Arterial reconstruction for non-specific arteritis (Takayasu's disease): medium to long term results

Clinical Outcome of Extraanatomic Bypass for Midaortic Syndrome Caused by Takayasu Arteritis

BACKGROUND

We investigated long-term outcomes and cardiac function after extraanatomic bypass surgery for Takayasu arteritis and midaortic syndrome.

METHODS

Between 2007 and 2016, 14 patients underwent extraanatomic bypass for Takayasu arteritis. Median age was 56.6 years. Median systolic pressure gradient in the stenotic lesion was 79 mm Hg. Nine patients underwent bypass surgery from the ascending aorta to the infrarenal aorta, 2 from the ascending aorta to the distal descending thoracic aorta, 1 from the ascending aorta to the supraceliac abdominal aorta, 1 from the descending thoracic aorta to the infrarenal abdominal aorta, and 1 from the descending thoracic aorta to the descending thoracic aorta. Five underwent additional 6 peripheral bypass procedures, and 6 underwent concomitant heart surgery.

RESULTS

There were no early deaths. Median hospital stay was 10.5 days. Median follow-up duration was 36.3 months, and late death occurred in 2 patients. One died at 1 year postoperatively because of an infection due to pancreatic injury and mediastinitis. The other was lost to follow-up, and death was confirmed through the national insurance database. No anastomotic site stenosis or aneurysmal change occurred. The number of antihypertensive medications was reduced significantly in all but 1 patient, and organ ischemia symptoms, including dizziness, visual disturbance, and claudication, improved in all patients. Interventricular septal diameter and left ventricular mass index decreased significantly. Serum creatinine level also decreased. Overall estimated 5-year survival was 79% ± 13%.

CONCLUSIONS

Extraanatomic bypass for Takayasu arteritis is safe and effective and can be useful for left ventricular unloading and reduction of organ ischemia.

Takayasu’s arteritis: a review of the literature and the role of endovascular treatment

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Fulminant Development of Mega-aorta Due to Takayasu's Arteritis: Case Report and Review of the Literature

Takayasu's arteritis is a rare inflammatory arteriopathy characterized by segmental involvement of the aorta, its major branches, and, occasionally, the pulmonary arteries. Arterial inflammation generally results in occlusion, but Takayasu's arteritis occasionally presents as aneurysm formation. Takayasu's arteritis generally afflicts young women and is most often characterized by an acute episode of systemic illness and neurologic symptoms secondary to stenoses of the carotid and vertebral circulation. We report an unusual case of Takayasu's arteritis in a 43-year-old man who presented with severe back pain and provide a brief review of the literature.

Nonarteriosclerotic vascular disease

Thromboangiitis obliterans, or Buerger disease, is a chronic nonatherosclerotic endarteritis manifesting as inflammation and thrombosis of distal extremity small and medium-sized arteries resulting in relapsing episodes of distal extremity ischemia. Takayasu arteritis is a rare syndrome characterized by inflammation of the aortic arch, pulmonary, coronary, and cerebral vessels, presenting with cerebrovascular symptoms, myocardial ischemia, or upper extremity claudication in young, often female, patients. Kawasaki disease is a small- and medium-vessel acute systemic vasculitis of young children, with morbidity and mortality stemming from coronary artery aneurysms. Microscopic polyangiitis, Churg-Strauss syndrome, and Wegener granulomatosis are systemic small-vessel vasculitides, affecting arterioles, capillary beds and venules, and each presenting with variable effects on the pulmonary, renal and gastrointestinal systems.

Retrospective Analysis of Surgery Versus Endovascular Intervention in Takayasu Arteritis

Background—

With recent advances in endovascular treatment, percutaneous endoluminal angioplasty has become particularly attractive for arterial lesions of Takayasu arteritis. However, data came from case reports or small series, and the long-term outcome has not been reported. The incidence of potential vascular complications after surgery or endovascular treatment is still to be determined.

