Reoperation results of arterial involvement in Behçet's disease

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Giant coronary aneurysm of Behcet's disease with sudden syncope: a case report

Behcet's disease(BD) is a chronic inflammatory vasculitis that rarely affects the arteries, making myocardial infarction unlikely. We report a 28-year-old patient who was admitted to our hospital with multiple sudden syncope. Cardiovascular risk factors such as hypertension (HT), diabetes and obesity were not found in her. Preoperatively, imaging examinations suggested thrombosis of the inferior and superior vena cava and right heart combined with coronary artery aneurysm. The patient was finally diagnosed with a huge coronary artery aneurysm proximal to the left anterior descending artery. Syncope is considered to be caused right ventricular outflow tract obstruction. The patient received a successful aneurysm resection and had an uneventful postoperative recovery.

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

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

Digestive hemorrhage and fever as a result of a double secondary aortoenteric fistula following the repair of a juxtarenal abdominal aortic aneurysm and an infection of the aortobifemoral bypass graft: a case report

A double secondary aortoenteric fistula (AEF) occurs in a patient who has had significant aortic surgery and is characterized by a direct connection between the gastrointestinal (GI) tract and the aorta at two separate sites.

IMPORTANCE

During aortoc reconstructive surgery, the patient may present with a variety of unusual complaints, including fever and GI bleeding. These symptoms are indicative of problems, including the development of an aortoentric fistula, particularly when there is a double secondary fistula.

CASE PRESENTATION

The patient was admitted to the hospital due to hematemesis, melena, and high-grade fever after undergoing synthetic grafting aortobifemoral bypass (anatomical reconstruction) and partial resection of the juxtarenal abdominal aortic aneurysm. Pus discharge and a double aortoenteric fistula in unusual sites such as the second-third portion of the duodenum and caecum are visible in upper GI endoscopy and computed tomography angiography. The patient underwent a two-stage open surgery, the first stage involving aortic limb graft exclusion and extra anatomical reconstruction, and the second stage involving graft removal, fistula management, and bowel repair. Then the patient spent a few days in the surgical intensive care unit before being discharged.

CLINICAL DISCUSSION

Primary and secondary AEF are the two categories of AEF. In patients who underwent aortic reconstruction surgery, the frequency of secondary AEF ranges from 0.36 to 1.6%. Due to the 8:1 injury ratio in the secondery AEF, men suffer more injuries than women.There are two types of fistula depending on whether or not the suture line is involved. The first form is graft enteric erosion, which excludes the suture line, while the second type is entric graft fistula, where the suture line is included. Most common site fistula is third and fourth part of duodenum and least common site is fistula formation in large bowel.

CONCLUSIONS

An uncommon complication is double secondary AEF following aortic reconstruction surgery. Since one of the most significant presentations an AEF patient can present with is major GI bleeding and sepsis, A delay in seeking immediate medical treatment could result in the patient's death. It should be emphasized that one of the mechanisms for AEF formation and a frequent cause of sepsis in patients is recurrent aortic graft infection following aortic reconstruction surgery.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Getting to the <em>heart</em> of the matter: diagnostic tools and therapeutic approach to cardiac involvement in Behçet syndrome A Tunisian case series

The aim was to investigate the frequency and spectrum of cardiac involvement (CI) in patients with Behçet syndrome (BS) in the Tunisian context, and to assess the clinical and imaging features, treatment, and outcomes. We retrospectively retrieved the medical records of patients with CI among 220 BS patients admitted to the hospital internal medicine department between February 2006 and April 2019, who fulfilled the International Study Group diagnostic criteria for BS. Ten patients (8 men, 2 women) were eligible for the study. Mean age was 37.3 years. Three patients had 2 isolated episodes of cardiac BS. The different types of CI were coronary artery disease (5/10), intracardiac thrombus (4/10), pericarditis (1/10), myocarditis (1/10), and myocardial fibrosis (1/10). Five patients had associated vascular involvement (50%). Medical treatment was based on corticosteroids and colchicine in all patients (100%), anticoagulants in 8 (80%), and cyclophosphamide followed by azathioprine in 9 (90%). The clinical course was favorable in 9 patients; 1 patient died. CI remains an important feature of BS because of its association with increased risk of mortality and morbidity. Therefore, early screening and detection with imaging methods are paramount. Also, better cooperation between rheumatologists and cardiologists could improve outcomes.

