A review of current management of vasculo-Behcet's

Thrombosis in vasculitis: An updated review of etiology, pathophysiology, and treatment

Introduction

Thromboembolic disease is a complication of many vasculitides. A common observation is that thromboembolic events coincide with the period of vasculitic disease, but the mechanism by which this occurs remains unclear. Inflammatory thrombosis is now recognized as a symptom of arteritis rheumatic, and vasculitides such as Behçet's syndrome (BS), and anti-neutrophil cytoplasmic antibodies (ANCA)-associated vasculitis (AAV) or giant cell arteritis (GCA). This systematic review aimed to explain recent findings related to etiology, pathophysiology, and treatment methods for BS, AAV, and medium/large-vessel vasculitis.

Methods

A comprehensive literature search on English sources from PubMed, Scopus, MEDLINE, Science Direct, ProQuest, AIM, CINAHIL, and ELDIS databases was used to find the relevant articles and reports. The relevant papers (having full text) were obtained until June 2023. Two independent reviewers screened the titles and abstracts of the obtained articles, and a third arbitrator resolved disputes between the reviewers.

Results and conclusion

It is becoming increasingly clear that certain systemic inflammatory diseases, like vasculitis, are linked to a higher risk of both venous and arterial thrombosis. An increased incidence of thromboembolic disease in AAV has been noted, particularly during times of active disease. Growing evidence supports the use of immunosuppression in the management of venous thrombosis in vasculitis. These patients also have a higher risk of developing ischemic disease.

Long Term Outcomes and Potential Risk Factors for Endovascular Repair of Aortic Pseudoaneurysms in Vascular Behçet's Disease

OBJECTIVE

This study aimed to analyse long term outcomes and risk factors for endovascular repair of aortic pseudoaneurysms in patients with vascular Behçet's disease (BD).

METHODS

Medical records of 26 aortic vascular BD patients who underwent endovascular treatment at the vascular department of Peking Union Medical College Hospital between January 2002 and December 2021 were reviewed retrospectively. Erythrocyte sedimentation rate (ESR) and C reactive protein were used to assess BD activity. Computed tomography angiography (CTA) was obtained pre- and post-operatively for almost all patients. Univariable logistic regression analysis was used to analyse risk factors for endovascular repair, such as inflammatory indicators, drug usage, and stent graft parameters.

RESULTS

The abdominal aorta (n = 17) was the most common site of 27 vascular BD pseudoaneurysms in this study. CTA also revealed one aortic arch pseudoaneurysm, seven descending thoracic aortic pseudoaneurysms, one thoraco-abdominal aortic pseudoaneurysm, and one pseudoaneurysm at the aortic bifurcation. Most of the pseudoaneurysms were treated with covered stent grafts. The technical success rate was 96% and no deaths occurred during hospital stay. The mean follow up was 5.8 ± 5.5 years and 31% (8/26) experienced post-operative complications. Overall one, three, and five year event free survival rates were 87%, 78%, and 74%, respectively. Univariable logistic regression analysis revealed that pre-operative ESR ≥ 16.0 mm/h (p = .040), pre-operative glucocorticoid (GC) use ≤ 11.5 days (p = .024), pre-operative immunosuppressant use ≤ 15.5 days (p = .028), and length of proximal landing zone ≤ 1.95 cm (p = .034) were associated with a worse prognoses following endovascular treatment. Proximal oversize ≥ 9.5% (p = .074) was also regarded as a risk factor, although not statistically significant.

CONCLUSION

This study further confirmed the feasibility of endovascular repair for aortic vascular BD patients. Risk factors predicting poor prognoses included elevated pre-operative ESR, insufficient pre-operative GC use or immunosuppressant use, inadequate proximal landing zone, and larger proximal oversize percentage.

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.

