Endovascular balloon angioplasty versus stenting in patients with Takayasu arteritis: A meta-analysis

Long-term patency of aorto-biiliac endoprosthesis for critical lower limb ischaemia in Takayasu arteritis after complicated angioplasty with a drug-coated balloon: Effect of dual antiplatelet therapy combined with tocilizumab

Takayasu arteritis is a chronic granulomatous vasculitis of unknown aetiology affecting the aorta and its major branches. Critical limb ischaemia may occur and eventually require surgical intervention. Surgical outcomes are influenced by disease activity, age, and comorbidities. We report a 43-year-old woman with Takayasu arteritis and stenosis of the left common iliac artery and occlusion of the left external iliac artery with limiting vascular claudication, who underwent angioplasty of the iliac artery with drug-eluting stent while being treated with infliximab. The artery ruptured a week later but was contained by the ilio-psoas muscle. She required subsequent stent placement to correct the lesion. Treatment comprised aspirin and clopidogrel, and the biological was switched to monthly intravenous tocilizumab. During an 8-year follow-up, serial imaging examinations showed a patent aorto-biiliac endoprosthesis, without evidence of thrombosis or restenosis. Clinically, the patient denies vascular claudication and pulses remain palpable in the left lower limb. This case highlights the risks inherent to these procedures in patients with large artery vasculitis and reinforces that the effectiveness of endovascular intervention can be increased by detailed preoperative evaluation, associated with a drug strategy including immunomodulatory and antiplatelet therapy as directed by the multispecialty team. Periodic imaging examinations are required because of the reported high rate of restenosis.

Drug-Coated Balloon Angioplasty for Thoracic Great Vessel Stenosis Due to Takayasu Arteritis With 1-Year Follow-up

PURPOSE

Takayasu arteritis is a large-vessel vasculitis in women of childbearing age that affects large vessels including the aorta and its main branches. Inflammation of arteries can produce lesions that lead to occlusion, stenosis, or aneurysms which can lead to complications. If signs of organ dysfunction are present, vascular intervention may be necessary.

CASE REPORT

In this article, we present a case of Takayasu arteritis with high-grade stenosis of all the great vessels of the thoracic aorta treated with drug-coated balloon (DCB) angioplasty and stenting requiring multiple follow-up interventions over a 1-year follow-up.

CONCLUSION

The DCB angioplasty is a potential endovascular treatment for thoracic great artery stenosis in Takayasu arteritis that could be further explored.

Diagnostik und Therapie der Großgefäßvaskulitiden – Wo stehen wir aktuell?

Die beiden Großgefäßvaskulitiden unterscheiden sich in mehrfacher Hinsicht, vor allem aber durch das Alter der betroffenen Patienten bei Erstmanifestation. Die Riesenzellarteriitis (RZA) ist eine Erkrankung des älteren Patienten wohingegen die Takayasu Arteriitis per definitionem vor dem 40 Lebensjahr auftritt. Die Diagnosen sind in den letzten Jahren durch verbesserte Bildgebung und Therapieoptionen mehr ins Bewusstsein gerückt. Neben der klassischen Steroidtherapie – welche bis heute Mittel der ersten Wahl ist – steht uns mit Tocilizumab, einem monoklonalen Antikörper gegen IL6-Rezeptor, zumindest für die RZA, eine zusätzliche hocheffektive Therapie zur Verfügung. Andere vielversprechende Substanzen befinden sich derzeit in Erprobung. Dieser Artikel soll einen Überblick zu Diagnostik und Therapie, aber auch einen Ausblick zu möglicherweise kommenden medikamentösen Optionen bieten.

Endovascular interventions in main renal artery pathologies: an overview and update

Renal arteries are involved in a wide spectrum of pathologies including atherosclerosis, fibromuscular dysplasia, Takayasu arteritis, aneurysms, and aortic type B dissections extending into main renal arteries. They manifest as renovascular hypertension, renal ischemia, and cardiovascular dysfunction. The location of the renal arteries in relation to the abdominal aortic aneurysm is a critical determinant of interventional options and long-term prognosis. This article provides a comprehensive review of the role of interventional radiologists in transcatheter interventions in various pathologies involving the main renal arteries with analysis of epidemiology, pathophysiology, newer interventional techniques, and management options.

