive thromboaortopathy or Takayasu arteritis is a large vessel vasculitis. The disease is systemic with an autoimmune and genetic etiology. The complete clinical and angiographic manifestations are reported for 78 cases based on diagnostic criteria of the American College of Rheumatology with a mean 6 +/- 3.2 years follow-up. The mean age was 34.7 and female:male ratio was 3.6:1. According to National Institute of Health criteria, 61.5% of patients were in the acute phase of disease with systemic symptoms such as fever, weight loss, malaise, and elevated C-reactive protein levels. Immunologic markers, such as antinuclear antibody and antineutrophil cytoplasmic antibodies, were negative. The tuberculin test result was positive in 47%. Vascular bruit was present in 89%. Almost all patients had stenoses, occlusions, or aneurysmatic changes of the aorta and its main branches. Hypertension was detected in 58% and left ventricular hypertrophy was initially present in 22 (28%) patients. The angiographic manifestations were classified as type I, cervicobrachial type with 20 cases (25.6%); type II, thoracoabdominal type with 13 cases (16.6%); type III, peripheral type with 10 cases (12.8%); and type IV, generalized type with 35 cases (44.8%). The coronary arteries were involved in 6 cases, pulmonary arteries in 11 initially 5 in follow-up (16 cases), and renal arteries in 28 cases, respectively. A good correlation of the clinical manifestations and the prognosis was observed. During follow-up, five patients suffered from myocardial infarction, six had cerebrovascular accident, seven patients underwent aortic valve replacement, and six patients died (mortality rate, 7.6%). The specificity and sensitivity of diagnostic criteria were 94% and 76%, respectively. In contrast to ours and Nasu's classification in the new classification of Numano, some angiographic types and subtypes of Takayasu arteritis are not present in our patients.

Giant cell arteritis and secondary amyloidosis: the natural history

Giant cell (temporal) arteritis (GCA) may be a cause of fever of unknown origin (FUO) in elderly patients. The development of secondary (reactive) amyloidosis is an unusual complication of the disease. We describe a 65-year-old male patient who was hospitalized in our hospital with FUO and was diagnosed as having GCA 5 years later. At that time, he also had a nephrotic syndrome and secondary amyloidosis (AA-type). He died due to end-stage renal failure. The probable explanation for the development of this rare complication might be the late diagnosis of this chronic inflammatory disease, which was left untreated for a long period of time.

Spectrum of giant cell vasculitis

Giant cell arteritis (GCA) is the commonest primary systemic vasculitis in the United States. Severe outcomes include blindness and stroke, and death may result from aortic dissection. Temporal artery biopsy remains the gold standard for diagnosis. Magnetic resonance imaging (MRI) of involved vessels shows promise as a useful noninvasive method for diagnosis and assessment of disease activity. Corticosteroid therapy is effective but is associated with considerable morbidity. Longitudinal studies with large numbers of patients are required to identify appropriate steroid-sparing agents. New insights into the immunopathogenesis of GCA have allowed us to identify heterogeneous subsets of patients with varying clinical presentations corresponding to specific cytokine profiles. The concept of the involved artery as an active participant in the events leading to luminal obstruction has been realized and provides the opportunity to evaluate novel therapies to modify the course of the disease.

Epidemiology and optimal management of polymyalgia rheumatica

Polymyalgia rheumatica (PMR) is a disease of unknown aetiology that occurs in elderly patients, predominantly affecting the Caucasian population. The disease has a slightly higher prevalence in women than in men. There is ongoing discussion regarding the relationship between PMR and giant cell arteritis; an increasing number of studies indicate that they are closely related. PMR has also been linked with rheumatoid arthritis, myopathy and malignant disease. Oral corticosteroids remain the mainstay of drug therapy for PMR. These drugs usually induce prompt relief of symptoms, and some authors consider this dramatic response to be diagnostic for PMR. However, the ideal initial dosage, the duration of treatment and the optimal tapering schedule are much debated. Other drugs, such as methotrexate and azathioprine, have been suggested as corticosteroid sparing agents. Nonsteroidal anti-inflammatory drugs are generally considered to be unsuitable for the long term treatment of PMR.