A Giant Pseudo-Aneurysm on the Anastomosis Site for a Redo Bentall Operation due to Behçet Disease Treated by Thoracic Endovascular Aortic Aneurysm Repair with a Custom-Made Stent Graft

A 34-year-old man who had undergone aortic valve replacement 8 years ago underwent an additional Bentall operation due to mechanical valve dehiscence 2 years later. Subsequently, he was diagnosed with Behçet disease and Batter syndrome. A week after being hospitalized again due to chest pain and dyspnea, a large pseudo-aneurysm was detected on computed tomography. Because of the excessively large size of the pseudo-aneurysm, surgical treatment seemed very risky. Therefore, we planned to perform thoracic endovascular aortic repair (TEVAR) and treated him successfully. However, the patient experienced recurrence of the same symptoms 4 months later, and was found to have type IV endoleak. He received a TEVAR procedure again, and it was successful.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

Background

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

Methods

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

Results

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

Conclusions

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

Open surgical repair of abdominal aortic aneurysms in Behçet's disease

BACKGROUND

Behçet's disease (BD) is a multisystem chronic autoimmune inflammatory disorder that involves multiple organs. Arterial involvement in BD is rare. Aortic involvement is one of the most severe manifestations and is associated with a much higher mortality. In this article, we will present our experience in open surgical repair of abdominal aortic aneurysm combined with immunosuppressive therapy.

METHODS

Between January 2010 and December 2017, 7 patients were treated for abdominal aortic aneurysms (5 infra-renal and 2 supra-renal, in 1 woman and 6 men). All patients were Moroccan, the age range being 25-59 years, mean age 43.2 years. Three Dacron tube grafts, two Dacron aortobiiliac grafts and two patch closures were used. All 7 patients received immunosuppresive therapy after surgery.

RESULTS

All patients underwent successful open surgical repair without major complications during the 30 days immediately after the procedure. During a mean follow-up of 36 months, there was no recurrent aneurysmal localization, but one patient had lost their sight. Until now, we have been following 6 patients and they continue to receive immunosuppressive therapy.

CONCLUSION

Long-term immunosuppressive therapy after aneurysm repair is important to limit pseudoaneurysm recurrence. Through our serie, we describe the results of the combination of surgical treatment and adjunctive immunosuppressive therapy, with a literature review.

Superior Mesenteric Artery Vasculitis in Behçet's Disease: A Case Report and Literature Review

A 55-year-old male presented with abdominal pain that had begun about 5 days ago. Physical examination revealed oral aphtha, genital aphthosis, and pseudofolliculitis, and the patient was diagnosed with incomplete Behçet's disease (BD). Contrast-enhanced computed tomography (CECT) showed dilation of the superior mesenteric artery and mesenteric infiltration of inflammation, indicating vasculo-BD. The symptoms were improved by 3-day of intravenous methylprednisolone pulse therapy followed by oral prednisolone. A literature review suggested that vasculo-BD should be included as a differential diagnosis in cases with unexplained abdominal pain, arterial dilation, and mesenteric invasion, and CECT examination and steroid therapy should be considered.

Aorto-enteric Fistula After Endovascular Abdominal Aortic Aneurysm Repair for Behcet's Disease Patient: A Case Report

Introduction

A 42 year old male with Behcet's disease (BD) had endovascular treatment of a symptomatic infrarenal abdominal aortic aneurysm (AAA). Thirteen months later he developed haematemesis and melaena.

Methods

Computed tomography (CT) and angiography showed an aorto-enteric fistula with migration and kinking of the stent graft. Explantation of the infected graft and axillobifemoral bypass, aneurysm sac debridement, and jejunal repair with omental interposition was performed on this severely contaminated patient.