Methods and Results—

This retrospective multicenter study analyzed the results and outcomes of 79 consecutive patients with Takayasu arteritis (median age, 39 years; interquartile range [IQR], 25–50 years; 63 women [79.7%]) who underwent 166 vascular procedures (surgery, 104 [62.7%]; endovascular repair, 62 [37.3%]) for the management of arterial complications. After a follow-up of 6.5 years (IQR, 2.2–11.5 years), 70 complications were observed, including restenosis (n=53), thrombosis (n=7), bleeding (n=6), and stroke (n=4). The overall 1-, 3-, 5-, and 10-year arterial complication–free survival rates were 78% (IQR, 69%–88%), 67% (IQR, 57%–78%), 56% (IQR, 46%–70%), and 45% (IQR, 34%–60%), respectively. Among the 104 surgical procedures, 39 (37.5%) presented a complication compared with 31 of the 62 (50%) with endovascular repair. In multivariate analysis, biological inflammation at the time of revascularization (odds ratio, 7.48; 95% confidence interval, 1.42–39.39; P =0.04) was independently associated with the occurrence of arterial complications after the vascular procedure. Patients who experienced complications had higher erythrocyte sedimentation rates ( P <0.001) and C-reactive protein ( P <0.001) and fibrinogen ( P <0.005) serum levels compared with those without complications.

Conclusions—

The overall 5-year arterial complication rate was 44%. Biological inflammation increased the likelihood of complications after revascularization in patients with Takayasu arteritis.

Takayasu arteritis in France: a single-center retrospective study of 82 cases comparing white, North African, and black patients

We conducted a single-center retrospective study to compare the characteristics of Takayasu arteritis (TA) among white, North African, and black patients in a French tertiary care center (Hospital Pitié-Salpêtrière, Paris). Eighty-two patients were studied (82.9% female) during a median follow-up of 5.1 years (range, 1 mo to 30 yr). Among these 82 patients, 39 (47.6%) were white, 20 (24.4%) were North African, and 20 (24.4%) were black patients. Median age at diagnosis was 39.3 years (range, 14-70 yr) in white patients vs. 28.4 years (range, 12-54 yr) in North African (p = 0.02), and 28.0 years (range, 13-60 yr) in black patients (p = 0.08). Patients aged >40 years at TA onset were more frequently white than non-white (40.0% vs. 18.6%, p = 0.03). North African patients had more frequent occurrence of ischemic stroke (p = 0.03) and poorer survival (p = 0.01) than white patients. Type V of the Hata classification was the most frequent type among white (38.5%), North African (65.0%), and black patients (40.0%). Corticosteroids were used in 96.1% of patients. Fifty-three percent of white and North African patients, and 44% of black patients required a second line of immunosuppressive treatment (p = 0.60). Vascular surgical procedures were respectively performed in 46.1%, 50.0%, and 55.0% of white, North African, and black patients, p = 0.81. The 5-year and 10-year survival rates were 100% and 95.0%, respectively, in white patients; 67.4% at both 5 years and 10 years in North African patients; and 100% at both 5 years and 10 years in black patients. This study is one of the first direct comparisons of TA profiles among patients of distinct ethnic backgrounds. Our data support the idea that late-onset TA or an overlap between TA and large-vessel giant cell arteritis may be observed in white patients. North African patients have a higher occurrence of ischemic stroke and poorer survival than white patients.

A rare cause of renovascular hypertension: Takayasu arteritis with only renal artery involvement

Takayasu arteritis is a chronic inflammatory disease that affects mainly the aorta, main branches of aorta, and pulmonary arteries with unknown etiology. Disease affecting solely the renal arteries is rare. We will present a case that had hypertension, hypokalemia, and metabolic alkalosis where the etiology was type 2 Takayasu arteritis, affecting renal arteries.

The Management of Takayasu's Arteritis: Personal Experience

Takayasu's arteritis is a chronic vasculitis mainly involving the aorta and its main branches. Almost all patients have ischemic disorders of the involved vessels. Treatment is nowadays controversial. Relapses are frequent. In the present study, we elucidate the long-term outcomes of our patients with Takayasu's arteritis. Between November 1993 and October 2003, 10 patients with Takayasu's disease were treated. All patients underwent medical treatment (corticosteroid for 7 months, cyclophosphamide for 3 months, and methotrexate for 12 months). Two patients stopped treatment with methotrexate when renal failure occurred. Four patients underwent a surgical procedure. During treatment, erythrocyte sedimentation rate and C-reactive protein concentrations were determined as indexes of inflammatory activity and treatment responsiveness. Four out of eight patients (50%) who underwent the full treatment with methotrexate had no relapse of the disease. The other four patients (50%) had relapse of the disease but had a better response to new corticosteroid treatment. The two patients who stopped methotrexate treatment died from complications of Takayasu's arteritis. In our personal experience, long-term treatment with methotrexate demonstrated a certain efficacy in avoiding relapse, maintaining stability of results, and amplifying the effects of steroid in patients with relapse.

