Takayasu's arteritis: management of left main stem stenosis

Left Main Snorkel Stent Thrombosis in Association With Takayasu Arteritis

Takayasu arteritis (TA) is a rare form of large vessel arteritis that predominantly affects the aorta and its major branches. This inflammation leads to thickening, fibrosis, and stenosis of the arterial walls, which may lead to thrombus formation. The resulting symptoms are typically due to ischemia of the end organs. Coronary artery involvement is uncommon and primarily affects the ostia of the arteries. Ostial involvement of the coronary arteries can have a dramatic course, including fatal outcomes. We present the case of a 16-year-old female with TA involving the ostium of the left main coronary artery, causing severe stenosis. A successful percutaneous coronary intervention was performed on the left main artery with snorkel stent placement, which was complicated by cardiac arrest seven months later due to complete thrombosis of the proximal opening of the protruding stent.

Cytokine Disturbances in Coronary Artery Ectasia Do Not Support Atherosclerosis Pathogenesis

BACKGROUND

Coronary artery ectasia (CAE) is a rare disorder commonly associated with additional features of atherosclerosis. In the present study, we aimed to examine the systemic immune-inflammatory response that might associate CAE.

METHODS

Plasma samples were obtained from 16 patients with coronary artery ectasia (mean age 64.9 ± 7.3 years, 6 female), 69 patients with coronary artery disease (CAD) and angiographic evidence for atherosclerosis (age 64.5 ± 8.7 years, 41 female), and 140 controls (mean age 58.6 ± 4.1 years, 40 female) with normal coronary arteries. Samples were analyzed at Umeå University Biochemistry Laboratory, Sweden, using the V-PLEX Pro-Inflammatory Panel 1 (human) Kit. Statistically significant differences (p < 0.05) between patient groups and controls were determined using Mann-Whitney U-tests.

RESULTS

The CAE patients had significantly higher plasma levels of INF-γ, TNF-α, IL-1β, and IL-8 (p = 0.007, 0.01, 0.001, and 0.002, respectively), and lower levels of IL-2 and IL-4 (p < 0.001 for both) compared to CAD patients and controls. The plasma levels of IL-10, IL-12p, and IL-13 were not different between the three groups. None of these markers could differentiate between patients with pure (n = 6) and mixed with minimal atherosclerosis (n = 10) CAE.

CONCLUSIONS

These results indicate an enhanced systemic pro-inflammatory response in CAE. The profile of this response indicates activation of macrophages through a pathway and trigger different from those of atherosclerosis immune inflammatory response.

Aortic intimal fold in Takayasu arteritis causing obstruction of left coronary ostium

An 11-year-old girl with Takayasu arteritis was presented with recurrent chest pain. A transthoracic echocardiogram showed moderate to severe aortic regurgitation with impaired cardiac function. Cardiac catheterization revealed the total occlusion of the small right coronary artery and left main stenosis of 40%. An intraoperative transesophageal echocardiogram showed a redundant intimal fold partially covering the left coronary ostium and this was further confirmed from the intraoperative finding. This is a case report of recurrent angina associated with obstruction of left main coronary artery orifice by an intimal fold secondary to Takayasu arteritis.

Patient with Takayasu arteritis presented as cardiogenic shock

Takayasu arteritis is a chronic inflammatory disease involving the aorta, its main branches and affects particularly young women. Symptomatic coronary artery disease and cardiogenic shock are rare signs of Takayasu arteritis. We describe a 47-year-old male patient in whom cardiogenic shock was the initial presentation of Takayasu arteritis with coronary, subclavian, celiac and total abdominal aortic occlusion.

Takayasu's Arteritis Involving the Ostia of Three Large Coronary Arteries

Takayasu's arteritis can involve the ostia of coronary arteries. We report a patient with Takayasu's arteritis involving the ostia of three large coronary arteries who was successfully treated by percutaneous coronary intervention (PCI) with a drug-eluting stent (DES) and had a good clinical outcome after 12 months. A 37-year-old male with unstable angina was admitted to our cardiovascular center. The patient had Takayasu's arteritis and an aortic valve replacement with a metallic valve due to severe aortic regurgitation 7 years previously. Coronary angiography (CAG) showed a 95% discrete eccentric luminal narrowing at the ostia of the large left anterior descending (LAD) and left circumflex (LCX) arteries, and a 99% discrete eccentric luminal narrowing at the ostium of the large right coronary artery (RCA). The patient was treated with prednisolone for 14 days. Two large paclitaxel-eluting stents (PES) were then implanted in the distal left main coronary artery using the kissing stent technique. After 6 months, a CAG did not reveal restenosis or recurrent coronary artery disease. Thus, PCI with a DES for patients with significant coronary involvement secondary to Takayasu's arteritis is an effective and an alternative treatment when coronary bypass grafting is not option.

