CT and MR Imaging of Cardiothoracic Vasculitis

Coronary artery lesions in Takayasu arteritis

Introduction

Takayasu arteritis (TAK) is a granulomatous inflammation of vessels of large diameter, mainly affecting the aorta and its proximal branches, which is more common in young women. The incidence of coronary artery disease in TAK is unknown and not sufficiently studied.

Material and methods

A literature review was performed for the period 2003 to 2023 using a search of the PubMed and Scopus scientific databases. We used the following key words to search the academic journal databases: "Takayasu arteritis", "coronary angiography", "myocardial revascularization", "coronary artery disease", "angina pectoris", and "myocardial infarction".

Results

The analysis of studies showed that coronary artery lesions (CAL) in TAK are not uncommon, being identified particularly in children and young individuals. Pathology of the coronary arteries increases the morbidity and mortality of TAK patients. In TAK, the ostia and proximal segments of the coronary arteries are more frequently affected, presenting as stenosis or occlusion with the development of stable coronary artery disease, unstable coronary artery disease, acute myocardial infarction, and sudden death. The diagnosis of TAK and coronary artery pathology is often complicated due to nonspecific manifestations and frequently the absence of symptoms. The treatment of patients with TAK with CAL is challenging and requires both pharmacological therapy and interventional or surgical methods of myocardial revascularization.

Conclusions

Takayasu arteritis is a more prevalent cause of CAL development, especially in young patients, than previously believed, and cardiovascular death due to CAL is not rare. Early diagnosis of TAK with CAL, particularly occlusion or hemodynamically significant stenosis, and the prompt initiation of appropriate treatment prevent dangerous complications, reduce mortality, and improve prognosis.

Isolated Coronary Arteritis in Adults: a Single-Center Experience from China

Isolated coronary arteritis (ICA) is an extremely rare and life-threatening vasculitis with only a limited number of reports in the literature. We retrospectively reviewed the clinical data of 10 ICA patients in our center from 2012 to 2022 and compared them with patients with Takayasu arteritis who presented with coronary arteritis initially (TAK-CA patients). We found that ICA predominantly affected women and most commonly involved the ostium and the proximal segment of the coronary arteries, causing mainly stenotic lesions. The C-reactive protein and erythrocyte sedimentation rate were grossly normal and significantly lower than those of TAK-CA patients (p = 0.027, p = 0.009, respectively). Intravascular ultrasound imaging showed superiority in differentiating coronary vasculitis from atherosclerosis. Restenosis of the coronary arteries occurred rapidly if not treated promptly and appropriately. Systemic glucocorticoid combined with immunosuppressive agents, especially cyclophosphamide, was a promising strategy for treating ICA.

MR and CT angiography in the diagnosis of vasculitides

Vasculitides represent the wide-ranging series of complex inflammatory diseases that involve inflammation of blood vessel walls. These conditions are characterized according to the caliber of the predominantly involved vessels. The work-up of vasculitides often includes imaging to narrow a differential diagnosis and guide management. Findings from CT and MR angiography in conjunction with a thorough history and physical exam are of utmost importance in making an accurate diagnosis. Further, imaging can be used for follow-up, in order to monitor disease progression and response to treatment. This wide-ranging literature review serves as the primary resource for clinicians looking to diagnose and monitor the progression of rare vascular inflammatory conditions. This article provides a comprehensive summary of the main findings on imaging related to each of these vasculitides. For each of the named vasculitis conditions, a thorough overview of the diagnostic modalities and their respective findings is described. Many specific hallmarks of pathology are included in this review article.

Atteintes coronariennes et artérite a cellules géantes : à propos de 2 cas et revue de la littérature

INTRODUCTION

Coronaritis is a rare but serious complication of giant-cell arteritis (GCA), with an estimated prevalence of less than 1%, however difficult to establish, and of early onset.

METHODS

We describe 2 cases of GCA presenting with coronaritis and present a review of the literature on this complication.

RESULTS

The first patient presented with stable angina on common trunk coronaritis with ostial stenosis. Corticosteroid combined with tocilizumab from the outset resulted in improvement. Angioplasty was performed at 6months with good outcome. The second patient presented with asymptomatic tritruncular ostial coronaritis. Corticosteroid allowed clinic-biological improvement of GCA. Two years later, he presented relapse with an acute coronary syndrome, with favorable evolution after angioplasty, increase of corticosteroids and addition of tocilizumab.

CONCLUSION

Patients presented were successfully treated with corticosteroids combined with tocilizumab and angioplasty of their coronary stenoses. Efficacy of tocilizumab in GCA has not been evaluated especially on coronaritis due to the rarity of this complication. Our experience and the cases reported in the literature suggest good results of angioplasty in this indication. Studies with long-term follow-up will be necessary to evaluate the risk of restenosis.