Estimation of Bone Trace Elements Following Prolonged Every-other Day Feeding in C57BL/6 Male and Female Mice

The purpose of this study was to examine the effect of prolonged every-other day (EOD) feeding on bone trace elements. Four-week old C57BL/6 female (n = 12) and male (n = 12) mice were employed in this experiment. Animals were assigned to four groups: ad libitum-AL (males and females), EOD fed (males, females). After 9 months, the mice were sacrificed. Long bones (humerus and radius) were isolated and prepared for analysis using inductively coupled plasma optical emission spectrometry to determine the Fe, Zn, Mo, Co, Cu, Mn, Cr contents. Estimation of cathepsin K expression on bone slides was performed to determine the activity of osteoclasts in bones of EOD- and AL-fed animals. Higher content of Fe in EOD-fed females compared to AL-fed females was found. In EOD-fed males, a significantly higher amount of Mo (p < 0.005) and Co (p < 0.05) in comparison to AL-fed males was noted. Gender differences in amounts of trace elements in control AL-fed males vs. females were observed. EOD feeding influences the amount of some trace elements in long bones of female and male C57BL/6 mice. However, this is not influenced by the activity of bone cells.

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.

Renal endovascular stenting of a non-atherosclerotic renal artery stenosis secondary to Takayasu arteritis

Non-atherosclerotic renal artery stenosis (RAS) secondary to Takayasu arteritis (TA) is rarely cited in the literature. Although stenting has been well-described in atherosclerotic RAS, it's role in non-atherosclerotic, Takayasu arteritis-induced renal artery stenosis (TARAS) has not been fully established. We report a 38-year old, Filipino, woman who presented with an incidental finding of small left kidney and hypertension. On CT aortogram, complete total occlusion of the left kidney, and significant stenosis of the right renal artery, and several aortic branches were demonstrated, consistent with Takayasu arteritis. After initiating immunosuppressive agents and undergoing renal endovascular stenting, the patient's blood pressure dramatically improved. Restenosis of the right renal artery was not observed after 6 months. Kidney function was also preserved 2 years after the procedure.

Renal Arteries Revisited: Anatomy, Pathologic Entities, and Implications for Endovascular Management

The renal arteries (RAs) are important vessels that usually arise from the abdominal aorta and supply the kidneys; thus, these arteries play a vital role in physiologic functions such as hemofiltration and blood pressure regulation. An understanding of the basis for embryologic development and the frequently variable anatomy of the RAs is necessary to fully appreciate the range of diseases and the implications for procedural planning. Hemorrhage from an RA is relatively common and is typically traumatic or spontaneous, with the latter form often seen in association with underlying tumors or arteriopathy. Accurate diagnostic evaluation of RA disease due to conditions such as atherosclerosis, fibromuscular dysplasia, vasculitis, aneurysm, arteriovenous shunt, embolic disease, and dissection is dependent on the use of multimodality imaging and is essential for selecting appropriate clinical management, with endovascular therapy having a key role in treatment. Surgical considerations include extra-anatomic renal bypass, which remains an important treatment option even in this era of endovascular therapy, and RA embolization as an adjunct to tumor surgery. A novel area of research interest is the potential role of RA denervation in the management of refractory hypertension. ^©RSNA, 2021.

Endovascular management of symptomatic stenosis of supra-aortic arteries in patients with Takayasu arteritis

BACKGROUND

Endovascular management is used to treat Takayasu arteritis (TA) involving the supra-aortic branches. However, the long-term outcome of this treatment remains unclear. Here, technical safety, outcomes, and restenosis management of supra-aortic arteries in TA patients receiving endovascular treatment were evaluated.

METHODS

TA patients with symptomatic supra-aortic stenosis who underwent percutaneous angioplasty and stenting between 2008 and 2018 at our institute were enrolled in this study. Pre- and post-procedural magnetic resonance imaging (MRI) evaluations, including high-resolution vessel wall imaging (HR-VWI), were performed. Technical efficacy, peri-procedural complications, early post-procedural MRI results, and stent patency were examined.