Discussion

There are no reports of an aorto-enteric fistula secondary to endovascular repair in the literature and this case describes the potential consequences of endovascular repair of AAA in BD. The aorto-enteric fistula was associated with persistent inflammatory aortitis, stent graft kinking, and infection. Five cases of secondary aorto-enteric fistulas following open AAA repair in BD patients have been reported including this case resulting from endovascular repair.

A giant pseudoaneurysm of coronary artery in a young patient with Behçet's disease

As an uncommon multisystem inflammatory disease, Behçet's syndrome is characterized by mouth and genital ulcers, skin lesions, and eye inflammation, which may also affect joints, blood vessels, central nervous system, or digestive tract. However, the inflammation of coronary artery is relatively rare. We thereby reported a young male of Behçet's syndrome presenting left anterior descending artery pseudoaneurysm with myocardial infarction. Surgical resection was performed with coronary bypass grafting.

Imaging of acquired coronary diseases: From children to adults

Acquired coronary diseases include aneurysms, fistulae, dissections, and stenosis. Aneurysms may occur secondarily to Kawasaki disease, a childhood vasculitis, the prognosis of which depends on the coronary involvement, or they may be degenerative, infectious, inflammatory, or traumatic in origin. Fistulae develop between the coronary arterial system and a pulmonary or bronchial artery, or cardiac cavity. Dissections may occur spontaneously or may be post-traumatic. These coronary abnormalities may be found incidentally or may present as complications, infarction or rupture. The goals of this article are to understand acquired childhood and adult coronary diseases and their usual means of presentation, the ways of investigating them, and the principles of their treatment.

[Aortitis and surgery]

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

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

BACKGROUND

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Durability of aneurysm treatments in patients with active Behcet's disease

OBJECTIVE

Aneurysms in Behcet's disease are rare, serious, and recurrent. To achieve durable treatment, patients should receive immunosuppressive therapy before intervention to induce remission. We present early and long-term results of emergency cases of active Behcet's disease, which did not permit waiting for suppressive treatment.

PATIENTS AND METHODS

The study was undertaken on all cases admitted to the vascular unit, King Fahd Hospital of University for aneurysm treatment in patients with active Behcet's disease over about 10 years. All patients had exclusion of the aneurysm either by open surgery or endovascular intervention. Morbidities and mortality were recorded within the hospital admission and on the follow-up.

RESULTS

During the study period, three cases were included. All interventions were successful and lifesaving. However, two cases, treated with surgical interposition grafts, were blocked in the intermediate term follow-up (2-12 months) and one case, treated with endovascular treatment, complicated with pseudoaneurysm at femoral puncture site after six months.

CONCLUSION

Although early results were good, intermediate ones were not satisfactory because of progressive graft thrombosis and formation of new aneurysms. Awareness of these rare cases help for early identification and proper immunosuppressive before emergency vascular intervention is warranted.

Endovascular Repair and Adjunctive Immunosuppressive Therapy of Aortic Involvement in Behçet's Disease

OBJECTIVES

Aortic aneurysm is a serious problem in Behçet's disease, but open surgical therapy carries the risk of recurrent pseudoaneurysm. Here the outcomes of endovascular repair and adjunctive immunosuppressive therapy for aortic disease in Behçet's disease are presented.

MATERIALS

This was a retrospective study. Between 2002 and 2012, nine patients with Behçet's disease (8 male, median age 41 years, range 33-60 years) were treated by endovascular stent grafting for abdominal or thoraco-abdominal aortic pseudoaneurysm.

METHODS

Computed tomography angiography revealed infrarenal pseudoaneurysm in six (66.6%) patients and suprarenal pseudoaneurysm in three (33.3%). Patients received immunosuppressive therapy with oral prednisolone (60 mg/day) and cyclophosphamide (200 mg/day) for 2 weeks or more before the procedure, and intravenous hydrocortisone (200 mg/day) combined with cyclophosphamide (200 mg/day) for 3 days after the procedure. Thereafter, oral immunosuppressive therapy was continued for 2 years.

