Novel Angiographic Scores for evaluation of Large Vessel Vasculitis

Large vessel giant cell arteritis

Giant cell arteritis is the principal form of systemic vasculitis affecting people over 50. Large-vessel involvement, termed large vessel giant cell arteritis, mainly affects the aorta and its branches, often occurring alongside cranial giant cell arteritis, but large vessel giant cell arteritis without cranial giant cell arteritis can also occur. Patients mostly present with constitutional symptoms, with localising large vessel giant cell arteritis symptoms present in a minority of patients only. Large vessel giant cell arteritis is usually overlooked until clinicians seek to exclude it with imaging by ultrasonography, magnetic resonance angiography (MRA), computed tomography angiography (CTA), or [18F]fluorodeoxyglucose-PET-CT. Although the role of imaging in treatment monitoring remains uncertain, imaging by MRA or CTA is crucial for identifying aortic aneurysm formation during patient follow up. In this Series paper, we define the large vessel subset of giant cell arteritis and summarise its clinical challenges. Furthermore, we identify areas for future research regarding the management of large vessel giant cell arteritis.

Association between the patterns of large-vessel lesions and treatment outcomes in patients with large-vessel giant cell arteritis

OBJECTIVES

We aimed to identify associations between patterns of large-vessel lesions of large-vessel giant cell arteritis (LV-GCA) and treatment outcomes.

METHODS

We extracted data on 68 newly diagnosed patients with LV-GCA from a retrospective, multi-centric, nationwide registry of GCA patients treated with glucocorticoids between 2007 and 2014. Patients with aortic lesions were identified based on the findings from contrast-enhanced computed tomography, magnetic resonance imaging, or positron emission tomography-computed tomography (Group 2, n = 49). Patients without aortic lesions were subdivided into LV-GCA with or without subclavian lesions defined as Group 1 (n = 9) or Group 3 (n = 10), respectively. The primary outcome evaluation was failure to achieve clinical remission by Week 24 and/or relapse within 104 weeks.

RESULTS

The mean age and proportion of patients with cranial lesions and polymyalgia rheumatica in Group 2 were numerically lower than in the other two groups. Large-vessel lesions in Group 3 included carotid, pulmonary, renal, hepatic, or mesenteric lesions. The cumulative rate of poor treatment outcomes >2 years was 11.1%, 55.3%, and 88.0% in Groups 1, 2, and 3, respectively (by Kaplan-Meier analysis). The mean time to poor outcome was significantly different between the groups.

CONCLUSIONS

Classification by subclavian and aortic lesions may be useful to determine treatment strategy.

Imaging in diagnosis, monitoring and outcome prediction of large vessel vasculitis: a systematic literature review and meta-analysis informing the 2023 update of the EULAR recommendations

OBJECTIVES

To update the evidence on imaging for diagnosis, monitoring and outcome prediction in large vessel vasculitis (LVV) to inform the 2023 update of the European Alliance of Associations for Rheumatology recommendations on imaging in LVV.

METHODS

Systematic literature review (SLR) (2017-2022) including prospective cohort and cross-sectional studies (>20 participants) on diagnostic, monitoring, outcome prediction and technical aspects of LVV imaging. Diagnostic accuracy data were meta-analysed in combination with data from an earlier (2017) SLR.

RESULTS

The update retrieved 38 studies, giving a total of 81 studies when combined with the 2017 SLR. For giant cell arteritis (GCA), and taking clinical diagnosis as a reference standard, low risk of bias (RoB) studies yielded pooled sensitivities and specificities (95% CI) of 88% (82% to 92%) and 96% (95% CI 86% to 99%) for ultrasound (n=8 studies), 81% (95% CI 71% to 89%) and 98% (95% CI 89% to 100%) for MRI (n=3) and 76% (95% CI 67% to 83%) and 95% (95% CI 71% to 99%) for fluorodeoxyglucose positron emission tomography (FDG-PET, n=4), respectively. Compared with studies assessing cranial arteries only, low RoB studies with ultrasound assessing both cranial and extracranial arteries revealed a higher sensitivity (93% (95% CI 88% to 96%) vs 80% (95% CI 71% to 87%)) with comparable specificity (94% (95% CI 83% to 98%) vs 97% (95% CI 71% to 100%)). No new studies on diagnostic imaging for Takayasu arteritis (TAK) were found. Some monitoring studies in GCA or TAK reported associations of imaging with clinical signs of inflammation. No evidence was found to determine whether imaging severity might predict worse clinical outcomes.

CONCLUSION

Ultrasound, MRI and FDG-PET revealed a good performance for the diagnosis of GCA. Cranial and extracranial vascular ultrasound had a higher pooled sensitivity with similar specificity compared with limited cranial ultrasound.