Endovascular repair of thoracic stent-graft bulging rupture in a patient with multiple thoracic aneurysms due to Takayasu disease

Isolated aortic aneurysms in Takayasu arteritis (TA) are rare. Reported operative mortality and operative complication rates seem low, with an infrequent need for surgical revision, even though most reports concern occlusive disease. Treatment of aneurysms in TA requires therapeutic strategies that are different from the ones used for atherosclerotic vessel dilatations because the pathology and the extensive, progressive, relapsing nature of the disease are deeply different from the atherosclerotic process. We report a case of thoracic stent-graft bulging rupture, a device previously implanted to exclude a thoracic aneurysm, associated with two small aneurysms near the distal implantation site. Both were treated with three new-generation stent grafts implanted in a telescope fashion.

Long-term outcome after surgical intervention and interventional procedures for the management of Takayasu’s arteritis in children

OBJECTIVE

There is little information available on the results of reconstructive arterial surgery for Takayasu's arteritis in children. This study evaluates midterm to long-term outcome after surgical, as well as interventional, procedures.

METHODS

From 1984 through 2004, 10 children (5 boys and 5 girls; age, 12.7 +/- 2.6 years) with Takayasu's arteritis were referred to our center. Baseline cardiovascular assessment included contrast angiography (n = 4), magnetic resonance imaging-angiography (n = 3), and combined contrast angiography plus magnetic resonance imaging-angiography (n = 3). Two patients had disease confined to the thoracic aorta, 4 had disease confined to the abdominal aorta, and 4 had combined thoracoabdominal aortic disease. Steno-occlusive lesions were predominant in 92% of cases. Seven patients were maintained on steroid therapy throughout the follow-up period. Eight children underwent complex surgical procedures, 1 patient had balloon dilatation of the renal and mesenteric arteries, and 1 patient had combined vascular surgery with percutaneous transluminal angioplasty. Overall, 24 grafts (polytetrafluoroethylene, Dacron grafts, and cryopreserved homografts) were implanted in various locations.

RESULTS

There were no perioperative deaths. Arterial hypertension regressed in all patients, and cardiac function normalized in all 4 patients with dilative cardiomyopathy. Over a 20-year period, 1 patient presented with sudden death and 2 showed nonfatal disease progression, one of whom required surgical reintervention. The occlusion rate was higher in Dacron grafts.

CONCLUSIONS

Our study shows that despite the extent and severity of vascular lesions, children with Takayasu's arteritis could benefit from reconstructive surgery, with low mortality, morbidity, and satisfactory long-term results.

Surgical outcome of aortic arch repair for patients with Takayasu arteritis

BACKGROUND

Takayasu arteritis can cause segmental dilatation or stenosis of the aorta and its major branches, and surgical treatment of it is still difficult. Our objective was to review late results of aortic arch repair for patients with Takayasu arteritis.

METHODS

Between 1987 and 2003, 21 patients underwent aortic arch repair under circulatory arrest. Diagnosis was performed by pathologic study of specimens for all patients. Total aortic arch repair was performed in 12 patients with separated branched grafts and in 2 patients with the island technique. Selective cerebral perfusion was used in 12 patients and retrograde cerebral perfusion in 2 patients in this type of surgery. Hemiarch replacement using retrograde cerebral perfusion was performed in 7 patients. Craniocervical vascular stenosis was found in 7 patients and aneurysm in 5 patients. The elephant trunk technique was used in 10 patients. The follow-up period was 6.2 +/- 4.2 years.

RESULTS

There was one hospital death due to renal failure, and two late deaths, both of which were sudden. Late in follow-up, a patient who had undergone hemiarch replacement 12 years previously required total aortic arch repair for dilatation of the distal arch. Three patients required thoracoabdominal aortic repair and one patient descending aortic repair for residual aortic dilatation late in follow-up. Postoperative spinal infarction occurred in one patient who underwent hemiarch replacement.