Ruptured true aneurysm of the superficial femoral artery leading to Behçet disease diagnosis

Femoral artery aneurysms are rare, and aneurysms of the superficial femoral artery (SFA) are even rarer, with ruptured true aneurysms of the SFA the rarest. In the present report, we have described the case of a young patient whose SFA had clinical findings suggestive of an aneurysm rupture, which resulted in the diagnosis of Behçet disease, in accordance with the clinical features of the disease. The patient underwent standard treatment, with aneurysmectomy and interposition of a synthetic graft.

Multiple concomitant arterial aneurysms in Behçet’s disease

Background

Behçet’s disease (BD) is a rare form of systemic vasculitis that affects small to large vessels. It is characterized by mucocutaneous, pulmonary, cardiovascular, gastrointestinal, and neurological manifestations. Large vessel involvement may occur in a third of cases. Veins are usually more affected than arteries. Furthermore aneurysms are the most frequent arterial complication.

Case presentation

A 41-year-old man presented with multiple arterial aneurysms. He had previous medical history of a right popliteal aneurysm treated with a reversed femoro-popliteal venous bypass, long-term steroids and immunosuppressive treatment. On admission, diagnostic computed tomography angiography revealed multiple aneurysms, including an 87 mm aneurysm of the femoro-popliteal bypass and an abdominal aortic and left common iliac artery aneurysm. He received an intensification of medical treatment with methylprednisolone and infliximab intravenous infusion. Aorto iliac artery aneurysms were treated by infrarenal bifurcated stent graft implantation. The aneurysm of the venous femoro-popliteal bypass was treated by explantation and prosthetic repair. One month later, he presented with acute right limb ischemia related to occlusion of the right limb of the stent graft despite anticoagulation which was treated by mechanical thrombectomy.

Conclusions

Vascular BD can worsen the vascular outcome after surgery. Except in an urgent context, BD must be controlled before surgery. This case report illustrates the importance of combined medical and surgical management, with first BD activity control with corticosteroids and immunosuppressive treatment, then surgical or endovascular treatment.

Efficacy and safety of tocilizumab in Behçet's syndrome with refractory arterial lesions: A single-centre observational cohort study in China

Objective

The aim of this observational cohort study was to assess the effectiveness and safety of the IL-6-receptor inhibitor tocilizumab (TCZ) in Behçet’s syndrome (BS) with refractory arterial involvement.

Methods

Ten patients admitted to the Rheumatology and Immunology Department of Peking University People’s Hospital between January 2014 and December 2019 were enrolled. The enrolled patients met the BS international criteria and exhibited severe arterial impairments. Refractory arterio-BS was diagnosed based on objective vascular symptoms unexplainable by other known illnesses, and resistance to traditional immunosuppressants and glucocorticoids after 12 weeks. Patients received 8 mg/kg TCZ infusions every 4 weeks for ≥24 weeks, with simultaneous continuation of immunosuppressants and glucocorticoids. Clinical and imaging data were assessed before and after TCZ treatment.

Results

The enrolled patients were men aged 44.3 (10.5) years; the median disease duration was 186.5 (45.7) months, and the average age of arterial impairment onset was 38.7 (12.9) years. The following trends were observed: improvement and maintenance of symptoms after the 26.8 (7.2)-month follow-up, n = 9; complete remission, n = 6; partial response, n = 3; immunosuppressant dose reduction, n = 4; radiologic improvement of arterial lesions, n = 4; and TCZ discontinuation owing to enlarged abdominal aortic aneurysm relapse, n = 1. The average daily glucocorticoid dose reduced from 54.5 (20.6) to 8.3 (3.6) mg/d (P < 0.001), while the median ESR and CRP values reduced from 50 (2–82) mm/h and 32.9 (2.1–62.3) mg/dl to 4 (1–10) mm/h and 2.9 (0.2–12.1) mg/dl, respectively (P < 0.001). No TCZ-associated side effects were noted.

Conclusion

TCZ proved to be safe and effective for refractory arterial lesions in BS, with a steroid- and immunosuppressant-sparing benefit.