RESULTS

A straight tube graft was implanted in seven patients and a bifurcated graft in two patients. Two stage procedures (debranching before endovascular therapy) were performed in three patients for thoraco-abdominal aortic pseudoaneurysms. Stent grafting was successful in all patients, without any peri-operative complications. However, two patients needed abdominal exploration later: one for seroma around the graft and the other for a fistula between the duodenum and the graft. No recurrence of aneurysm was observed during a mean follow up of 40 ± 16 months. One patient died in the 15th month from a non-vascular cause.

CONCLUSIONS

Endovascular stent graft implantation and adjunctive immunosuppressive therapy seems to be safe and effective in the treatment of aortic involvement in Behçet's disease, but this approach needs further evaluation.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Asymptomatic giant coronary aneurysm in an adolescent with Behcet's syndrome

OBJECTIVE

Behcet's is an idiopathic multi-organ syndrome, which may have onset during childhood. Vascular involvement is uncommon, with rarely reported coronary aneurysm formation. We present a case report of a teenager girl who developed recalcitrant life-threatening Behcet's vasculitis, involving both small and large venous and arterial systems including a giant coronary aneurysm.

CASE REPORT

De-identified data were collected retrospectively in case report format. Although our sixteen year old female with Behcet's vasculitis had resolution of many arterial aneurysms, she had persistent venous thrombosis of large vessels, as well as persistent, giant arterial aneurysms requiring intra-arterial coiling of a lumbar artery and coronary bypass grafting despite intensive immunosuppression including glucocorticoids, cyclophosphamide, infliximab, methotrexate, azathioprine and intravenous immunoglobulin.

CONCLUSIONS

Vascular manifestations may be seen in Behcet's syndrome, including asymptomatic coronary aneurysm, which may be refractory to immunosuppression and ultimately require surgical intervention. Increased awareness is essential for prompt diagnosis and management.

Surgical treatment of peripheral aneurysms in patients with Behcet's disease

INTRODUCTION

Our aim was to report our experience with 23 patients presenting with 32 peripheral aneurysms secondary to Behcet's disease (BD) and their outcome after vascular surgery.

METHODS

The study was retrospective in nature. Except for those presenting with aneurysm rupture, patients underwent surgery after treatment of acute inflammatory lesions. All aneurysms appeared to be pseudo-aneurysms. Graft interposition with polytetrafluoroethylene or saphenous vein was most commonly employed. Postoperatively, all patients were put on immunosuppressive and antiplatelet therapy. Follow-up was done every 6-12 months, complications recorded and managed appropriately.

RESULTS

All the patients were males. The mean age at diagnosis of a peripheral aneurysm was 41.0 ± 9 years. There were 17 (53%) femoral, 8 (25%) popliteal, two carotid, two external iliac, two brachial and one internal iliac aneurysms. Fourteen (61%) patients had a single peripheral aneurysm while nine had two. Surgery was performed for all initially presenting 23 aneurysms. Six patients with multiple peripheral aneurysms had surgery for their second asymptomatic aneurysm. The mean follow-up period was 84 ± 62 months. Of 29 aneurysms operated on, 7 (24%) anastomotic pseudo-aneurysms and 11 (38%) graft occlusions developed. Five (22%) patients underwent major lower extremity amputations. Six (26%) mortalities were recorded.

CONCLUSION

Surgery for peripheral aneurysms in BD is warranted in many instances. Results of operation can be improved by prolonged monitoring. However, despite all efforts, peripheral aneurysm involvement in BD worsens the prognosis.

A case with giant right coronary artery aneurysm in a patient with Behçet's disease

Behçet's disease is a chronic, relapsing, multi-systemic inflammatory disorder characterized by recurrent orogenital aphthous ulcers, uveitis, and skin lesions. Vascular involvement affects the veins more commonly than the arteries of these patients. Arterial involvement may include aneurysm formation, occlusive disease, and stenosis, with the most common sites being the abdominal aorta and femoral and pulmonary arteries. Thus, coronary arterial involvement is very rare but can cause serious complications when it occurs. In this report, we present a 28-year-old male patient with Behçet's disease who developed a giant right coronary artery aneurysm with minimal cardiac manifestation of a recently developed slight palpitation. The patient underwent surgical repair. We present the results of cardiovascular imaging and histopathological examinations. Our case demonstrates the necessity of regular cardiovascular examination for patients with Behçet's disease, even for those without cardiac symptoms.