Arterial wall fibrosis in Takayasu arteritis and its potential for therapeutic modulation

Arterial wall damage in Takayasu arteritis (TAK) can progress despite immunosuppressive therapy. Vascular fibrosis is more prominent in TAK than in giant cell arteritis (GCA). The inflamed arterial wall in TAK is infiltrated by M1 macrophages [which secrete interleukin-6 (IL-6)], which transition to M2 macrophages once the inflammation settles. M2 macrophages secrete transforming growth factor beta (TGF-β) and glycoprotein non-metastatic melanoma protein B (GPNMB), both of which can activate fibroblasts in the arterial wall adventitia. Mast cells in the arterial wall of TAK also activate resting adventitial fibroblasts. Th17 lymphocytes play a role in both TAK and GCA. Sub-populations of Th17 lymphocytes, Th17.1 lymphocytes [which secrete interferon gamma (IFN-γ) in addition to interleukin-17 (IL-17)] and programmed cell death 1 (PD1)-expressing Th17 (which secrete TGF-β), have been described in TAK but not in GCA. IL-6 and IL-17 also drive fibroblast activation in the arterial wall. The Th17 and Th1 lymphocytes in TAK demonstrate an activation of mammalian target organ of rapamycin 1 (mTORC1) driven by Notch-1 upregulation. A recent study reported that the enhanced liver fibrosis score (derived from serum hyaluronic acid, tissue inhibitor of metalloproteinase 1, and pro-collagen III amino-terminal pro-peptide) had a moderate-to-strong correlation with clinically assessed and angiographically assessed vascular damage. In vitro experiments suggest the potential to target arterial wall fibrosis in TAK with leflunomide, tofacitinib, baricitinib, or mTORC1 inhibitors. Since arterial wall inflammation is followed by fibrosis, a strategy of combining immunosuppressive agents with drugs that have an antifibrotic effect merits exploration in future clinical trials of TAK.

Imaging of giant cell arteritis - recent advances

Imaging is increasingly being used to guide clinical decision-making in patients with giant cell arteritis (GCA). While ultrasound has been rapidly adopted in fast-track clinics worldwide as an alternative to temporal artery biopsy for the diagnosis of cranial disease, whole-body PET/CT is emerging as a potential gold standard test for establishing large vessel involvement. However, many unanswered questions remain about the optimal approach to imaging in GCA. For example, it is uncertain how best to monitor disease activity, given there is frequent discordance between imaging findings and conventional disease activity measures, and imaging changes typically fail to resolve completely with treatment. This chapter addresses the current body of evidence for the use of imaging modalities in GCA across the spectrum of diagnosis, monitoring disease activity, and long-term surveillance for structural changes of aortic dilatation and aneurysm formation and provides suggestions for future research directions.

Association of 18 F-Fluorodeoxyglucose-Positron Emission Tomography Activity With Angiographic Progression of Disease in Large Vessel Vasculitis

OBJECTIVE

To assess whether vascular activity seen on 18 F-fluorodeoxyglucose-positron emission tomography (FDG-PET) scan is associated with angiographic change in large vessel vasculitis (LVV).

METHODS

Patients with LVV were recruited into a prospective cohort. All patients underwent magnetic resonance angiography or computed tomography angiography and FDG-PET imaging. Follow-up imaging using the same imaging modalities was obtained ≥6 months later per a standardized imaging protocol. Arterial damage, defined as stenosis, occlusion, or aneurysm, and corresponding FDG uptake were evaluated in 17 arterial territories. On follow-up, development of new lesions was recorded, and existing lesions were characterized as improved, worsened, or unchanged.

RESULTS

A total of 1,091 arterial territories from 70 patients with LVV (38 patients with Takayasu arteritis, 32 patients with giant cell arteritis) were evaluated. Over a median 1.6 years of follow-up, new lesions developed only in 8 arterial territories in 5 patients with Takayasu arteritis. Arterial lesions improved in 16 territories and worsened in 6 territories. Most arterial territories that did not have vascular activity on FDG-PET scan at baseline had no angiographic change over the follow-up period (787 [99%] of 793). Few territories with baseline FDG-PET activity had angiographic change over time (24 [8%] of 298), but of the territories that developed angiographic change, 80% had FDG-PET activity at baseline. Within the same patient, an arterial territory with baseline FDG-PET activity had significantly increased risk for angiographic change compared to a paired arterial territory without FDG-PET activity (odds ratio 19.49 [95% confidence interval 2.44-156.02]; P < 0.01). Concomitant edema and wall thickening further increased risk for angiographic change.

CONCLUSION

Development of angiographic change was infrequent in this cohort of patients with LVV. A lack of baseline FDG-PET activity was strongly associated with stable angiographic disease. In cases of angiographic progression, change was preceded by the presence of FDG-PET activity.