Abnormal right ventricular myocardial strain generation in mild pulmonary hypertension

BACKGROUND

Although right ventricular (RV) dyssynchrony has been identified in patients with severe pulmonary hypertension due to significant RV enlargement and compromise in systolic function, a more clinically relevant question pertains to RV mechanical properties in patients with mild elevation in pulmonary artery systolic pressures (PASP).

METHODS

Several echocardiographic parameters and peak longitudinal strain were measured in 40 patients and divided into two groups of 20 patients based on their PASP.

RESULTS

Group I included 20 individuals (mean age 48 +/- 16 years with a mean PASP of 27 +/- 5 mmHg) and Group II included 20 patients (mean age 63 +/- 14 years with a mean PASP of 49 +/- 7 mmHg.) All time intervals were adjusted for heart rate. RV fractional area change and tricuspid annular plane systolic excursion for Group I (62 +/- 12% and 2.74 +/- 0.56 cm) and Group II (49 +/- 14%; P < 0.02 and 2.09 +/- 0.40; P < 0.002) were both normal. However, Group II had lower peak longitudinal RV free wall (RVF) strain (-27.3 +/- 7.1 % vs. -31.9 +/- 8.7%, P < 0.04), longer time to peak RVF strain (448 +/- 57 ms vs. 411 +/- 43 ms; P < 0.03) and evidence of significant RV dyssynchrony (-83 +/- 55 ms vs. 1 +/- 17 ms, P < 0.00001) in contrast to Group I.

CONCLUSION

In conclusion, mild elevations in PASP affect the mechanical properties of the RV and result in RV dyssynchrony despite absence of gross abnormalities in RV size or function.

[18F]Fluorodeoxyglucose PET in Large Vessel Vasculitis

[(18)F]fluorodeoxyglucose (FDG) PET is a noninvasive metabolic imaging modality based on the regional distribution of [18F]FDG that is highly effective in assessing the activity and extent of giant cell arteritis and Takayasu's arteritis, respectively. Metabolic imaging using [18F]FDG-PET has been shown to identify more affected vascular regions than morphologic imaging with MRI in both diseases. The visual grading of vascular [18F]FDG uptake helps to discriminate arteritis from atherosclerosis and therefore provides high specificity. High sensitivity is attained by scanning during the active inflammatory phase. Thus, [18F]FDG-PET has the potential to develop into a valuable tool in the diagnostic workup of giant cell arteritis and Takayasu's arteritis.

Takayasu's arteritis in a young Caucasian female: case report and review

We report a case of a 24-year-old Caucasian woman presenting with fatigue, weight loss, a cardiac murmur, anaemia and biochemical markers of inflammation due to Takayasu's arteritis (TA), a vasculitis of the aorta and large vessels that typically affects young women. The rarity of the disease, the great variability in presentation together with the absence of specific symptoms as well as the absence of specific biochemical markers, makes early diagnosis difficult. Besides (magnetic resonance) arteriography, new promising diagnostic tools are discussed, including transoesophageat echocardiography (TEE) and Positron Emission Tomography (PET). Nevertheless, a high index of suspicion remains the key to an early diagnosis, and hence a better prognosis, of TA.

Alterations in Left Ventricular Structure and Diastolic Function in Professional Football Players: Assessment by Tissue Doppler Imaging and Left Ventricular Flow Propagation Velocity

BACKGROUND

Long-term regular exercise is associated with physiologic and morphologic cardiac alterations. Tissue Doppler imaging (TDI) and ventricular early flow propagation velocity (Vp) are new tolls in the evaluation of myocardial function. We sought to compare TDI and Vp findings in professional football players and age-adjusted sedentary controls to assess the effect of regular athletic training on myocardial function.

METHODS

Twenty-four professional football players and age-, sex-, and weight-adjusted 20 control subjects underwent standard Doppler echocardiography pulsed TDI, performed parasternal four-chamber views by placing sample volume septal and lateral side of mitral annulus and lateral tricuspid annulus. Vp values were obtained by measuring the slope delineated by first aliasing velocity from the mitral tips toward the apex by using apical four-chamber color M-mode Doppler images.