Giant aneurysm of the left anterior descending coronary artery in a pediatric patient with Behcet's disease

Behcet's disease is a rare autoimmune vasculitis characterized by oral aphthosis, genital ulcers, and ocular and cutaneous lesions. Vascular involvement usually affects the veins more commonly than the arteries, and coronary arterial involvement is extremely rare. We report an adolescent with Behcet's disease who developed a large pseudoaneurysm of the left anterior descending coronary artery requiring a coronary arterial bypass graft.

Effectiveness and safety of endovascular aneurysm treatment in patients with vasculo-Behçet disease

PURPOSE

To compare long-term outcomes of endovascular and surgical treatment of arterial aneurysms in patients with vasculo-Behçet disease (VBD).

METHODS

The medical records of 912 patients with Behçet disease who were seen between May 1995 and January 2007 were reviewed. Among them, 34 (3.7%) patients with 39 non-cerebral aneurysmal lesions were diagnosed with VBD. Between February 1998 and November 2006, 16 VBD patients (14 men; mean age 39.2+/-9.2 years, range 25-63) were treated for 20 arterial aneurysms with an endovascular technique (stent-graft and/or coil embolization). All patients received immunosuppressive therapy (prednisolone 60 mg/d) before endovascular therapy to induce remission. From February 1993 to January 2007, 8 arterial aneurysms in 7 patients (all men; mean age 33.0+/-7.9 years, range 25-51) were treated with surgical graft interposition over 31.5+/-23.2 months.

RESULTS

The endovascular procedure was successful in all lesions. The mean follow-up was 47.6+/-41.8 months, during which 4 complications in 3 patients (3/16, 18.8%) occurred (2 occluded stent-grafts and 2 access site pseudoaneurysm). There were no deaths. The cumulative primary patency rate in the endovascular group was 89% at 24 months. In the 7 patients undergoing graft interposition for 8 arterial aneurysms, 3 (42.9%) events occurred in follow-up: 2 recurrent pseudoaneurysms and 1 aneurysm-related death.

CONCLUSION

In Behçet disease, aneurysm treatment is performed whenever possible because of the high risk of rupture. Endovascular treatment of arterial aneurysms was effective and safe, with an acceptable vascular complication rate and excellent patency of the treated site.

Significance of serum interleukin-8 levels in patients with Behcet's disease: high levels may indicate vascular involvement

BACKGROUND

Interleukin-8 (IL-8) has been shown previously to associate with different individual clinical manifestations and activity of Behcet's disease (BD), but its association with vascular involvement has not been established.

METHODS

Forty-five untreated patients with BD and 29 healthy individuals were included in the study. The activity of patients was based on the existence of two or more symptoms and a statistically significantly high Behcet's Disease Activity Index (BDAI) at the time of the study. IL-8, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) results were evaluated with respect to activity, vascular involvement, and other specific individual clinical manifestations of the disease.

RESULTS

IL-8 levels were found to be significantly elevated in active BD compared with inactive BD (P = 0.006) and healthy controls (P = 0.000), with median values of 267 (53-2000), 137 (52-290), and 58 pg/mL (53-160 pg/mL), respectively. Unlike ESR and CRP, IL-8 levels showed a high correlation with BDAI scores (r = 0.743, P = 0.00) and the number of active clinical manifestations (r = 0.646, P = 0.00). Serum levels of IL-8 were increased in patients with oral ulcers, genital ulcers, eye lesions, and vascular lesions, with median values and significance levels of 254.5 (53-2000), P = 0.05; 254.5 (52-1400), P = 0.03; 254.5 (72-2000), P = 0.029; and 593 pg/mL (110-2000 pg/mL), P = 0.001, respectively. In addition, IL-8 levels in the active patient group with vascular involvement were significantly higher than the levels in those without vascular involvement.

CONCLUSION

Serum IL-8 levels are increased in the active phase of BD. This marker may be useful in the early detection of vascular involvement.