CONCLUSIONS

Surgical and late outcomes of aortic arch repair under circulatory arrest appear favorable, though late dilatation of the residual aorta is a matter of concern.

Takayasu’s arteritis: Operative results and influence of disease activity

OBJECTIVES

To determine the short- and long-term outcomes of patients treated operatively for Takayasu's arteritis and the effect of disease activity on results.

METHODS

Forty-two (17%) of the 251 patients enrolled in our Takayasu's arteritis registry between 1975 and 2002 required operation for symptomatic disease. Data were obtained from the registry, patient records, phone correspondence, and written surveys.

RESULTS

There were 38 females and 4 males with a median age of 29 years (range, 12 to 56 years), and 32 (76%) were white. Sixty operations were performed for symptomatic disease. The mean duration of symptoms before operation was 5.6 months (range, 0 to 25 months). Thirteen (31%) patients had active disease and underwent operation for acute presentation or failure of medical management. Thirty-nine patients (93%) had operation for occlusive disease. Twenty-two (52%) patients had involvement of both the great and abdominal aortic branch vessels; 10 (24%) had great vessel disease alone; 9 (21%) had involvement of abdominal arteries; and 1 (2%) had coronary artery disease. There was no operative death, myocardial infarction, major stroke, or renal failure. Three patients had early graft thrombosis, two had a minor stroke, and two developed hyperperfusion syndrome. The median follow-up was 6.7 years (range, 1 month to 19.3 years). Eleven (26%) patients required 15 graft revisions; five of the patients had active disease at the time of initial operation. All early revisions (<1 year) were in patients with active disease. By Kaplan-Meier analysis, freedom from revision at 5 and 10 years was 100% in patients with quiescent disease not requiring steroids (group I, n = 5, 12%), 95% and 81% in patients whose disease was quiescent on steroids (group II, n = 24, 57%), 57% in patients with active disease on steroids (group III, n = 7, 17%), and 33% in patients with active disease and no long-term steroids (group IV, n = 6, 14%) (P < .006). The rate of revision or progression of disease at another site in 5 years was 0% in group 1, 10% in group 2, 57% in group 3, and 67% in group 4 (P < .001) The differences were even more pronounced when an analysis was done on the basis of disease activity alone, irrespective of steroid use. During the follow-up period, 3 of 39 great vessel, 2 of 18 mesenteric/renal, and 1 of 9 aortofemoropopliteal reconstructions occluded. The predicted mortality for patients was 4% at both 5 and 10 years (95% CI) respectively (confidence interval [CI], 0% to 11%) and 10 (CI, 0% to 14%) years, respectively.

CONCLUSIONS

The minority of patients with Takayasu's arteritis require operation. In our predominantly white female patient population, occlusive symptoms were the most common indication for operation. Operation for these selected patients was safe, with no operative mortality, myocardial infarction, major stroke, or renal failure. Patients with active disease requiring operation are more likely to require revision or develop progressive symptomatic disease at another site. Long-term survival is excellent, regardless of disease activity at the time of operation.

Surgical Treatment of Aortic Regurgitation due to Takayasu Arteritis

Background— The goal of this retrospective study was to determine the late outcome of surgical treatment for aortic valve regurgitation due to Takayasu arteritis and correlate it with evidence of inflammation on pathological examination.

Methods and Results— Ninety consecutive patients who underwent surgery for aortic valve regurgitation due to Takayasu arteritis between 1979 and 2003 were studied. Intraoperative pathological specimens of the aortic wall from 69 patients were retrospectively examined for inflammation. Aortic valve replacement was performed in 63 patients (group A) and composite graft repair in 27 patients (group B). The aortic root diameter was 39.9±9.5 mm in group A and 54.4±13.6 mm in group B ( P <0.0001). Preoperative steroid therapy was performed in 40 patients (44.4%). Hospital mortality was 4.8% (3/63) in group A and 7.4% (2/27) in group B. The overall 15-year survival rate was 76.1%. Detachment of the valve or graft occurred in 11.1% (7/63) of group A and in 3.7% (1/27) of group B patients ( P =0.43). Late dilatation (>50 mm) of the residual ascending aorta occurred in 11.1% (7/63) of group A and in 3.7% (1/27) of group B patients ( P =0.43). Active inflammation was confirmed in intraoperative pathological specimens of 10 patients, and detachment of the valve or graft occurred in 4 of these patients. Univariate analysis of background variables revealed active inflammation to be a risk factor for detachment ( P =0.0001; risk ratio 55).