RESULTS

Age, body surface area, blood pressure, and heart rate were comparable between two groups. Football players had significantly increased LV mass, mass index (due to both higher wall thickness and end-diastolic diameter), end-systolic and end-diastolic volume, left atrial diameter, and decreased transmitral diastolic late velocity. In athletes TDI analysis showed significantly increased mitral annulus septal DTI peak early diastolic (e) velocity (0.22 +/- 0.04 vs 0.19 +/- 0.04, P < 0.05), lateral DTI peak e velocity (0.19 +/- 0.03 vs 0.16 +/- 0.02, P < 0.05) and lateral DTI e/a peak velocity ratio (1.96 +/- 0.41 and 1.66 +/- 0.23, P < 0.05). The ratio of transmitral peak early diastolic velocity (E) to e in both lateral (4.72 +/- 1.20 vs 5.95 +/- 1.38, P = 0.007) and septal (3.90 +/- 0.80 vs 5.25 +/- 1.50, P = 0.002) side of mitral annulus were significantly lower in athletes. In Vp evaluation, we found higher Vp values (60.52 +/- 6.95 in athletes and 56.56 +/- 4.24 in controls, P = 0.03) in football players.

CONCLUSIONS

Professional football playing is associated with morphologic alteration in left ventricle and left atrium and improvement in left ventricle diastolic function that can be detected by TDI and Vp. These techniques may be new tools to define and quantitate the degree of LV diastolic adaptations to endurance exercise.

Isolated bilateral coronary ostial stenosis—An uncommon presentation of aortoarteritis

Aortoarteritis presenting with isolated bilateral coronary artery ostial stenosis is a serious but rare condition. This letter emphasizes on a very atypical presentation of aortoarteritis and also distinct but unusual form of angiographic findings involving total occlusion of left main coronary artery from the ostium and tight ostial right coronary artery stenosis that had a fulminant disease course.

Pre-pulseless Takayasu's arteritis evaluated with 18F-FDG positron emission tomography and gadolinium-enhanced magnetic resonance angiography

Takayasu's arteritis is a primary vasculitis that affects large vessels and is characterized by chronic granulomatous inflammation. Diagnosis has been primarily clinical, with verification by angiography as the gold standard. More recently, however, it has become apparent that positron emission tomography enables better evaluation of vascular inflammation. This study presents 2 cases of Takayasu's arteritis. Magnetic resonance angiography was used to evaluate aortic anatomy by analyzing vascular wall thickness and also to quantify disease activity by measuring gadolinium enhancement. Positron emission tomography was used to evaluate active vascular inflammation by quantifying fluorodeoxyglucose F18 uptake. We conclude that both techniques support clinical diagnosis and aid in the evaluation of disease activity during and after treatment.

Successful Coronary Revascularization Using the PAS-Port System in a Patient With Takayasu’s Arteritis and Behcet’s Disease

Coronary artery disease is rare in patients with Takayasu's arteritis or Behcet's disease. We report the case of a patient with concomitant Takayasu's arteritis and Behcet's disease who had angina pectoris develop due to severe narrowing of the left main coronary artery. The patient underwent revascularization with saphenous vein grafts with the assistance of the PAS-Port Proximal Anastomosis System (Cardica, Inc, Redwood City, CA). In conclusion, the PAS-Port Proximal Anastomosis System seems to be a safe and effective method of facilitating revascularization, particularly when severe calcification of the ascending aorta precludes cross-clamping during off-pump coronary artery bypass grafting.

Takayasu's arteritis: A case report and a brief review of the literature

Takayasu’s arteritis primarily affects young women. The current case report focuses on a Caucasian middle-aged woman who complained of weakness, malaise, and fatigue for as many as 19 years. Delayed diagnosis and lack of specific treatment could explain the extent and the clinical severity of the disease at time of hospital admission. Angiography showed focal narrowings of the abdominal and thoracic aorta and occlusion of both the subclavian arteries, of the right coronary artery and severe stenosis of the first marginal obtuse. Takayasu’s arteritis is not limited to women of Japanese origin but is present worldwide. Early diagnosis and treatment is warranted. Outcome appears to be favorable when the disease is quiescent.