Infliximab therapy in parenchymal neuro-Behçet's disease: A single-center experience

BACKGROUND

Parenchymal neuro-Behçet's disease involvement is the most serious complication of Behçet's disease, and no sufficient data on its treatment exists. This study aims to investigate the efficacy and safety of infliximab treatment in neuro-Behçet's disease patients with parenchymal involvement.

MATERIALS AND METHODS

Patients who were diagnosed with Behçet's disease with parenchymal neurological involvement and underwent infliximab treatment for at least 12 months were included in the study. Demographic, clinical, and radiological data of the patients were accessed through the electronic database of our hospital.

RESULTS

This study comprises 19 patients who were diagnosed with neuro-Behçet's disease and used infliximab: 12 male and 7 female patients. The mean age of the patients was 36.5 ± 11.7 years, and the diagnostic age was 26.3 ± 10.8 years. The duration of treatment with infliximab was 32.3 months (minimum 11, max 79). In the 19 patients receiving infliximab treatment, 11 (58%) patients achieved remission (complete disappearance of neurological symptoms) and 7 (37%) patients achieved disease stability (no new neurological findings); steroid treatments were discontinued for these 18 patients. In addition, only 5 patients were concomitantly taking immunosuppressive drugs with the infliximab. Infliximab was discontinued after the development of a new parenchymal attack in the 9th month of infliximab treatment.

CONCLUSION

In conclusion, parenchymal neurological involvement in Behçet's disease is an important cause of disability, and no sufficient data exists in literature on its treatment. The results of our study suggest that infliximab treatment was effective and safe in neuro-Behçet's disease parenchymal involvement for preventing long-term neurological attacks and discontinuing corticosteroid treatment.

Sacciform aneurysm of the right common iliac artery in Behcet's disease treated with EVAR: Case report

Introduction

Behcet's disease is a systemic vasculitis with vascular tropism usually manifested by phlebitis. Arterial manifestations are rare, most often result in aneurysms than occlusions. The objective of this article, is to relate our experience and pretherapeutic reasoning for the indication of an endovascular treatment of an atypical sacciform iliac aneurysm, in an elderly patient followed for Behcet's disease.

Case report

This is a 73-year-old patient, followed for Behcet's disease under immunosuppressive treatment and corticosteroids treatment, admitted to our structure, for the surgical management of an aneurysm of the right common iliac artery diagnosed by computed tomographic angiography performed for chronic paroxysmal abdominal pain, treated by EVAR after a multidisciplinary discussion, complicated by a thrombosis of the left leg of the bifurcated aortic stent graft the, managed by performing an extra anatomical bypass, complicated late by the appearance of a Scarpa hematoma, who was evacuated.

Discussion

Behcet's disease is a systemic vasculitis with vascular tropism, usually affecting young. Our case is an elderly subject, whose diagnosis and follow-up of Behcet's disease is recent and whose discovery of this aneurysm was fortuitous, after performing a CT angiogram required for another reason.

The objective of this article, is to relate our experience and pre-therapeutic reasoning for theindication of an endovascular treatment, and our management of the complications.

Conclusion

Endovascular treatment of iliac sacciform aneurysm by placing a covered stent is a good alternative to conventional surgery with fewer complications; especially in front of a field of Behcet's disease.

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Arterial involvement in Behcet's disease is rare.

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Endovascular treatment is an alternative to conventional surgery in treating iliac aneurysms in Behcet's disease.

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The interest of CT scan in suspicion of vascular involvement in Behcet's disease.

Comparison of relapse rates in Behçet's disease with venous involvement on different doses of azathioprine therapy, a retrospective observational study

AIM

The aim of this study was to investigate relapse rates in azathioprine (AZA) maintenance therapy at different doses in Behçet's disease (BD) with venous involvement.

METHOD

Clinical records of patients who met the diagnostic criteria of International Study Group (ISG) for BD, were diagnosed with venous involvement of BD for at least 6 months and sustained clinical remission with AZA for at least 3 months were analyzed retrospectively. The analysis cohort was divided into 2 groups based on AZA dose (Group A: ≥ 2 mg/kg/d and Group B: <2 mg/kg/d). Relapse was defined as requiring another antirheumatic/immunosuppressive drug or more than dose of 10 mg/d of prednisolone.