Conclusions— Late dilatation of the ascending aorta after aortic valve replacement is a clinically important finding. Active inflammation could be related to valve or graft detachment.

Takayasu arteritis: clinical features and management: report of 272 cases

BACKGROUND

Takayasu's arteritis is a condition of unknown aetiology with an unpredictable natural history. Most of the literature available has originated from Asia, with a few contributions from Africa where the pattern of the disease may be different. This is a single institution's experience review.

METHODS

Data were obtained retrospectively from the angiographic and medical records of patients treated at Groote Schuur Hospital over the period 1952-2002. The criteria for inclusion were those proposed by the Aortitis Syndrome Research Committee of Japan and the American College of Rheumatology.

RESULTS

Two hundred and seventy-two patients were identified. The mean age at presentation was 25 years (range 14-66 years) and 75% were female. Only 8% were Caucasian. Hypertension was the most common presentation (77%) and was usually a consequence of renal artery stenosis or aortic coarctation. Cardiac failure was the most common problem. Cerebrovascular symptoms were recorded in 20%. Convincing evidence of tuberculosis was present in 20%. The entire aorta was involved in 70% of cases. Thirty per cent had aortic bifurcation involvement. Occlusions were noted in 93% and aneurysms in 46%. Vascular reconstruction was performed on 115 occasions in 99 patients, with an operative mortality of 4%. Cardiac failure was the usual cause of death. One hundred and six patients (39%) were followed for a minimum of 5 years. No further progression of disease was noted in 70 patients.

CONCLUSION

The natural history and prognosis of Takayasu's arteritis still remain poorly defined.

Takayasu's Arteritis Presenting as Uveitis in a 5-Year-Old Girl

A 5-year-old patient presented with uveitis as initial manifestation of Takayasu's arteritis. Our patient is unique not only in the initial presentation but also in the extent of arteritis in the aortic arch and great vessels. This is only the second case reported in the literature with this unusual presentation.

Long-term survival after surgical treatment of patients with Takayasu's arteritis

BACKGROUND

Surgical interventions have been performed to ameliorate the complications of Takayasu's arteritis. However, the efficacy of surgery to increase long-term survival has not been established.

METHODS AND RESULTS

A retrospective review was performed on the survival of 106 consecutive patients with Takayasu's arteritis who underwent surgical treatment during the past 40 years. Their ages ranged from 5 to 69 years (mean+/-SEM, 31.7+/-1.3 years). Survival was compared with the reported results of medically treated patients according to Ishikawa's prognostic classification. There were 12 hospital deaths, and the remaining 94 patients were followed up from 8 months to 41.8 years (mean, 19.8 years). A serious long-term complication was anastomotic aneurysm, with a cumulative incidence at 20 years of 13.8%. Thirty-one late deaths were observed, and the major cause was congestive heart failure. The overall cumulative survival rate at 20 years was 73.5%. The prognostic classification by Ishikawa had little influence on the survival of surgically treated patients. For stage 3 patients, surgery seemed to increase survival; however, surgery-related complications conversely decreased the survival of stage 1 patients.

CONCLUSIONS

Surgery seems to increase the long-term survival of patients with stage 3 Takayasu's arteritis, whereas conservative treatment is recommended for those with stage 1 or 2 disease. An anastomotic aneurysm may occur at any time after surgery, and regular follow-up using imaging modalities such as multi-detector CT, MRI, or ultrasonography at least once every several years for the rest of the patient's life is mandatory for the early detection of anastomotic aneurysm.

Isolated supradiaphragmatic descending thoracic aorta stenosis in a Takayasu's disease: surgical cure

A 21-year-old male patient presented with a typical middle aortic syndrome. Echography disclosed a severe narrowing of the lower thoracic aorta with parietal thickening. The isolated character of the lesion was confirmed by magnetic resonance imaging and aortography. The surgical cure was realized by a Dacron bypass between the upper thoracic descending aorta and the juxta-diaphragmatic thoracic aorta. Aortic biopsy confirmed Takayasu's disease. Postoperative course was uneventful with normalized blood pressure. The therapeutic options, surgery versus percutaneous dilatation and stent, are discussed.