Outcome Measures and Biomarkers for Disease Assessment in Takayasu Arteritis

Takayasu arteritis (TAK) is a less common large vessel vasculitis where histopathology of involved arteries is difficult to access except during open surgical procedures. Assessment of disease activity in TAK, therefore, relies on surrogate measures. Clinical disease activity measures such as the National Institutes of Health (NIH) score, the Disease Extent Index in TAK (DEI.TAK) and the Indian TAK Clinical Activity Score (ITAS2010) inconsistently associate with acute phase reactants (APRs). Computerized tomographic angiography (CTA), magnetic resonance angiography (MRA), or color Doppler Ultrasound (CDUS) enables anatomical characterization of stenosis, dilatation, and vessel wall characteristics. Vascular wall uptake of 18-fluorodeoxyglucose or other ligands using positron emission tomography computerized tomography (PET-CT) helps assess metabolic activity, which reflects disease activity well in a subset of TAK with normal APRs. Angiographic scoring systems to quantitate the extent of vascular involvement in TAK have been developed recently. Erythrocyte sedimentation rate and C-reactive protein have a moderate performance in distinguishing active TAK. Numerous novel biomarkers are under evaluation in TAK. Limited literature suggests a better assessment of active disease by combining APRs, PET-CT, and circulating biomarkers. Validated damage indices and patient-reported outcome measures specific to TAK are lacking. Few biomarkers have been evaluated to reflect vascular damage in TAK and constitute important research agenda.

Large-vessel vasculitis

Large-vessel vasculitis (LVV) manifests as inflammation of the aorta and its major branches and is the most common primary vasculitis in adults. LVV comprises two distinct conditions, giant cell arteritis and Takayasu arteritis, although the phenotypic spectrum of primary LVV is complex. Non-specific symptoms often predominate and so patients with LVV present to a range of health-care providers and settings. Rapid diagnosis, specialist referral and early treatment are key to good patient outcomes. Unfortunately, disease relapse remains common and chronic vascular complications are a source of considerable morbidity. Although accurate monitoring of disease activity is challenging, progress in vascular imaging techniques and the measurement of laboratory biomarkers may facilitate better matching of treatment intensity with disease activity. Further, advances in our understanding of disease pathophysiology have paved the way for novel biologic treatments that target important mediators of disease in both giant cell arteritis and Takayasu arteritis. This work has highlighted the substantial heterogeneity present within LVV and the importance of an individualized therapeutic approach. Future work will focus on understanding the mechanisms of persisting vascular inflammation, which will inform the development of increasingly sophisticated imaging technologies. Together, these will enable better disease prognostication, limit treatment-associated adverse effects, and facilitate targeted development and use of novel therapies.

HLA-B52 allele in giant cell arteritis may indicate diffuse large-vessel vasculitis formation: a retrospective study

Background

This study aimed to identify new characteristics of elderly onset large-vessel vasculitis (EOLVV) by focusing on human leucocyte antigen (HLA) genotype, polymyalgia rheumatica (PMR), and affected vascular lesions observed on positron emission tomography/computed tomography (PET/CT) imaging.

Methods

We retrospectively studied 65 consecutive Japanese patients with large-vessel vasculitis (LVV) who had extracranial vasculitis lesions and underwent PET/CT imaging. PET/CT images were assessed using the semi-quantitative PET visual score of each affected vessel, and the PET vascular activity score (PETVAS) and number of affected vessels were calculated. Subjects were subsequently grouped based on age at onset, superficial temporal artery (STA) involvement, and presence of PMR and compared each group according to HLA genotype. Unsupervised hierarchical cluster analysis was used to identify the patients with similar characteristics in terms of affected vascular lesions detected through PET/CT imaging. The clinical characteristics and PET/CT findings of the population newly identified in this study were examined.

Results

Twenty-seven patients with EOLVV did not meet the American College of Rheumatology 1990 criteria for giant cell arteritis (GCA) and Takayasu arteritis and were considered as unclassified EOLVV (UEOLVV). The unsupervised hierarchical cluster analysis revealed that UEOLVV with PMR and large-vessel GCA (LV-GCA) formed a cluster of LVV with GCA features (i.e., PMR and/or STA involvement) when restricted to patients who were HLA-B52-positive. Patients who were HLA-B52-positive with LVV and GCA features had similar clinical characteristics and patterns of affected vessels and presented with diffuse LVV lesions. HLA-B52-positive patients who had LVV with GCA features also presented with higher PETVAS, more affected vessels, and lower rates of biologics usage and relapse compared to HLA-B52-positive patients with TAK.

Conclusions

Patients who had UEOLVV with PMR had similar characteristics to patients with LV-GCA. Patients who were HLA-B52-positive and had LVV with GCA features presented with diffuse vascular lesions and may comprise a core population of Japanese patients with EOLVV. The findings of HLA-B52 positivity and diffusely affected vessels in patients with EOLVV can be considered as suspicious findings of LV-GCA.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13075-021-02618-4.