RESULTS

All six patients successfully received stent placement or percutaneous transluminal angioplasty in a total of 22 treated arteries without neurologic complications. During follow-up (mean, 56.3 ± 41.1 months), no recurrent stroke occurred, yet significant restenosis developed in 12 of 22 (54.5%) of the treated arteries. Three of the patients underwent HR-VWI before surgery. Concentric wall thickening and enhancement of the left common carotid artery was detected in one patient, indicating acute inflammation. Angioplasty with drug-eluting balloon (DEB) successfully treated a case of refractory restenosis. Among 10 early post-procedure MRI performed, only two asymptomatic new lesions were detected with diffusion-weighted imaging.

CONCLUSION

Endovascular treatment of supra-aortic arteries of TA patients was safe and effective, yet was associated with a high restenosis rate. Thus, close follow-up is needed. HR-VWI is helpful for pre-procedural selection of patients for percutaneous angioplasty and stenting and drug-eluting balloon angioplasty appears to be a promising treatment for refractory in-stent restenosis.

[Long-term complications, monitoring and interventional treatment of large vessel vasculitis]

Giant cell arteritis (GCA) and Takayasu's arteritis (TAK) both belong to the group of large vessel vasculitides and require long-term drug treatment. Glucocorticoids (GC) are the first choice for the treatment of both diseases. For GCA immunosuppressants, such as tocilizumab or methotrexate should be considered in cases of treatment refractory and relapses or if there is a high risk for GC-related adverse events. In TAK patients the use of immunosuppressive agents should be considered for all patients. In the course of the disease, severe disease-associated and treatment-associated complications can occur. The most frequent disease-associated complications include visual impairment up to blindness in GCA, as well as vascular stenoses with ischemia and aortic aneurysms with possible dissection in GCA and TAK. Percutaneous transluminal angioplasty (PTA) and stenting are minimally invasive, low-risk interventional procedures for GCA and TAK patients with clinically significant vascular stenoses, despite a tendency to restenosis. Interventional procedures should be weighed up against vascular surgical approaches depending on the localization and the total clinical situation. All interventions should be conducted in a phase of stable remission when possible. For monitoring of disease activity in patients with GCA and TAK, assessment of clinical manifestations as well as C‑reactive protein (CRP) and the erythrocyte sedimentation rate (ESR) are useful; however, both are unreliable under interleukin‑6 block with tocilizumab. The value of new biomarkers independent from interleukin‑6 and the importance of imaging (sonography, magnetic resonance angiography, computed tomography and positron emission tomography-CT) for monitoring GCA and TAK still have to be investigated in future studies.

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.

[Treatment of Takayasu arteritis]

Despite advances in the diagnosis and treatment, the mortality rate of Takayasu arteritis (TAK) is still elevated even today. The diagnosis is often made after a long time delay and the course of the disease is characterized by progressive structural vascular lesions. Recently, new recommendations for the management of large vessel vasculitis were published by the European League Against Rheumatism (EULAR). For induction of remission oral glucocorticoids (GC) are administered in an initial daily dose of 40-60 mg. As experience has shown that the cumulative GC demand in TAK is high, GC-sparing treatment with moderately potent immunosuppressants, such as methotrexate, azathioprine and mycophenolate mofetil is recommended from the time of initial diagnosis. In cases of a relapsing course, tocilizumab or tumor necrosis factor (TNF)-alpha inhibitors can be used as an additive off-label treatment. If vascular stenoses persist despite supposedly sufficient inflammation control and if these stenoses are symptomatic, vascular surgery or interventional treatment procedures can be indicated. Such revascularization or even surgical procedures for the treatment of aneurysms should be performed during phases of sufficient drug control of the vasculitis. In quite a few patients progressive vascular lesions continue to develop despite clinical and laboratory analytical remission. Due to the poor correlation of clinical symptoms and acute phase markers with the progression of vascular lesions, the distinction between active and inactive diseases is often a challenge in the clinical practice. Imaging studies can then support therapeutic decisions but are not yet formally and comprehensively validated in the long-term course of TAK.

Characteristics and Medium-term Outcomes of Takayasu Arteritis-related Renal Artery Stenosis: Analysis of a Large Chinese Cohort

OBJECTIVE

To investigate the characteristics of patients with Takayasu arteritis (TA)-related renal artery stenosis and identify the predictors of medium-term adverse outcomes.