Occlusive arterial disease in HIV-infected patients: a preliminary report

OBJECTIVES

to preliminarily describe the clinical features and management of arterial occlusive disease in human immunodeficiency virus (HIV) infected patients.

MATERIALS

twenty HIV positive patients with symptomatic large-vessel arterial occlusion treated by a tertiary vascular unit in a 3-year period.

METHODS

retrospective review of clinical case records.

RESULTS

patients were noted to be young (median age 37 years), with preponderance of males. Twelve patients had evidence of advanced HIV infection. All patients had critical ischaemia, involving the upper limbs in four and the lower limbs in 16. Coagulation abnormalities were noted in two cases. Operative intervention in 18 patients included revascularisation in seven. Thrombotic occlusion of normal-looking arteries was noted. Arterial biopsy revealed leucoIcytoclastic vasculitis indicative of HIV arteritis in three of five cases examined.

CONCLUSIONS

initial experience with large-vessel occlusive disease in HIV positive patients suggests an underlying arteritic aetiology, with clinical and pathological features distinct from atherosclerosis. Further in-depth study is necessary to clarify the pathophysiological basis thereof.

Surgical treatment of Takayasu's arteritis

Takayasu's disease is an unusual arteritis that affects young females. Stroke is a common presenting symptom usually due to sudden occlusion of one or more thoracic aortic arch arteries. The author recommends prophylactic bypass of involved aortic arch arteries to prevent strokes. Abdominal aortic involvement causes severe claudication of the lower extremities which can be treated by bypass originating from the thoracic aorta. Involved upper extremity arteries should be bypassed for ischemic symptoms for accurate blood pressure measurement to diagnose and treat hypertension. Renal artery involvement is common and best treated by percutaneous transluminal angioplasty. Surgical results are excellent with minimal morbidity and mortality. Anastomatic complications such as false aneurysms are unusual although anastomatic stenoses do occur.

Surgical treatment of recurrent abdominal aortic aneurysm in a patient with systemic lupus erythematosus

Reports of true abdominal aortic aneurysms (AAAS), especially those due to severe inflammation, in patients with systemic lupus erythematosus (SLE) are very few in number. However, we had the experience of surgically treating a recurrent AAA due to severe inflammation found in a patient with SLE. The recurrence took place after an earlier operation for an infrarenal AAA and involved the left renal artery. In both situations, the previous infrarenal aaa and the recurrence, the aneurysms demonstrated more rapid growth and more irregularities in shape. Etiology of the AAA might be a combination of Takayasu's arteritis and SLE because the two entities appeared to have overlapped.

Posterior pericardial approach for ascending aorta-to-descending aorta bypass through a median sternotomy

BACKGROUND

Bypass grafting for repeat operation or complex forms of descending aortic disease is an alternative approach to decrease potential complications of anatomic repair.

METHODS

Between December 1985 and February 1998, 17 patients (13 men, 4 women; mean age, 47.6 +/- 18.5 years) underwent ascending aorta-to-descending aorta bypass through a median sternotomy and posterior pericardial approach. Indications for operation were coarctation or recoarctation of aorta in 8 patients, Takayasu's aortitis in 2, prosthetic aortic valve stenosis associated with coarctation of aorta, complex descending aortic arch aneurysm, reoperation for chronic descending aortic dissection, long-segment stenosis of descending aorta, acquired coarctation after repair of traumatic transection of descending aorta, severe aortic atherosclerosis, and false aneurysm of descending aorta after repair of coarctation in 1 patient each. Concomitant procedures were performed in 12 patients.

RESULTS

No early or late mortality has occurred. Follow-up was 100% complete and extended to 12 years (mean, 2.7 +/- 3.3 years). No late graft-related complications have occurred; 1 patient had successful repair of perivalvular leak after mitral valve replacement, and 1 patient had replacement of lower descending and abdominal aorta.

CONCLUSIONS

Exposure of the descending aorta through the posterior pericardium for ascending aorta-descending aorta bypass is a safe alternative and particularly useful when simultaneous intracardiac repair is necessary.