A susceptibility locus in the IL12B but not LILRA3 region is associated with vascular damage in Takayasu arteritis

HLA-B*52 is an established genetic factor in Takayasu arteritis (TAK). Recently, single nucleotide polymorphisms (SNPs) in IL12B (rs6871626) and LILRA3 (rs103294) were newly identified as non-HLA susceptibility loci in TAK. Here, we examined how these SNPs contribute to clinical characteristics and vascular damage in TAK. We retrospectively reviewed the medical records of 99 TAK patients enrolled in our previous genome-wide association study, and whose genotypes for IL12B rs6871626, LILRA3 rs103294, and HLA-B*52 were available. Incidence of aortic regurgitation (AR) was significantly associated with the A allele (risk allele) of IL12B rs6871626 (CC 42%, AC 61%, AA 81%; p = 0.0052; odds ratio [OR] 2.45), as well as with the incidence of hypertension (p = 0.049; OR 1.82) and the proportion of patients who underwent aortic valve replacement (p = 0.023; OR 3.64). Regarding vascular damage, there was positive correlation between the Takayasu Arteritis Damage Score and the A allele of IL12B rs6871626 (CC 3.42 ± 2.71, AC 4.06 ± 3.25, AA 6.00 ± 2.81; p = 0.0035; β = 1.35) and between the Vasculitis Damage Index and the A allele (CC 3.47 ± 1.98, AC 4.33 ± 2.40, AA 5.37 ± 2.22; p = 0.0054; β = 0.96). Contrarily, no correlation was found between LILRA3 rs103294 and vascular damage. In the present study, IL12B rs6871626 was associated with vascular damage in TAK, whereas LILRA3 rs103294 was not. Genotyping of IL12B rs6871626 may help to identify patients at risk of disease progression.

The effect of coarctation degrees on wall shear stress indices

Coarctation of the aorta (CoA) is a congenital tightening of the proximal descending aorta. Flow quantification can be immensely valuable for an early and accurate diagnosis. However, there is a lack of appropriate diagnostic approaches for a variety of cardiovascular diseases, such as CoA. An accurate understanding of the disease depends on measurements of the global haemodynamics (criteria for heart function) and also the local haemodynamics (detailed data on the dynamics of blood flow). Playing a significant role in clinical processes, wall shear stress (WSS) cannot be measured clinically; thus, computation tools are needed to give an insight into this crucial haemodynamic parameter. In the present study, in order to enable the progress of non-invasive approaches that quantify global and local haemodynamics for different CoA severities, innovative computational blueprint simulations that include fluid-solid interaction models are developed. Since there is no clear approach for managing the CoA regarding its severity, this study proposes the use of WSS indices and pressure gradient to better establish a framework for treatment procedures in CoA patients with different severities. This provides a platform for improving CoA therapy on a patient-specific level, in which physicians can perform treatment methods based on WSS indices on top of using a mere experience. Results show how severe CoA affects the aorta in comparison to the milder cases, which can give the medical community valuable information before and after any intervention.

Imaging modalities used in diagnosis and follow-up of patients with Takayasu’s arteritis

Background/aim

Takayasu’s arteritis (TA) is a rare, large-vessel vasculitis of unknown etiology, affecting aortic arch, and its main branches. Noninvasive imaging methods are frequently used in diagnosis and follow-up in Takayasu’s arteritis. Studies investigating optimal timing of follow up imaging are rare. This study is aimed to investigate the radiologic changes in vascular involvements of Takayasu’s arteritis patients one year after diagnosis.

Materials and methods

Database of our Vasculitis Center was analyzed retrospectively and 97 patients were included into the study. Demographic, clinical, radiological, and therapeutic findings of patients were recorded. Patients with follow-up imaging after approximately one year of diagnosis were recruited into further analysis. Radiological changes and the effect of different immunosuppressive agents on vascular involvements were investigated.

Results

Mean age and disease duration of patients were 43.0 and 9.0 years. The most commonly used imaging methods/modalities for the diagnosis of TA were computer tomography-angiography (CT-Ang) (58.8%), magnetic resonance-angiography (MR-Ang) (29.9%), and doppler ultrasonography (11.3%). Subclavian and common carotid arteries were the most frequently involved vessels. Fifty-three patients underwent follow-up imaging after one year of diagnosis and, in 64% of patients, same imaging method had been used. MR-Ang (62.3%) and CT-Ang (35.9%) were the most preferred follow-up imaging studies. Sixty-eight percent of patients had stable vascular involvement, 28% had progression, and 4% had regression. No difference was found in radiological changes regarding patients with usage of different immunosuppressive agents (P = 0.634). There was no association between the change in serum acute phase reactants and radiological disease activity.