Imaging of Immune Checkpoint Inhibitor Immunotherapy for Non-Small Cell Lung Cancer

The normal immune system identifies and eliminates precancerous and cancerous cells. However, tumors can develop immune resistance mechanisms, one of which involves the exploitation of pathways, termed immune checkpoints, that normally suppress T-cell function. The goal of immune checkpoint inhibitor (ICI) immunotherapy is to boost T-cell-mediated immunity to mount a more effective attack on cancer cells. ICIs have changed the treatment landscape of advanced non-small cell lung cancer (NSCLC), and numerous ICIs have now been approved as first-line treatments for NSCLC by the U.S. Food and Drug Administration. ICIs can cause atypical response patterns such as pseudoprogression, whereby the tumor burden initially increases but then decreases. Therefore, response criteria have been developed specifically for patients receiving immunotherapy. Because ICIs activate the immune system, they can lead to inflammatory side effects, termed immune-related adverse events (irAEs). Usually occurring within weeks to months after the start of therapy, irAEs range from asymptomatic abnormal laboratory results to life-threatening conditions such as encephalitis, pneumonitis, myocarditis, hepatitis, and colitis. It is important to be aware of the imaging appearances of the various irAEs to avoid misinterpreting them as metastatic disease, progressive disease, or infection. The basic principles of ICI therapy; indications for ICI therapy in the setting of NSCLC; response assessment and atypical response patterns of ICI therapy, as compared with conventional chemotherapy; and the spectrum of irAEs seen at imaging are reviewed. An invited commentary by Nishino is available online. ^©RSNA, 2022.

Imaging of intestinal vasculitis focusing on MR and CT enterography: a two-way street between radiologic findings and clinical data

Diagnosis of intestinal vasculitis is often challenging due to the non-specific clinical and imaging findings. Vasculitides with gastrointestinal (GI) manifestations are rare, but their diagnosis holds immense significance as late or missed recognition can result in high mortality rates. Given the resemblance of radiologic findings with some other entities, GI vasculitis is often overlooked on small bowel studies done using computed tomography/magnetic resonance enterography (CTE/MRE). Hereon, we reviewed radiologic findings of vasculitis with gastrointestinal involvement on CTE and MRE. The variety of findings on MRE/CTE depend upon the size of the involved vessels. Signs of intestinal ischemia, e.g., mural thickening, submucosal edema, mural hyperenhancement, and restricted diffusion on diffusion-weighted imaging, are common in intestinal vasculitis. Involvement of the abdominal aorta and the major visceral arteries is presented as concentric mural thickening, transmural calcification, luminal stenosis, occlusion, aneurysmal changes, and collateral vessels. Such findings can be observed particularly in large- and medium-vessel vasculitis. The presence of extra-intestinal findings, including within the liver, kidneys, or spleen in the form of focal areas of infarction or heterogeneous enhancement due to microvascular involvement, can be another radiologic clue in diagnosis of vasculitis. The link between the clinical/laboratory findings and MRE/CTE abnormalities needs to be corresponded when it comes to the diagnosis of intestinal vasculitis.

Chest Pain of Atypical Cause in a Young Man

Granulomatosis with polyangiitis (GPA) is a rare systemic vasculitis that classically affects the upper respiratory tract, lungs, and kidneys. The involvement of other organs occurs but is less frequent. Clinically overt cardiac involvement is rare. We present a rare case of thoracic pain caused by cardiac involvement in GPA, without any other symptoms. The diagnosis was made using an integral approach, with several complementary imaging modalities, including cardiac histology.

Side Effects of Oncologic Treatment in the Chest: Manifestations at FDG PET/CT

Fluorodeoxyglucose (FDG) PET/CT is a vital imaging technique used for staging, assessing treatment response, and restaging following completion of therapy in patients who are undergoing or have completed oncologic treatment. A variety of adverse effects from chemotherapy, targeted therapy, immunotherapy, and radiation therapy are commonly encountered in oncologic patients. It is important to be aware of the manifestations of these adverse effects seen on FDG PET/CT images to avoid misinterpreting these findings as disease progression. Furthermore, early identification of these complications is important, as it may significantly affect patient management and even lead to a change in treatment strategy. The authors focus on the FDG PET/CT manifestations of a broad spectrum of oncologic therapy-related adverse effects in the thorax, as well as some treatment-related changes that may potentially mimic malignancy. Online supplemental material is available for this article. ^©RSNA, 2021.