Cerebrovascular findings in Takayasu disease

The authors define the frequency, nature, and extent of cerebrovascular sequelae of Takayasu arteritis using functional imaging. Retrospective analysis of the cases derived from the Durban Stroke Data Bank (n = 1100) and Durban Metropolitan Vascular Surgery Database (n = 5300) consisted of evaluation by contemporary neuroimaging modalities including single positron emission computed tomography (SPECT), magnetic resonance imaging (MRI) diffusion scanning, and transcranial Doppler (TCD). Of all the patients identified with Takayasu disease (n = 142), 29 (20%) patients were identified with a primarily cerebrovascular presentation. The recent advent of modern functional imaging techniques allowed only the 10 most recent patients with a cerebrovascular presentation to be evaluated. Of these 10, 8 (80%) had normal neurologic deficit scores (Canadian neurologic score) and 9 (90%) were not disabled as determined by handicap scores (Rankin). The anatomic brain scans (9 MRI, 1 CT) were normal in 5 patients (50%). In 7 patients, transcranial Doppler sonography revealed increased velocities mainly in the anterior circulation with turbulence that was not circumscribed. Single positron emission computed tomography scanning revealed areas of hypoperfusion, mostly multiple, in all of the 7 cases investigated. The cerebral perfusion index was determined in 7 patients, with a good prognosis in 2 patients and a moderate prognosis in 5. Cerebral effects of Takayasu disease are best monitored by a combination of clinical and functional imaging such as TCD and SPECT scanning.

Neurosurgical and neuroendovascular management of Takayasu's arteritis

OBJECTIVE

The roles of surgical and endovascular treatments for patients with Takayasu's arteritis are not clear. We report our experience in the neurosurgical and/or neuroendovascular treatment of patients with Takayasu's arteritis who exhibited ischemic neurological symptoms.

METHODS

Between 1994 and 1998, seven patients with Takayasu's arteritis and neurological symptoms were treated at the Stanford University Medical Center. All patients were angiographically evaluated and received maximal medical therapy. Cerebral blood flow studies were performed for six patients. Three patients underwent surgical revascularization procedures alone, two underwent combinations of surgical and endovascular procedures, and two underwent endovascular treatment alone.

RESULTS

The most common neurological symptoms were dysequilibrium, syncope, and visual disturbances. The characteristic angiographic features of Takayasu's arteritis were identified for all patients. The subclavian arteries and proximal carotid and vertebral arteries were involved in all patients. Two patients exhibited improvement of their symptoms after endovascular treatment alone. There were two deaths after surgery, involving patients with severe global cerebral hypoperfusion. All other surgically treated patients exhibited improvement of their symptoms, with patent grafts, up to 4 years after surgery. Cerebral blood flow improved after treatment.

CONCLUSION

Improvement of symptoms can be achieved with surgical revascularization and/or endovascular treatment. Staged revascularization might be better than one-stage bilateral high-flow grafting for patients with severe global hypoperfusion.

Surgical treatment of Takayasu's arteritis: case report and literature review

Surgical intervention during the early stages of Takayasu's arteritis is rarely necessary. In the chronic stages of this disease, however, surgeons may be faced with difficult decisions regarding the timing of complex arterial reconstructions. These issues can be especially challenging in the pediatric population. We report the case of an 8-year-old girl with chronic Takayasu's arteritis complicated by malignant hypertension. Despite aggressive medical therapy, her blood pressure remained uncontrolled. Imaging studies demonstrated infrarenal aortic and right common iliac artery aneurysms with concomitant segmental stenosis of the right common iliac artery. Since her transplant kidney was based off the right external iliac artery, it was felt that this high-grade stenosis was responsible for her severe hypertension. Immediate surgical reconstruction was therefore recommended. Intraoperatively, the aneurysmal aorta and iliac arteries were found to be densely calcified. The transplant kidney was perfused during aortic clamping by placement of a suprarenal aorta to the right external iliac artery shunt. Endoaneurysmorrhaphy was then performed to reconstruct the aorta after extensive endarterectomy. In the early postoperative period, antihypertensive medications were decreased to two oral agents. She was discharged on the seventh postoperative day and placed on two agents. At a 1-year follow-up visit, she is on one antihypertensive medication. Her right leg complaints have resolved. Ultrasound surveillance revealed no evidence of recurrent aneurysmal or occlusive disease. A brief review of complications related to Takayasu's arteritis in the children and indications for surgical intervention completes this report.