METHODS

Data for 567 patients registered in the East China Takayasu arteritis cohort, a large prospective observational cohort, up to April 30, 2019, were retrospectively analyzed.

RESULTS

Renal artery stenosis was confirmed in 172/567 (30.34%) patients, with left renal artery involvement seen in 73/172 (42.44%) patients. Renal insufficiency at presentation (HR 2.37, 95% CI 1.76-15.83, P = 0.03), bilateral renal artery involvement (HR 6.95, 95% CI 1.18-21.55, P = 0.01), and severe stenosis (> 75%; HR 4.75, 95% CI 1.08-11.33, P = 0.05) were predictors of adverse outcomes. A matrix model constructed using 3 variables (renal function, stenosis severity, and bilateral renal artery involvement) could identify 3 risk groups. Revascularization was performed for 46 out of 172 (26.74%) patients. Patients without preoperative treatment had higher rate of restenosis (41.46% vs 16.67%, P < 0.01) and worsening hypertension (25.93% vs. 10.53%, P < 0.01) after the procedure. Nonreceipt of preoperative treatment (HR 6.5, 95% CI 1.77-32.98, P = 0.04) and active disease at revascularization (HR 4.21, 95% CI 2.01-21.44, P = 0.04) were independent predictors of adverse outcomes after revascularization.

CONCLUSION

Patients with TA-associated renal artery stenosis and uncontrolled or worsening hypertension or/and renal function may benefit from revascularization. Those who have received preoperative treatment may have more favorable revascularization outcomes. Prognosis appears to be poorer for patients with renal insufficiency at presentation, bilateral artery involvement, and severe stenosis.

Management of Takayasu arteritis: a systematic literature review informing the 2018 update of the EULAR recommendation for the management of large vessel vasculitis

Objective

To collect available evidence on management of large vessel vasculitis to inform the 2018 update of the EULAR management recommendations.

Methods

Two independent systematic literature reviews were performed, one on diagnosis and monitoring and the other on drugs and surgical treatments. Using a predefined PICO (population, intervention, comparator and outcome) strategy, Medline, Embase and Cochrane databases were accessed. Eligible papers were reviewed and results condensed into a summary of findings table. This paper reports the main results for Takayasu arteritis (TAK).

Results

A total of 287 articles were selected. Relevant heterogeneity precluded meta-analysis. Males appear to have more complications than females. The presence of major complications, older age, a progressive disease course and a weaker inflammatory response are associated with a more unfavourable prognosis. Evidence for details on the best disease monitoring scheme was not found. High-quality evidence to guide the treatment of TAK was not found. Glucocorticoids are widely accepted as first-line treatment. Conventional immunosuppressive drugs and tumour necrosis factor inhibitors were beneficial in case series and uncontrolled studies. Tocilizumab failed the primary endpoint (time to relapse) in a randomised controlled clinical trial; however, results still favoured tocilizumab over placebo. Vascular procedures may be required, and outcome is better when performed during inactive disease.

Conclusions

Evidence to guide monitoring and treatment of patients with TAK is predominantly derived from observational studies with low level of evidence. Therefore, higher-quality studies are needed in the future.

[Revascularization of supra-aortic trunks in Takayasu's arteritis]

INTRODUCTION

Takayasu's disease is an inflammatory arteritis mainly affecting the aorta, its main divisional branches and pulmonary arteries. The arterial damage during Takayasu's disease is essentially occlusive and preferentially affects supra-aortic trunks. Indications for revascularization of supra-aortic trunks are clear but results are rarely reported. The purpose of this study was to evaluate the results of supra-aortic trunk revascularization in Takayasu's arteritis.

PATIENTS AND METHODS

We report a retrospective study conducted between 2012 and 2018 about patients with Takayasu's arteritis who underwent revascularization of supra-aortic trunks.