ACR Appropriateness Criteria® Noncerebral Vasculitis

Noncerebral vasculitis is a wide-range noninfectious inflammatory disorder affecting the vessels. Vasculitides have been categorized based on the vessel size, such as large-vessel vasculitis, medium-vessel vasculitis, and small-vessel vasculitis. In this document, we cover large-vessel vasculitis and medium-vessel vasculitis. Due to the challenges of vessel biopsy, imaging plays a crucial role in diagnosing this entity. While CTA and MRA can both provide anatomical details of the vessel wall, including wall thickness and enhancement in large-vessel vasculitis, FDG-PET/CT can show functional assessment based on the glycolytic activity of inflammatory cells in the inflamed vessels. Given the size of the vessel in medium-vessel vasculitis, invasive arteriography is still a choice for imaging. However, high-resolution CTA images can depict small-caliber aneurysms, and thus can be utilized in the diagnosis of medium-vessel vasculitis. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Coronary Vasculitis

The term coronary “artery vasculitis” is used for a diverse group of diseases with a wide spectrum of manifestations and severity. Clinical manifestations may include pericarditis or myocarditis due to involvement of the coronary microvasculature, stenosis, aneurysm, or spontaneous dissection of large coronaries, or vascular thrombosis. As compared to common atherosclerosis, patients with coronary artery vasculitis are younger and often have a more rapid disease progression. Several clinical entities have been associated with coronary artery vasculitis, including Kawasaki’s disease, Takayasu’s arteritis, polyarteritis nodosa, ANCA-associated vasculitis, giant-cell arteritis, and more recently a Kawasaki-like syndrome associated with SARS-COV-2 infection. This review will provide a short description of these conditions, their diagnosis and therapy for use by the practicing cardiologist.

Systemic vasculitides and the role of multitechnique imaging in the diagnosis

Vasculitis, a systemic disease characterised by inflammation of the blood vessels, remains challenging to diagnose and manage. Vessel size has been the basis for classifying systemic vasculitides. Imaging plays a vital role in diagnosing this challenging disease. This review article aims (a) to summarise up-to-date literature in this field, as well as include classification updates and (b) to review available imaging techniques, recent advances, and emphasis on imaging findings to diagnose large vessel vasculitides.

A Review on the Value of Imaging in Differentiating between Large Vessel Vasculitis and Atherosclerosis

Imaging is becoming increasingly important for the diagnosis of large vessel vasculitis (LVV). Atherosclerosis may be difficult to distinguish from LVV on imaging as both are inflammatory conditions of the arterial wall. Differentiating atherosclerosis from LVV is important to enable optimal diagnosis, risk assessment, and tailored treatment at a patient level. This paper reviews the current evidence of ultrasound (US), 2-deoxy-2-[18F]fluoro-D-glucose positron emission tomography (FDG-PET), computed tomography (CT), and magnetic resonance imaging (MRI) to distinguish LVV from atherosclerosis. In this review, we identified a total of eight studies comparing LVV patients to atherosclerosis patients using imaging—four US studies, two FDG-PET studies, and two CT studies. The included studies mostly applied different methodologies and outcome parameters to investigate vessel wall inflammation. This review reports the currently available evidence and provides recommendations on further methodological standardization methods and future directions for research.

Coronary artery vasculitis: a review of current literature

Cardiac vasculitis is recognized as a heterogeneous disease process with a wide spectrum of manifestations including pericarditis, myocarditis, valvular heart disease and less frequently, coronary artery vasculitis (CAV). CAV encompasses an emerging field of diseases which differ from conventional atherosclerotic disease and have a proclivity for the younger population groups. CAV portends multiple complications including the development of coronary artery aneurysms, coronary stenotic lesions, and thrombosis, all which may result in acute coronary syndromes. There are several aetiologies for CAV; with Kawasaki's disease, Takayasu's arteritis, Polyarteritis Nodosa, and Giant-Cell Arteritis more frequently described clinically, and in literature. There is a growing role for multi-modality imaging in assisting the diagnostic process; including transthoracic echocardiography, cardiac magnetic resonance imaging, computed tomography coronary angiography, fluorodeoxyglucose-positron emission tomography and conventional coronary angiogram with intravascular ultrasound. Whilst the treatment paradigms fundamentally vary between different aetiologies, there are overlaps with pharmacological regimes in immunosuppressive agents and anti-platelet therapies. Interventional and surgical management are is a consideration in select populations groups, within a multi-disciplinary context. Further large-scale studies are required to better appropriately outline management protocols in this niche population.