Conclusion

The most commonly used imaging modality for the diagnosis of TA was CT-Ang, whereas MR-Ang was the most preferred for follow-up. Almost 30% of TA patients in our Vasculitis Center had progression at around one year concordant with previous literature. A follow-up imaging at around one year of treatment seems feasible in management of TA.

Quantification of intracranial arterial stenotic degree evaluated by high-resolution vessel wall imaging and time-of-flight MR angiography: reproducibility, and diagnostic agreement with DSA

OBJECTIVES

The purpose of this study was to compare the reproducibility and diagnostic agreement of high-resolution vessel wall imaging (HR-VWI) and time-of-flight magnetic resonance angiography (TOF-MRA) with digital subtraction angiography (DSA) to evaluate intracranial arterial stenosis.

METHODS

We retrospectively enrolled patients who underwent HR-VWI and TOF-MRA with suspected intracranial artery disease and had DSA results from our institutional imaging database. Two neuroradiologists separately and independently evaluated anonymous image data for the stenotic lesions. DSA was analyzed by two neurointerventionalists and it served as a standard criterion. The reproducibility of these two MR techniques was determined by the intraclass correlation coefficients (ICCs). The diagnostic agreement to DSA was assessed by the concordance correlation coefficients (CCCs).

RESULTS

A total of 246 lesions from 106 individuals were analyzed for stenotic degrees. The total intra-observer and inter-observer reproducibility of HR-VWI was excellent for identifying stenosis and better than of TOF-MRA. The overall concordance of HR-VWI with DSA was excellent with CCC = 0.932, whereas TOF-MRA was 0.694. In addition, HR-VWI could provide additional vessel wall information.

CONCLUSIONS

HR-VWI has more advantages over TOF-MRA, such as better reproducibilities and diagnostic agreements with DSA to analyze intracranial arterial stenosis. It provides additional information that helps in clinical diagnosis and management.

KEY POINTS

• High-resolution vessel wall imaging can assess intracranial arterial stenosis with a better reproducibility than TOF-MRA and has a higher diagnostic agreement with DSA. • High-resolution vessel wall imaging had a higher diagnostic agreement with DSA compared with TOF-MRA. • Apart from evaluating vascular stenosis, HR-VWI provided additional vessel wall information to help in clinical diagnosis.

Blood Biomarkers for Monitoring and Prognosis of Large Vessel Vasculitides

PURPOSE OF REVIEW

Large vessel vasculitides (LVVs) are inflammatory conditions of the wall of large-sized arteries, mainly represented by giant cell arteritis (GCA) and Takayasu arteritis (TA). The inflammatory process within the vessel wall can lead to serious consequences such as development of aneurysms, strokes and blindness; therefore, early diagnosis and follow-up of LVV are fundamental. However, the arterial wall is poorly accessible and blood biomarkers are intended to help physicians not only in disease diagnosis but also in monitoring and defining the prognosis of these conditions, thus assisting therapeutic decisions and favouring personalised management. The field is the object of intense research as the identification of reliable biomarkers is likely to shed light on the mechanisms of disease progression and arterial remodelling. In this review, we will discuss the role of blood biomarkers in LVVs in the light of the latest evidence.

RECENT FINDINGS

In clinical practice, the most widely performed laboratory investigations are the erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). However, these indices may be within normal limits during disease relapse and they are not reliable in patients receiving interleukin-6 (IL-6) receptor inhibitors. New biomarkers struggle to gain traction in clinical practice and no molecule with good accuracy has been identified to date. IL-6, a pro-inflammatory cytokine that drives CRP synthesis and increases the ESR, is one of the most promising biomarkers in the field. IL-6 analysis is increasingly performed, and serum levels are more sensitive than ESR for active GCA and might reflect persistent inflammation with high risk of relapse in patients on IL-6 receptor inhibitors. A future with biomarkers that reflect different disease features is an important aspiration. Accordingly, intense effort is being made to identify IL-6-independent inflammatory biomarkers, such as S100 proteins, pentraxin-3 and osteopontin. Moreover, metalloproteinases such as MMP2/9 and angiogenic modulators such as VEGF, YLK-40 and angiopoietins are being studied as markers of arterial remodelling. Lastly, biomarkers indicating organ damage may guide prognostic stratification as well as emergency therapeutic decisions: the most promising biomarkers so far identified are NT-proBNP, which reflects myocardial strain; pentraxin-3, which has been associated with recent optic nerve ischemia; and endothelin-1, which is associated with ischaemic complications. Currently, the use of these molecules in clinical practice is limited because of their restricted availability, lack of sufficient studies supporting their validity and associated costs. Further evidence is required to better interpret their biological and clinical value.

Intervention in Takayasu Aortitis: When, Where and How?

