Surgical repair of visceral artery occlusions in Takayasu's disease

Visceral Artery Interventions in Takayasu's Arteritis

Takayasu's arteritis is an idiopathic chronic inflammatory disease affecting the aorta, its major branches and the pulmonary arteries. It leads to stenosis, occlusion, dilatation, and aneurysm formation in the involved vessels. Visceral arterial involvement occurs in 11 to 68% cases. Steno-obstructive lesions are most commonly seen and are usually symptomatic. Dilative and aneurismal lesions are uncommon and, when present, are usually clinically silent. Renal arteries are most commonly involved (24 to 68%), resulting in renovascular hypertension, whereas mesenteric arterial involvement is seen in 11 to 28% cases and is usually clinically silent. The assessment of disease activity is of utmost importance in its management as revascularization is best performed in the inactive phase. The disease activity can be assessed by clinical, biochemical, or radiological markers. The primary objectives of treatment include the control of disease activity by drug therapy, pharmacologic control of blood pressure (BP), supportive management and revascularization (surgical or endovascular) of the symptomatic ischemic territory. Surgical treatment is challenging due to the diffuse nature of the disease and involvement of adjacent aortic walls. It has a high incidence of anastomotic aneurysm formation (12 to 14%) and graft failure (20 to 40%) over time. Endovascular therapy (usually in the form of balloon angioplasty) has specific technical and procedural issues, but is safe and effective in the control of hypertension with success rates ranging between 80 to 96%. The overall complication rates are low. The cumulative 5-year patency rate for the management of renal artery stenosis is 67%. The use of stents is usually restricted as a bailout to treat obstructive dissection after angioplasty, due to a variety of reasons as their use may adversely affect the long-term outcome of treatment. Angioplasty is less effective in relieving obstruction in the mesenteric arteries and the outcomes are also infrequently reported.

[Fulminant course of a Takayasu's arteritis and rare mesenteric arterial maninfestion]

Takayasu's arteritis is a systemic disease, presenting as chronic inflammation of the main arteries. It usually affects the aorta and its large branches. General symptoms often include fatigue, subfebrile temperatures and weight loss. Complaints due to perfusion disorders are, for example, muscle pain, dizziness or claudication. Takayasu's arteritis is a rare disease which generally occurs in female patients under 40 years of age. We report on a patient with primary involvement of the mesenteric arteries. The disease process was fulminant and refractory to all therapeutic strategies. According to our knowledge this is the first case report from Germany of Takayasu's arteritis with mesenteric infarction.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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