Diagnosis and Treatment of Angiography Positive Medium to Large Vessel Childhood Primary Angiitis of Central Nervous System (p-cPACNS): An International Survey

Childhood Primary Angiitis of Central Nervous System (cPACNS) is rare, but can cause significant damage and result in disability or even death. Because of its rarity, the sometimes acute and variable presentation, limited awareness, and the absence of widely accepted diagnostic and therapeutic standards, cPACNS is a diagnostic and therapeutic challenge. Three subcategories of cPACNS exist, including angiography-positive non-progressive p-cPACNS, angiography-positive progressive p-cPACNS which both affects the medium to large vessels, and angiography-negative small vessel sv-cPACNS. Diagnosis and treatment of cPACNS relies on personal experience, expert opinion and case reports/case series. To collect information on diagnostic and therapeutic approaches to transient and progressive cPACNS, a survey was shared among international clinicians (German Society for Pediatric Rheumatology, the Pediatric Rheumatology European Society, the German speaking "Network Pediatric Stroke," and members of the American College of Rheumatology/CARRA Pediatric Rheumatology list server). Results from this survey will be used to define statements toward a consensus process allowing harmonization of diagnostic and therapeutic approaches and the generation of evidence in a rare condition.

Thoracic Manifestations of Rheumatoid Arthritis

Rheumatoid arthritis (RA) is one of the most common chronic systemic inflammatory diseases and the most common chronic inflammatory arthritis. Classically a progressive symmetric polyarthritis, RA is characterized by inflammation, erosions, bone loss, and joint destruction. Up to half of patients with RA exhibit extra-articular manifestations (EAMs), which may precede articular disease and are more common in patients with seropositive RA (patients with detectable serum levels of rheumatoid factor and/or anticitrullinated peptide antibodies). Cardiovascular and pulmonary EAMs are the largest contributors to morbidity and mortality in RA and may be especially devastating. Imaging has a significant role in diagnosing these EAMs and assessing response to treatment. Although treatment with disease-modifying antirheumatic drugs has redefined the natural history of RA and helped many patients achieve low disease activity, patients are at risk for treatment-related complications, as well as infections. The clinical features of drug-induced lung disease and infection can overlap considerably with those of EAMs, presenting a diagnostic challenge. Radiologists, by recognizing the imaging characteristics and evolution of these various processes, are essential in diagnosing and distinguishing among EAMs, treatment-related complications, and unrelated processes and formulating an appropriate differential diagnosis. Moreover, recognizing these disease processes at imaging and contextualizing imaging findings with clinical information and laboratory and pathologic findings can facilitate definitive diagnosis and proper treatment. The authors review the articular and extra-articular thoracic imaging manifestations of RA, including cardiovascular, respiratory, and pleural diseases, as well as treatment-related complications and common infections. ^©RSNA, 2021.

Cardiac involvement in the adult primary vasculitides

INTRODUCTION

Heart involvement in vasculitis is rare, but potentially severe. The ascertainment of cardiac disease in vasculitis is complex and requires an integrated multidisciplinary approach involving the Rheumatologist, Radiologist, Cardiologist, and Heart surgeon.

AREAS COVERED

the authors searched PubMed using the keywords 'heart'[Mesh] and vasculitis"[Mesh].

EXPERT OPINION

Virtually any vasculitis can affect the heart, but cardiac involvement is more common in some vasculitides such as Takayasu arteritis, polyarteritis nodosa, and eosinophilic granulomatosis with polyangiitis. Immunosuppressive treatment and when indicated surgery can improve the prognosis.

MR Imaging of the Mesenteric Vasculature

MR angiography is a flexible imaging technique enabling morphologic assessment of mesenteric arterial and venous vasculature. Conventional gadolinium-based contrast media and ferumoxytol are used as contrast agents. Ferumoxytol, an intravenous iron replacement therapy approved by the US Food and Drug Administration for iron deficiency anemia, is an effective and well tolerated blood pool contrast agent. The addition of 4D flow MR imaging enables a functional assessment of the arterial and venous vasculature; when coupled with a meal challenge, the severity of mesenteric arterial stenosis is well appreciated. Noncontrast MR angiographic techniques are useful for evaluating suspected mesenteric ischemia.

Myocardial Infarction With Nonobstructive Coronary Arteries (MINOCA): Potential Etiologies, Mimics and Imaging Findings

Myocardial infarction with nonobstructive coronary arteries (MINOCA) occurs when a patient presents with positive cardiac enzymes in the absence of obstructive atherosclerosis on coronary angiography. Several hypotheses for the pathogenesis of MINOCA have been suggested and multiple potential underlying etiologies have been reported. This review will outline the reported causes of MINOCA and associated major imaging features. In doing so, it will increase awareness of this entity and equip cardiac imagers with the knowledge to appropriately tailor imaging to make a prompt and accurate diagnosis.

Computed Tomography of Acquired Aortic Diseases

Computed tomography angiography (CTA) has the ability to evaluate the aortic wall and the lumen easily, quickly, and reproducibly without the need for invasive techniques. The images are isotropic, allowing several reconstructions. When imaging the aorta, CTA has replaced catheter angiography in the diagnosis of acquired disease such as aortoiliac disease, aneurysm, and infectious and inflammatory disease of the aorta.