Takayasu arteritis is a large vessel vasculitis which commonly affects the aorta and its major branches. Active arterial inflammation is characterised by the presence of T and B lymphocytes, natural killer cells, macrophages and occasional multinucleate giant cells. Uncontrolled vascular inflammation can progress to cause arterial stenosis, occlusion or aneurysmal dilatation. Medical treatment involves combination immunosuppression and more recently biologic therapies targeting TNF-α and IL-6. Due to the typical delays in diagnosis and accumulation of arterial injury, open and endovascular surgical intervention are important and potentially life-saving treatment options for Takayasu arteritis. Common indications for surgery include aortic coarctation and ascending aortic dilatation ± aortic valve regurgitation, renal artery stenosis, ischaemic heart disease, supra-aortic disease, mesenteric ischaemia, severe limb-threatening claudication and aneurysm repair. Surgical outcomes are markedly improved in patients with clinically inactive disease and those who receive adequate periprocedural immunosuppression. Decisions regarding surgical approaches are best made as part of a multi-disciplinary team.

Associations between clinical features and therapy with macrophage subpopulations and T cells in inflammatory lesions in the aorta from patients with Takayasu arteritis

Takayasu arteritis (TAK) is a large-vessel granulomatous vasculitis; the inflammatory infiltration in arteries comprises macrophages, multi-nucleated giant cells, CD4⁺ and CD8⁺ T cells, γδ T cells, natural killer (NK) cells and neutrophils. However, it is unknown which subtype of macrophages predominates. This study aims to evaluate macrophages subpopulations in the aorta in TAK. Immunohistochemistry was performed in the aorta from TAK patients (n = 22), patients with atherosclerotic disease (n = 9) and heart transplant donors (n = 8) using the markers CD68, CD86, CD206, CD3, CD20 and CD56. Active disease was observed in 54·5% of patients and active histological lesions were found in 40·9%. TAK patients presented atherosclerotic lesions in 27·3% of cases. The frequency of macrophages, M1 macrophages, T, B and NK cells was higher in the aorta from TAK and atherosclerotic patients compared to heart transplant donors. In TAK, macrophages and T cells were the most abundant cells in the aorta, and the expression of CD206 was higher than CD86 (P = 0·0007). No associations were found between the expression of cell markers and active disease or with atherosclerotic lesions. In TAK patients, histological disease activity led to higher T cell counts than chronic fibrotic lesions (P = 0.030), whereas prednisone use was associated with lower T cell counts (P = 0·035). In conclusion, M1 macrophages were more frequent in TAK and atherosclerotic patients compared to heart transplant donors, while M2 macrophages dominated M1 macrophages in TAK. T cells were associated with histological disease activity and with prednisone use in TAK.

Geometric Analysis of Type B Aortic Dissections Shows Aortic Remodeling After Intervention Using Multilayer Stents

Recently, multilayer stents for type B aortic dissections (TBAD) have been proposed to decrease false lumen flow, increase and streamline true lumen flow, and retain branch vessel patency. We aimed to provide a protocol with standardized techniques to investigate aortic remodeling of TBAD by multilayer flow modulators (MFM) in static geometric and hemodynamic analyses. Combining existing literature and new insights, a standardized protocol was designed. Using pre- and postoperative CT scans, geometric models were constructed, lumen dimensions were calculated, computational fluid dynamics (CFD) models were composed, and velocity and pressures were calculated. Sixteen TBAD cases treated with MFM were included for analysis. For each case, aortic remodeling was analyzed using post-processing medical imaging software. After 3D models were created, geometrical anatomical measurements were performed, and meshes for finite element analysis were generated. MFM cases were compared pre- and postoperatively; true lumen volumes increased (p < 0.001), false lumen volumes decreased (p = 0.001), true lumen diameter at the plane of maximum compression (PMC) increased (p < 0.001), and false lumen index decreased (p = 0.008). True lumen flow was streamlined, and the overall fluid velocity and pressures decreased (p < 0.001 and p = 0.006, respectively). This protocol provided a standardized method to evaluate the effects of MFM treatments in TBAD on geometric analyses, PMC, and CFD outcomes.

Biologic therapy in supra-aortic Takayasu arteritis can improve symptoms of cerebral ischaemia without surgical intervention

OBJECTIVES

Takayasu arteritis commonly results in severe arterial injury with stenoses, occlusions and occasionally aneurysms. Arterial disease may compromise organ blood flow and result in significant cardiovascular morbidity and premature mortality. Involvement of the supra-aortic arteries is common, and in its most severe form may compromise cerebral blood supply, resulting in signs of cerebral ischaemia including visual impairment, dysphasia, transient hemiparesis, loss of consciousness and stroke. In addition to combination immunosuppression, the management paradigm for symptomatic cerebral ischaemia includes revascularization. The invasive nature of this surgery, the risk of complications and the relatively high rate of re-stenosis is of concern to patients and their physicians alike. The aim of this study was to determine whether combined immunosuppression with early escalation to biologic therapy improved outcomes and reduced the need for high risk surgical intervention.