Rupture of thoracoabdominal aortic aneurysm associated with Behcet's disease

Surgical treatment of arterial Behcet's disease (BD) has a higher incidence of graft-related complications such as anastomotic pseudoaneurysm or graft occlusion. A 64-year-old man presented with a rupture of the thoracoabdominal aortic aneurysms associated with BD. Evaluation shows a large hematoma in the retroperitoneum and multiple aneurysms of the thoracoabdominal aorta. Physical examination and past history fulfills the diagnostic criteria of BD. The abdominal aorta was replaced with an allograft and the major branches were reconstructed with its branches. The postoperative course was uneventful. A 10-month follow-up computed tomographic scan did not show any graft-related complications. This case suggests the usefulness of an allograft for arterial involvement of BD.

Chylothorax and chylopericardium as the initial clinical manifestation of Behcet’s disease

Behcet's disease (BD) is a chronic relapsing systemic vasculitic disorder affecting the arteries, veins, and vessels of any size. Large vein thrombosis in BD is not commonly developed and most commonly observed in the veins in the lower extremities and inferior or superior vena cava. In this report, a 18-year-old male patient with large vein thrombosis involving superior vena cava was presented. He was treated due to chylothorax and chylopericardium with SVC syndrome before diagnosis of BD. SVC thrombosis complicated by chylothorax and chyolpericardium can be a rare presenting initial symptom of BD.

Surgical outcomes and risk factors for postoperative complications in patients with Behcet's disease

This study aims to investigate surgical outcomes in patients with Behcet's disease (BD) and to identify risk factors for the occurrence of postoperative complications. The medical records of 37 patients with newly diagnosed BD were reviewed retrospectively. All patients fulfilled the International Study Group criteria for diagnosis of BD and underwent surgeries after diagnosis. Demographic, clinical, and laboratory data at the time when surgeries were performed were collected and surgical modalities, postoperative complications, and postoperative medical treatments were evaluated. Forty-three surgeries were performed in 37 patients. During mean follow-up duration of 78.2 +/- 50.3 months, 14 surgeries (32.6%) were complicated by wound dehiscence, infection, and graft occlusion or failure with the mean lag time of 6.0 +/- 4.6 months from surgeries. Cumulative incidence of postoperative complications was 7.7% at 3 months, 25.6% at 6 months, 33.3% at 12 months, and 35.9% at 18 months. Postoperative complications occurred more frequently after surgeries that were performed in patients with positive pathergy test (P < 0.001) and after vascular surgeries than after nonvascular surgeries (P < 0.05). Moreover, surgeries that were followed by glucocorticoids with immunosuppressive agents showed a significantly lower postoperative complication rate compared to those that were followed by glucocorticoids alone and those that were not followed by medical treatment (P < 0.05). Multivariate analysis showed that a positive pathergic reaction (P < 0.05, hazard ratio = 1.91) at the time of surgery and surgeries that were not followed by treatment with glucocorticoids and immunosuppressive agent (P < 0.01, hazard ratio = 2.11) was an independent risk factor for the occurrence of postoperative complications. Our findings suggest that the occurrence of postoperative complications can be reduced when postsurgical immunosuppressive treatment was implemented and that the pathergy test can be used as screening methods for occurrence of postoperative complications in patients with BD.

W, Akel CJ, Etchebehere RM, Cardoso RM, Izukawa NM. Aneurisma de artéria poplítea como manifestação da doença de Behçet descompensada

A doença de Behçet consiste em uma vasculite sistêmica que acomete veias, artérias e capilares, mas predominantemente pequenos vasos. Raramente há o envolvimento de veias e artérias de médio e grande calibre, sendo as artérias menos acometidas que as veias. No presente trabalho, os autores apresentam um relato de caso de aneurisma da artéria poplítea em um paciente com a doença de Behçet descompensada. Discutem-se os aspectos clínicos e radiológicos e o manejo cirúrgico dos pacientes com essa doença inflamatória sistêmica que apresentam peculiaridades importantes.