RESULTS

Our series consisted of six patients. All patients were female. The average age was 29 (range 18-48) years. The operative indication was cerebrovascular ischemic symptoms in five patients and intermittent claudication of the upper limb in one. We performed aorto-bi-carotid bypass in four patients, a subclavian artery angioplasty in one and a vertebral artery angioplasty in one. At 1 month, operative mortality was zero and morbidity was marked by hemorrhagic stroke in one patient operated by conventional surgery. The average follow-up was 4 years (1.8). During the follow-up, one patient was reoperated after 18 months for an anastomotic false aneurysm in the ascending aorta. We noted a favorable outcome with total resolution of the symptomatology for the other patients and Doppler ultrasound confirmed patency during follow-up.

CONCLUSION

Surgical revascularization of supra-aortic trunks in Takayasu's arteritis can be associated with a risk of stroke and a risk of anastomotic pseudoaneurysms. Endovascular revascularization appears to be less invasive but its long-term results are rarely reported.

Renal autotransplantation for the management of renal artery in-stent restenosis in an adult patient with Takayasu arteritis

Renovascular hypertension is a common clinical presentation in Takayasu arteritis (TA), when the renal arteries are involved. Although most of the patients respond to optimal antihypertensive drug therapy, certain patients with TA require percutaneous or surgical renal artery revascularisation to manage renovascular hypertension. We, hereby, present a 45-year-old woman, who had resistant hypertension secondary to in-stent restenosis (ISR) of renal artery stent in a single functioning kidney. She had successful renal autotransplantation following a failed endovascular attempt to treat ISR. Endovascular and surgical interventions related to renal artery stenosis in TA are discussed in the article.

Surgical intervention and its role in Takayasu arteritis

Vascular surgery remains an important option in the management of Takayasu arteritis (TA). Its use is predominantly confined to the treatment of symptomatic organ ischaemia or life-threatening aneurysm formation. In most cases, this follows the failure of medical therapy to prevent arterial injury. Open surgery and endovascular approaches are used. The choice between them, at least in part, is determined by the site and nature of the lesion. Open surgery, although more invasive, offers enhanced duration of arterial patency, whereas for endovascular intervention, primary angioplasty without stenting is preferred, with stenting reserved for primary or secondary angioplasty failures. Although there is increasing interest in the role of stent grafts and tailor-made endovascular stents, long-term outcomes remain to be reported. Interventional outcomes are improved and complications reduced by therapeutic control of disease activity before and after surgery. The wider use of combined immunosuppression and the introduction of biologic therapy for refractory TA may reduce future requirements for surgical intervention.

Endovascular Versus Open Surgical Intervention in Patients with Takayasu's Arteritis: A Meta-analysis

OBJECTIVE/BACKGROUND

Although medical treatment has advanced, surgical treatment is needed to control symptoms of Takayasu's arteritis (TA), such as angina, stroke, hypertension, or claudication. Endovascular or open surgical intervention is performed; however, there are few comparative studies on these methods. This meta-analysis and systematic review aimed to examine the outcome of surgical treatment of TA.

METHODS

A meta-analysis comparing outcomes of endovascular and open surgical intervention was performed using MEDLINE and Embase. This meta-analysis included only observational studies, and the evidence level was low to moderate. Data were pooled and analysed using a fixed or random effects model with the I2 statistic.

RESULTS

The included studies involved a total of 770 patients and 1363 lesions, with 389 patients treated endovascularly and 420 treated by surgical revascularization. Restenosis was more common with endovascular than open surgical intervention (odds ratio [OR] 5.18, 95% confidence interval [CI] 2.78-9.62; p < .001). In subgroup analysis according to the involved lesions, endovascular intervention patients showed more restenosis than open surgical intervention patients in the coronary artery, supra-aortic branches, and renal artery. In both the active and inactive stages, restenosis was more common in those treated endovascularly than in those treated by open surgery. However, stroke occurred less often with endovascular intervention than with open surgical intervention (OR 0.33, 95% CI 0.12-0.90; p = .003). Mortality and complications other than stroke and mortality did not differ between endovascular and open surgical intervention.

CONCLUSION

This meta-analysis has shown a lower risk of restenosis with open surgical intervention than with endovascular intervention. Stroke was generally more common with open surgical intervention than with endovascular intervention. However, there were differences according to the location of the lesion, and the risk of stroke in open surgery is higher when the supra-aortic branches are involved rather than the renal arteries.