METHODS

A retrospective review of 145 Takayasu arteritis patients attending Imperial College Healthcare between 2010-2018 was conducted to identify those with cerebral ischaemia secondary to supra-aortic disease and to analyse their treatment and outcomes.

RESULTS

Eight patients (5.5%) were identified. Seven patients received long-term combined immunosuppressive therapy and six were prescribed biologics. The data revealed a higher than expected comprehensive response to therapy, with significant falls in disease activity, the cerebral ischaemia score and the prednisolone dose required, over a median follow-up of 37 months. Serial imaging analysis detected no arterial disease progression after the initiation of optimal therapy. Only one patient required surgical intervention for persistent neurological symptoms.

CONCLUSION

Early use of biologic therapy in those with supra-aortic Takayasu arteritis presenting with cerebral ischaemia may reduce the numbers of patients requiring surgical intervention and improve outcomes.

Childhood-onset Takayasu Arteritis

Childhood-onset Takayasu Arteritis (cTAK) is a rare, large-vessel type of vasculitis seen in children, mainly affecting the aorta and its major branches. Clinical manifestations are often severe and arise as a result of systemic and local inflammation, along with end-organ ischemia. Disease flares are common and the disease burden is high, with a significant rate of morbidity and mortality. Recent advances in understanding the underlying disease pathobiology resulted in the use of pathway-targeting agents, such as TNF- or IL-6 inhibitors with improved disease control. Nonetheless, the prognosis often remains guarded and the accrued damage is significant. This review aims at summarizing the recent evidence and observations regarding this condition, with a focus on pediatric publications.

[Imaging diagnostics in large vessel vasculitis]

Imaging procedures have become an important diagnostic tool in vasculitis. In large vessel vasculitides, such as giant-cell arteritis (GCA) and Takayasu arteritis, ultrasound, magnetic resonance imaging (MRI), computed tomography (CT) and 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET) can depict specific abnormalities of the arterial wall. A clinically suspected diagnosis can be confirmed by imaging if performed by a trained specialist using appropriate equipment, without histological investigations. Ultrasound, MRI and CT show a homogeneous, concentric thickening of the arterial wall and PET can detect increased glucose metabolism of the arterial wall. Ultrasound is the method of choice, especially in predominantly cranial GCA. Imaging should be performed before or within the first few days of glucocorticoid treatment as the PET findings of all arteries as well as ultrasound and MRI findings in temporal arteries normalize quickly with treatment. A planned imaging examination must not delay initiation of glucocorticoid treatment.

YKL-40 as a new biomarker of disease activity in Takayasu arteritis

OBJECTIVE

To evaluate the role of YKL-40 as a biomarker of disease activity in patients with Takayasu arteritis (TA).

METHODS

The study included 40 patients diagnosed with TA between January 2017 and January 2018. 40 age and sex matched healthy controls were included. Serum levels of YKL-40, as well as IL-6, IL-8, IL-17, sCD163, VEGF, MMP-2, MMP-9, OPN, PTX-3 and IFN-γ, were detected at the base line and end of the 6-month follow-up. Modified Kerr criteria, in which MRA was performed instead of traditional angiography, was used a standard measure of disease activity. The association of the measured biomarkers with disease activity was analysed.

RESULTS

The serum levels of YKL-40, IL-6, IL-8, IFN-γ, MMP-2, MMP-9, PTX-3 and OPN were significantly higher in active disease than in inactive disease. Significant differences in the serum levels of YKL-40, IL-6 and PTX-3 were also observed according to the disease activity degree. Logistic analysis demonstrated that high YKL-40 levels and high IL-6 levels were independent risk factors for active disease. When YKL-40 was combined with IL-6, the specificity and sensitivity for detecting active disease were increased (87.6% and 70.4% respectively); similar findings were obtained when YKL-40 was combined with CRP (72.3% and 84.6% respectively). A predictive model of active disease using ESR, CRP, IL-6, PTX-3 and MMP-9 showed significantly improved diagnostic efficiency when YKL-40 was added to the model (sensitivity: 85.1%; specificity: 94.3%; NRI value: 12.4%; IDI value: 4.6%, p < 0.05).

CONCLUSIONS

Serum YKL-40 concentrations may be a useful biomarker of disease activity in TA.

Advances in Therapies and Imaging for Systemic Vasculitis

Vasculitis is a systemic disease characterized by immune-mediated injury of blood vessels. Current treatments for vasculitis, such as glucocorticoids and alkylating agents, are associated with significant side effects. Furthermore, the management of both small and large vessel vasculitis is challenging because of a lack of robust markers of disease activity. Recent research has advanced our understanding of the pathogenesis of both small and large vessel vasculitis, and this has led to the development of novel biologic therapies capable of targeting key cytokine and cellular effectors of the inflammatory cascade. In parallel, a diverse range of imaging modalities with the potential to monitor vessel inflammation are emerging. Continued expansion of combined structural and molecular imaging using positron emission tomography with computed tomography or magnetic resonance imaging may soon provide reliable longitudinal tracking of vascular inflammation. In addition, the emergence of radiotracers able to assess macrophage activation and immune checkpoint activity represents an exciting new frontier in imaging vascular inflammation. In the near future, these advances will allow more precise imaging of disease activity enabling clinicians to offer more targeted and individualized patient management.