RESULTS

Of 78 patients who were included into the study, there was no significant difference between the 2 groups in terms of age, gender and clinical characteristics. Mean relapse-free survival time was found to be higher in group A compared to group B (111.6 ± 11.2, 95% CI 89.5 ± 133.8 versus 51.5 ± 6.1, 95% CI 39.5 ± 63.4 months).

CONCLUSION

Relapse-free survival rate was less in the group receiving low-dose AZA and shows the importance of effective dose of AZA in maintenance therapy.

Acute coronary syndrome in Behcet's syndrome: A systematic review

Behcet syndrome is a rare vasculitis that affects both arteries and veins. Vasculo-Bechet Syndrome (VBS) is seen predominantly in men. Genetic predisposition and immune dysregulation leading to inflammation, endothelial damage, and impaired fibrinolysis contribute to its pathogenesis. Isolated case reports of Behcet syndrome (BS) with associated acute coronary syndrome (ACS) have been reported in the past. In this study, we present the first systematic review of such cases. A systematic search was conducted using Pubmed, Google Scholar, CINAHL, Cochrane CENTRAL, and Web of Science databases from 1980-2018 to identify case reports of myocardial infarction associated with BS. Cases that fulfilled the criteria for BS were selected for analysis. Demographic data, electrocardiography, echocardiography, angiography findings, and management were analyzed when available. We identified 62 case reports. Most subjects were men with a mean age of 37 years. Twenty-one percent were smokers, but other traditional cardiovascular risk factors were less common. Myocardial infarction was confirmed in half of the cases with findings on electrocardiogram (ECG). Echocardiogram revealed wall motion abnormality in 76% of patients, and angiography showed double-vessel disease in more than half of the cases. Mortality was reported in 1.6% of the cases. This systematic review shows that ACS in BS affects young males with low prevalence of coronary artery disease risk factors. Chest pain is the most common presenting feature and ST-segment elevation myocardial infarction (STEMI) was the most common ECG finding. Immunotherapy may be helpful to prevent future ACS in these patients.

Optic neuritis as a presenting feature of Behçet's disease: case-based review

Behçet's disease (BD) is vasculitis affecting vessels of variable sizes characterized with recurrent oral and/or genital aphthous ulcers accompanied by cutaneous, ocular, articular, gastrointestinal, and/or central nervous system inflammatory lesions. The disease is characterized by recurrent attacks and remissions of different durations, which is one of the reasons why the diagnosis is, in most cases, made several years after the onset of first symptoms. We present a 24-year old male, with South Eastern European heritage, with relapsing bilateral optic neuritis as a first symptom of the disease, followed by aseptic meningitis 2 years, and vascular manifestation 3 years after onset, which finally led to the diagnosis of Behçet's disease. Vascular symptoms were thromboembolism of the right leg and aneurism of the right popliteal artery that due to the size required surgical treatment. The patient was treated with glucocorticoids, azathioprine and anti-tumor necrosis factor-alpha therapy, that proved to be the best treatment options for all manifestations of the disease. Based on our literature review, optic neuritis is a known and rare clinical feature of BD. To our knowledge, there are only several literature reports in which optic neuritis is the initial symptom of BD. Our case report and literature review emphasize the importance of recognizing optic neuritis without inflammatory eye disease as a possible presenting symptom of BD and accentuate detailed medical history review at each patient's visit.

Infliximab treatment in refractory vascular Behcet's disease: A single-center experience

OBJECTIVE

This study aims to investigate the efficacy and reliability of infliximab treatment in Behcet's disease with vascular involvement.

METHODS

This single-center retrospective study included a total of 18 patients diagnosed with Behcet's disease with vascular involvement who were initiated infliximab treatment after exhibiting resistance to conventional immunosuppressive treatments.