Vascular Behçet's disease with coronary artery aneurysm

A 33-year-old man with a 4-year history of Behçet's disease was hospitalized with acute myocardial infarction. Percutaneous coronary intervention (PCI) treated 99% stenosis of the right coronary artery but follow-up coronary arteriography clearly revealed a coronary artery aneurysm (CAA) at the lesion proximal to the PCI site and intravascular ultrasound confirmed that it was a true aneurysm. We speculated that Behçet's disease might be involved in coronary lesion, especially in CAA formation. We decided to increase the dose of prednisolone and to add warfarin. The size of the CAA was not altered after 6 months.

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

OBJECTIVE

Surgical treatment of arterial lesions associated with Behçet disease (BD) is often complicated by graft occlusion and recurrence of aneurysms. The purpose of this study was to clarify the long-term outcome of surgical intervention for arterial involvement in BD.

METHODS

Ten patients with BD (9 men, 1 woman) who underwent surgical treatment for arterial aneurysms between 1980 and 2004 were included in the study. The age of patients at the first operation ranged from 36 to 69 years (mean, 50.4 +/- 9.0 years). The mean period between the onset of BD and that of arterial manifestations was 8.0 +/- 5.0 years. We retrospectively reviewed their postoperative courses, including survival, graft occlusion, formation of anastomotic false aneurysms, and the development of aneurysms at different sites. The Kaplan-Meier method was used to calculate the chronologic incidence of complications after surgery.

RESULTS

The mean follow-up period was 133 +/- 92 months, ranging from 5 to 285 months. One patient died of rupture of a dissecting aortic aneurysm after undergoing several surgical interventions for multiple aneurysms. There were five graft occlusions among 21 grafts. The cumulative primary graft patency rate in the infrainguinal region was 83.9% at 3 years. Five anastomotic false aneurysms formed among 49 anastomoses between grafts and host arteries. The overall cumulative incidence of formation of anastomotic pseudoaneurysm was 12.9% at 5 and 10 years. All of them formed within 18 months after surgery. Development of new aneurysms in different arteries was observed in two patients.

CONCLUSIONS

Early occurrence of anastomotic false aneurysm is characteristic of BD. Further investigation is necessary to establish effective postoperative treatment.

Association of aneurysmal and occlusive lesions in Behçet's disease

Arterial involvement in Behçet's disease is rare, occurring in various locations with multiple clinical expressions. When Behçet's disease is associated with large arteries, lesions are usually in the form of aneurysms or occlusions. The simultaneous occurrence of these two lesions is even more unusual. We present a case of Behçet's disease in which arterial involvement included an iliac artery thrombosis and an asymptomatic aneurysm of the infrarenal abdominal aorta. Behçet's disease must be considered in the diagnosis of any unexplained inflammatory arteriopathy. Surgery is indicated for the majority of aneurysms and severe symptoms. The postoperative follow-up is based on noninvasive radiologic examinations.

Compelling nature of arterial manifestations in Behçet disease

INTRODUCTION

We present our experience with surgical treatment of arterial complications in Behcet disease (vasculo-Behcet disease), and the long-term results and pitfalls of surgical treatment.

MATERIAL AND METHODS

Between January 1990 and January 2003, 20 consecutive patients underwent surgery to treat vasculo-Behcet disease. Most patients (17 of 20) were men, with mean age of 38.4 years.

RESULTS

Thirty-four operations were performed in 20 patients. The operative mortality rate was 5.8% (2 patients). There were 17 emergency operations, 6 because of ruptured primary abdominal aneurysms. There were five others with critical limb ischemia, resulting in 3 amputations. All patients were followed up postoperatively on average for 44 months (range, 6 months-14 years). Two additional patients were lost to follow-up. After the initial operation 10-year survival rate was 30%, 10-year complication-free survival rate was 13%, and 5-year repeat operation-free survival rate was 26%.

CONCLUSION

Although surgical intervention should be postponed until active inflammation has subsided, often this is not possible, because of the emergent nature of these problems. Most arterial complications of vasculo-Behcet disease present with a pseudoaneurysm rupture or with impending rupture. An aggressive surgical approach can be life-saving in such instances, and should be undertaken regardless of long-term complications, which are more common when the operation is performed in the presence of active inflammation. Early and late results can be improved by individualizing, selecting a disease-free area for reconstruction, and eliminating use of autologous graft material.