PTX3 Intercepts Vascular Inflammation in Systemic Immune-Mediated Diseases

PTX3 is a prototypic soluble pattern recognition receptor, expressed at sites of inflammation and involved in regulation of the tissue homeostasis. PTX3 systemic levels increase in many (but not all) immune-mediated inflammatory conditions. Research on PTX3 as a biomarker has so far focused on single diseases. Here, we performed a multi-group comparative study with the aim of identifying clinical and pathophysiological phenotypes associated with PTX3 release. PTX3 concentration was measured by ELISA in the plasma of 366 subjects, including 96 patients with giant cell arteritis (GCA), 42 with Takayasu's arteritis (TA), 10 with polymyalgia rheumatica (PMR), 63 with ANCA-associated systemic small vessel vasculitides (AAV), 55 with systemic lupus erythematosus (SLE), 21 with rheumatoid arthritis (RA) and 79 healthy controls (HC). Patients with SLE, AAV, TA and GCA, but not patients with RA and PMR, had higher PTX3 levels than HC. PTX3 concentration correlated with disease activity, acute phase reactants and prednisone dose. It was higher in females, in patients with recent-onset disease and in those with previous or current active vasculitis at univariate analysis. Active small- or large- vessel vasculitis were the main independent variables influencing PTX3 levels at multivariate analysis. High levels of PTX3 in the blood can contribute to identify an increased risk of vascular involvement in patients with systemic immune-mediated diseases.

Assessment of disease activity in Takayasu arteritis: A quantitative study with computed tomography angiography

BACKGROUND

Identifying disease activity in Takayasu arteritis (TAK) is challenging. This study aimed to investigate the value of quantitative characterization with computed tomography angiography in the assessment of disease activity in patients with TAK.

METHODS

We retrospectively analysed the data on 162 aortic CT angiography from 140 TAK patients. Patients were categorized based on disease activity according to the National Institutes of Health criteria into two groups: active disease group (n = 65) and inactive disease group (n = 97).

RESULTS

Patients with active TAK had a thicker wall compared with patients with inactive TAK (5.2 ± 2.4 mm vs. 2.5 ± 0.8 mm, p < 0.001). The relative post-contrast enhancement ratio of the thickened wall was higher in active TAK than in inactive TAK (1.5 ± 0.3 vs. 1.1 ± 0.2, p < 0.001). Given a thickness cutoff of 3.3 mm, sensitivity for active-phase TAK was 83.1%, specificity 89.7%, positive predictive value 84.4%, and negative predictive value 88.8%. With a relative post-contrast enhancement ratio cutoff of 1.2, sensitivity for active-phase TAK was 89.2%, specificity 76.3%, positive predictive value 71.6%, and negative predictive value 91.3%. In receiver-operating characteristic curves comparison, maximal wall thickness and relative post-contrast enhancement ratio were superior to C-reactive protein and erythrocyte sedimentation rate for determining active phase disease (p < 0.05).

CONCLUSIONS

Quantitative characterization with CT angiography was a useful tool to assess disease activity in TAK patients. Maximal wall thickness and relative post-contrast enhancement ratio have a high sensitivity and specificity for detecting TAK activity.

The Role of Vascular Imaging to Advance Clinical Care and Research in Large-Vessel Vasculitis

Purpose of the Review

The two main forms of large-vessel vasculitis (LVV) are giant cell arteritis (GCA) and Takayasu's arteritis (TAK). Vascular imaging can characterize disease activity and disease extent in LVV. This review critically analyzes the clinical utility of vascular imaging in LVV and highlights how imaging may be incorporated into the management and study of these conditions.

Recent Findings

There are multiple imaging modalities available to assess LVV including ultrasonography, CT angiography (CTA), magnetic resonance angiography (MRA), and ¹⁸F-fluorodeoxyglucose (FDG) positron emission tomography (PET). As these techniques are refined, imaging may be increasingly useful to evaluate the cranial arteries and the aorta and its primary branches. In addition, vascular imaging may be useful to monitor disease activity and may have prognostic value to predict future clinical events.

Summary

There are strengths and weaknesses associated with vascular imaging that should be considered when evaluating patients with LVV. Vascular imaging will likely play an increasingly important role in the clinical management of patients and the conduct of research in LVV and may ultimately be incorporated as outcome measures in clinical trials in these conditions.