Unprotected left main stent placement in a patient with Takayasu's arteritis: an unusual solution for an unusual disease

We describe the case of a young woman with Takayasu's arteritis that initially manifested as heart failure due to left main coronary artery stenosis. The patient's occluded subclavian artery and the active inflammatory process of Takayasu's arteritis precluded coronary artery bypass grafting with the use of arterial grafts. Therefore, a drug-eluting stent was placed in the unprotected left main artery. This procedure resulted in the resolution of symptoms, with a patent stent and no new coronary lesions observed on 3-month angiography, and normal left ventricular function on 9-month echocardiography. We conclude that the use of drug-eluting stents may be an important treatment option for Takayasu's arteritis patients with life-threatening coronary artery disease for whom coronary artery bypass grafting is not an option.

Use of ultrasonography and positron emission tomography in the diagnosis and assessment of large-vessel vasculitis

PURPOSE OF REVIEW

Ultrasonography and positron emission tomography have been increasingly studied and, in part, introduced in clinical practice to diagnose large-vessel vasculitides, such as temporal arteritis, Takayasu arteritis, large-vessel giant cell arteritis, and isolated aortitis.

RECENT FINDINGS

Ultrasonography reveals characteristic homogenous, concentric wall thickening in vasculitis, often combined with stenoses and, less frequently, with acute occlusions. Thirteen studies describe sensitivities of 40 to 100% (median, 86%) for temporal artery vessel wall edema compared with histology, and of 35 to 86% (median, 70%) compared with clinical diagnosis. If wall edema, stenoses, and occlusions are included, sensitivities increase to 91 to 100% (median, 95%) compared with histology, and to 83 to 100% (median, 88%) compared with clinical diagnosis. Specificities for wall edema are 68 to 100% (median, 93%) compared with histology, and 78 to 100% (median, 97%) compared with clinical diagnosis. One should be aware of large-vessel giant cell arteritis in all patients with temporal arteritis and polymyalgia rheumatica. Ultrasonography reveals characteristic wall thickening, particularly of the distal subclavian, axillary, and proximal brachial arteries. Findings in Takayasu arteritis are similar, but the vessel wall swelling is usually brighter. Positron emission tomography reveals vasculitis in arteries with a diameter of more than 4 mm. Ultrasonography and positron emission tomography agreed completely in the anatomic distribution of changes in patients with large-vessel giant cell arteritis. It reveals asymptomatic large-vessel vasculitis in giant cell arteritis and Takayasu arteritis. Positron emission tomography is not suitable for the assessment of temporal arteries.

SUMMARY

Ultrasonography and positron emission tomography are new, promising techniques to assess large-vessel vasculitides.

The value of [18F]FDG-PET in the diagnosis of large-vessel vasculitis and the assessment of activity and extent of disease

PURPOSE

This study was performed to investigate the value of( 18)F-fluorodeoxyglucose positron emission tomography ([(18)F]FDG-PET) in the diagnosis of large-vessel vasculitis and the assessment of activity and extent of disease.

METHODS

Twenty-six consecutive patients (21 females, 5 males; median age - years, range 17-86 years) with giant cell arteritis or Takayasu's arteritis were examined with [(18)F]FDG-PET. Follow-up scans were performed in four patients. Twenty-six age- and gender-matched controls (21 females, 5 males; median age 71 years, range 17-86 years) were included. The severity of large-vessel [(18)F]FDG uptake was visually graded using a four-point scale. C-reactive protein (CRP) and the erythrocyte sedimentation rate (ESR) were measured and correlated with [(18)F]FDG-PET results by logistic regression.

RESULTS

[(18)F]FDG-PET revealed pathological findings in 18 of 26 patients. Three scans were categorised as grade I, 12 as grade II and 3 as grade III arteritis. Visual grade was significantly correlated with both CRP and ESR levels (p=0.002 and 0.007 respectively; grade I: CRP 4.0 mg/l, ESR 6 mm/h; grade II: CRP 37 mg/l, ESR 46 mm/h; grade III: CRP 172 mg/l, ESR 90 mm/h). Overall sensitivity was 60% (95% CI 40.6-77.3%), specificity 99.8% (95% CI 89.1-100%), positive predictive value 99.7% (95% CI 77-100%), negative predictive value 67.9% (95% CI 49.8-80.9%) and accuracy 78.6% (95% CI 65.6-88.4%). In patients presenting with a CRP <12 mg/l or an ESR <12 mm/h, logistic regression revealed a sensitivity of less than 50%. In patients with high CRP/ESR levels, sensitivity was 95.5%/80.7%.

CONCLUSION

[(18)F]FDG-PET is highly effective in assessing the activity and the extent of large-vessel vasculitis. Visual grading was validated as representing the severity of inflammation. Its use is simple and provides high specificity, while high sensitivity is achieved by scanning in the state of active inflammation.