RESULTS

Seventeen patients achieved remission with infliximab treatment. While 18 patients were receiving a median of 50 (IQR: 20-61) mg/day equivalent of methylprednisolone before infliximab treatment, after infliximab treatment, only four patients were receiving 4 mg/day equivalent of methylprednisolone (p < 0.001). Only 4 patients were receiving oral anticoagulant treatment during infliximab treatment, and compared to the patients who were not receiving oral anticoagulants, there was no significant difference between the two groups according to occurrence of new vascular events.

CONCLUSION

Infliximab seems to be an effective and reliable treatment in Behcet's disease with vascular involvement and may also allow reduced dosage or even the discontinuation of corticosteroids. The results of our study suggest that oral anticoagulant use is unnecessary in Behcet's disease with vascular involvement. However, further long-term randomized controlled studies are needed to investigate the length of infliximab regimen, whether or not it should be discontinued, and if so, whether or not immunosuppressants should be given as maintenance after discontinuation.

Is Immunosuppressive and Thrombolytic Therapy Really Effective in a Patient With Intracardiac Thrombosis and Pulmonary Artery Aneurysm due to Behçet's Disease?

Behçet's disease (BD) is a rare, multisystemic, chronic vasculitic disorder with unknown etiology. Intracardiac thrombus formation and pulmonary artery aneurysm in BD are very rare. The treatment protocol in patients with vascular involvement, particularly those with pulmonary artery aneurysm accompanied by thrombosis, have not been clearly defined. In this article, we report an exceptional case, who had been treated unsuccessfully with a combination of anti-inflammatory/immunosuppressive therapy and thrombolytic agents, to discuss the poor prognosis of pulmonary artery aneurysm accompanying intracardiac thrombosis in juvenile BD.

Two-Stage Hybrid Approach for Treatment of Abdominal Aortic Pseudoaneurysm Combined with Superior Mesenteric Artery Occlusion Secondary to Vasculo-Behçet's Disease

Behçet's disease (BD) is a chronic multisystem autoinflammatory disorder. Multiple arterial involvement in vasculo-BD was extremely rare. A 40-year-old man suffered from abdominal pain and increased lower back pain. He was diagnosed with BD 4 years ago. Computed tomography angiography indicated a 40 mm × 90 mm abdominal aortic saccular pseudoaneurysm and a proximal superior mesenteric artery (SMA) occlusion. We report here a case of successful treatment for abdominal aortic pseudoaneurysm (AAP) and SMA occlusion in a complicated vasculo-BD using 2-stage procedure, including endovascular intervention for AAP and hybrid approach with laparotomy and retrograde canalization and revascularization for SMA occlusion. Retrograde open mesenteric stenting was effective in the treatment of SMA occlusion in patients with vasculo-BD.

Prolonged fever and intra-cardiac thrombosis revealing Behçet's disease

BACKGROUND

Prolonged fever (PF) is a challenging problem for physicians since it can be the first manifestation of a large variety of pathologies. Exceptionally, intra-cardiac thrombus (ICT) could explain PF and reveal Behçet's disease (BD). We are reporting a 45-year-old man with BD who has these unusual manifestations.

CASE REPORT

A 45-year-old man presented with PF and inflammatory biological syndrome during a few months. Echocardiography showed an inhomogeneous and mobile mass in the left auricle. During his hospitalization, the patient had multiple oral aphtosis. The angioscanner showed a sacciform aneurysm of the coeliac trunk. The diagnosis of BD was retained and he was treated with high doses of steroids and cyclophosphamide with a favorable follow-up.

CONCLUSION

The search for BD should be systematic in view of any suggestive manifestation of severe cardiovascular complications like ICT especially in a young adult man from a high endemicity region.