Spontaneous carotid artery aneurysms

BACKGROUND

Spontaneous carotid artery aneurysms are infrequently reported, and are almost always non-atherosclerotic.

METHODS

The records of 29 patients with a spontaneous carotid aneurysm treated in an academic vascular unit between 1990 and 1998 were reviewed.

RESULTS

All 29 patients were black South Africans; three had bilateral aneurysms. There were 24 men and five women, of mean age 35 (range 13-62) years. Some 25 aneurysms involved the common carotid artery, 12 of which affected the bifurcation, and seven were located in the internal carotid artery. Twenty-five aneurysms were managed surgically, four of which were ligated owing to sepsis. Histo- logical evaluation showed human immunodeficiency virus-related arteritis in four, tuberculous aneurysms in ten, Takayasu's arteritis in two, atherosclerosis in three and non-specific chronic inflammation in four patients. Microbiological examination was negative in all but one patient who had Salmonella sp. cultured. Outcome was generally favourable, but one patient died from massive hemispheric infarction. There were no other new neurological deficits.

CONCLUSION

Carotid aneurysms pose a considerable surgical challenge but are amenable to operative intervention with good result. Ligation appears to be well tolerated in this group of predominantly non-atherosclerotic aneurysms.

Subclavian steal syndrome secondary to Takayasu arteritis

We present a case of 'subclavian steal syndrome' secondary to Takayasu arteritis, in a 32-year-old, Japanese woman, whose clinical manifestations result from severe ocular and brain ischemia, refractory to high dose systemic corticosteroids. Surgical management using two bypass-grafts was carried out. The first one, a GoreTex, 8 mm in diameter, thin wall, stretch type with ring-bypass graft, from the left external iliac artery to the ipsilateral axillary artery. The second one, an autologous reverse saphenous vein graft from the left subclavian artery to the ipsilateral common carotid artery. The result was a remarkable improvement of the patient's general condition and symptoms. Patency of the extra-anatomic conduits was established by digital subtraction angiography (DSA), and transcranial Doppler evaluation, as well as flow velocity assessment revealed an objective improvement of the blood supply to the ischemic areas. The present surgical approach was justified since the inflammatory process extended to the aortic arch. The development of new and efficient operatory techniques, and continuous improvement of the graft-materials provide better expectations for the long-term outcome of refractory syndromes.

Anastomotic aneurysms after surgical treatment of Takayasu's arteritis: a 40-year experience

PURPOSE

To evaluate the clinical characteristics of anastomotic aneurysms that develop in surgically treated patients with Takayasu's arteritis.

METHODS

Among 103 patients with Takayasu's arteritis treated surgically over 40 years, 91 patients with 259 anastomoses (allowing for exclusion of 12 operative deaths) participated in follow-up study from 1 month to 37.3 years with a mean value +/- SEM of 17.3 +/- 1.1 years with a follow-up completion rate of 93% at 30 years. The clinical characteristics of anastomotic aneurysms were clarified, and the influences of several factors (sites of anastomoses, occlusive or aneurysmal disease, suture material, preoperative systemic inflammation, and administration of corticosteroids) on formation of anastomotic aneurysms were analyzed by means of life-table method and Cox regression analysis.

RESULTS

Twenty-two uninfected anastomotic aneurysms were found among 14 patients (22 of 259 anastomoses, 8.5%). The interval between the previous operation and diagnosis varied from 1.6 to 30 years with a mean value +/- SEM of 9.8 +/- 1.8 years. The cumulative incidence of anastomotic aneurysm at 20 years was 12.0%. Systemic inflammation or steroid administration had little influence on formation of anastomotic aneurysm. Instead, anastomotic aneurysm tended to occur after operations for aneurysmal lesions.

CONCLUSIONS

Anastomotic aneurysm can occur anytime after operations for Takayasu's arteritis. The development of anastomotic aneurysm is not influenced by any factor specific to this disease except the presence of an aneurysmal lesion.