Multiple Overlapping Stent Implantation Combined with Coil Embolization for a Suprarenal Aortic Pseudoaneurysm with Impending Rupture in a Patient with Behçet's Disease

Behçet's disease is an autoimmune vasculitis, which mainly manifests as aneurysm when arteries are involved. Treatments including graft interposition or stent-graft implantation are best performed after active inflammation subsides, otherwise there will be complications such as anastomotic pseudoaneurysms and graft occlusion. We report the treatment of a suprarenal abdominal aortic pseudoaneurysm in a patient with Behçet's disease via multiple overlapping stent implantation combined with coil embolization which was performed in a subacute fashion because of impending rupture of the pseudoaneurysm. She was maintained on long-term immunosuppressive therapy and remained symptom free at 2-year follow-up.

Emerging Roles of Redox-Mediated Angiogenesis and Oxidative Stress in Dermatoses

Angiogenesis is the process of new vessel formation, which sprouts from preexisting vessels. This process is highly complex and primarily involves several key steps, including stimulation of endothelial cells by growth factors, degradation of the extracellular matrix by proteolytic enzymes, migration and proliferation of endothelial cells, and capillary tube formation. Currently, it is considered that multiple cytokines play a vital role in this process, which consist of proangiogenic factors (e.g., vascular endothelial growth factor, fibroblast growth factors, and angiopoietins) and antiangiogenic factors (e.g., endostatin, thrombospondin, and angiostatin). Angiogenesis is essential for most physiological events, such as body growth and development, tissue repair, and wound healing. However, uncontrolled neovascularization may contribute to angiogenic disorders. In physiological conditions, the above promoters and inhibitors function in a coordinated way to induce and sustain angiogenesis within a limited period of time. Conversely, the imbalance between proangiogenic and antiangiogenic factors could cause pathological angiogenesis and trigger several diseases. With insights into the molecular mechanisms of angiogenesis, increasing reports have shown that a close relationship exists between angiogenesis and oxidative stress (OS) in both physiological and pathological conditions. OS, an imbalance between prooxidant and antioxidant systems, is a cause and consequence of many vascular complains and serves as one of the biomarkers for these diseases. Furthermore, emerging evidence supports that OS and angiogenesis play vital roles in many dermatoses, such as psoriasis, atopic dermatitis, and skin tumor. This review summarizes recent findings on the role of OS as a trigger of angiogenesis in skin disorders, highlights newly identified mechanisms, and introduces the antiangiogenic and antioxidant therapeutic strategies.

Behçet Syndrome and Crohn's Disease: What Are the Differences?

Behçet syndrome (BS) is a variable vessel vasculitis that has pleiotropic manifestations. A 43-year-old male with a previous diagnosis of Crohn’s disease (CD) presented with deep venous thrombosis and bilateral superficial femoral artery aneurysms. A diagnosis of BS was made, and the patient was treated aggressively with immunosuppressive therapy and bilateral bypass surgery, attaining a favourable outcome. CD has many features that overlap with BS, and it may be challenging to distinguish between these two conditions, as our case illustrates. Nonetheless, the combination of venous thrombosis and arterial aneurysms should point the clinician towards a diagnosis of BS.

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.

Coeliac artery dissection as a rare manifestation of Behcet's disease

Behcet's disease is a multisystemic vasculitis. Arterial involvement in the form of acute dissection is rare. A 42-year-old Lebanese man with Behcet's disease presented with severe abdominal pain. On exam, blood pressure was 162/104 mm Hg, and he exhibited epigastric tenderness. CT angiogram demonstrated an acute dissection of the coeliac artery trunk, common hepatic artery and proper hepatic arteries, with asymmetric thickening of the proximal left subclavian artery and circumferential thickening of the abdominal infrarenal aorta suggestive of vasculitis. Treatment included intravenous clevidipine, nitroprusside and methylprednisolone, which transitioned to oral metoprolol, amlodipine and prednisone. He responded well. Arterial dissections have been described with Behcet's. We report a coeliac artery aneurysm in association with a flare of Behcet's disease. Arterial wall inflammation combined with the sheering forces of hypertension likely predisposes to arterial dissection.