Endovascular therapy combined with immunosuppressive treatment for pseudoaneurysms in patients with Behçet's disease

Cardiovascular Manifestations in Behçet's Disease

Cardiovascular involvement in Behçet's disease (BD) is considerably related to morbidity and mortality. However, the cardiovascular manifestation is sometimes difficult to distinguish from those of other causes. The suspicion of BD and proper treatment is pivotal in the management of BD. Histology demonstrates perivasculitis. Neutrophil seems to play an important role in the inflammation of BD. It is thought that inflammation causes venous thrombosis and arterial aneurysm. Characteristically, BD involves both arteries and veins of variable size in any region. Venous thrombosis needs immunosuppression, and inferior vena cava thrombosis and Budd-Chiari syndrome require intensive immunosuppressive therapy. Arterial involvement causes aneurysm which usually is treated by surgical or endovascular intervention with immunosuppression. Pulmonary artery aneurysm and cardiac involvement require multimodal managements.

Hybrid surgery management challenges of a Behcet's disease patient with recurrence of aortic aneurysms: a case report

Background

Behcet's disease is a vasculitis of unknown origin that can involve multiple organs or tissues. Aneurysm or pseudoaneurysm, also one of the complications of Behcet's disease, is usually accompanied by a poor prognosis. Surgery is usually accompanied by a high risk of complications, such as the recurrence of anastomotic pseudoaneurysms and blockage of the target vessel. Using hybrid surgery, we successfully treated a complex and recurrent abdominal aortic pseudoaneurysm in a patient with BD.

Methods

We report a 32-year-old female diagnosed with Behcet's disease with recurrent thoracoabdominal aortic aneurysm. Adequate immunotherapy was given during the perioperative period. The splanchnic artery branches were reconstructed, and the aneurysm was sequestered with endovascular repair. The patient recovered uneventfully and was discharged from the hospital 8 days after hybrid surgery. At the 60-month follow-up, no aneurysm was observed, the stent had no displacement or internal leakage, and the reconstructed blood vessels were unobstructed.

Conclusion

Hybrid surgery could be a feasible and effective strategy for BD aneurysms. Adequate preoperative and postoperative immunotherapy with arterial anastomosis away from the diseased artery may be the key to success.

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.

Vascular complications of Behçet disease

Behçet disease is a multi-systemic complex vasculitis with unknown etiology characterized by different clinical involvements, including mucocutaneous, ocular, vascular, articular, neurological, and gastrointestinal manifestations. Growing evidence supports that different phenotypes, characterized by clusters of co-existing involvements, can be distinguished. Namely, the vascular phenotype identifies a specific group of patients who suffer from recurrent inflammatory thrombosis and arterial involvement. Vascular disease develops in up to 40% with a definite male preponderance and is usually an early manifestation. Venous involvement is significantly more common than arterial disease, and lower extremity deep vein thrombosis is its most frequent manifestation. Arterial disease involves mostly pulmonary arteries and aorta and manifests mainly in the form of aneurysms. Glucocorticoids and immunosuppressants are the recommended first-line treatments in vasculo-Behçet. Furthermore, controlled trials are still needed to assess the role of adding anticoagulation to the treatment regimen, with an accent on new oral anticoagulants. Treatment with anti-TNF alpha agents seems promising, but the management strategies are not clear yet.

Milestones in thromboangiitis obliterans. A position paper of the VAS-European Independent Foundation in Angiology/Vascular Medicine

BACKGROUND

Unfortunately, even today Thromboangiitis Obliterans has disease features that remain misunderstood or underappreciated. The epidemiology, etiology and pathophysiology of the disease are still unclear. Biomarkers and disease activity markers are lacking, thus clinical assessment is difficult. We are still struggling to establish unique diagnostic, staging and treatment criteria. This is an academic-collaborative effort to describe the pathophysiology, the clinical manifestations, the diagnostic approach, and the challenges of management of patients with TAO.

METHODS

A systematic search for relevant studies dating from 1900 to the end of 2020 was performed on the PubMed, SCOPUS, and Science Direct databases.

RESULTS

Given the intriguing nature of presentation of TAO, its management, to some extent is not only different in different regions of the world but also varies within the same region. Following this project, we discovered ambiguity, overlap and lack of clear-cut criteria for management of TAO.

CONCLUSIONS AND RELEVANCE

An international group of experts however came to one conclusion. They all agree that management of TAO is in need of a call for action for a renewed global look with multi-center studies, to update the geographical distribution of the disease and to establish a unique set of diagnostic criteria and a consensus-based guideline for best treatment based on current evidence.

Short-term outcome of primary stent graft for peripheral artery aneurysm in patients with Behçet disease

OBJECTIVE

Endovascular treatment of peripheral artery aneurysms (PAAs) in patients with Behçet disease is controversial. We report a single-institution experience of primary stent graft repair of PAAs in Behçet patients.

METHODS

Behçet patients who had endovascular stent graft repair of PAAs at a single center between January 2012 and December 2018 were identified. Demographics, past medical history, cardiovascular risk profile, and perioperative details were analyzed.

RESULTS

Twenty-two patients (mean age, 38 ± 7 years; 100% male) were included. The distribution of PAAs was external iliac artery in 2 (9%) patients, common femoral artery in 4 (18%) patients, superficial femoral artery in 15 (68%) patients, and above-knee popliteal artery in 1 (5%) patient. Pseudoaneurysm was diagnosed in five (23%) patients. We used antegrade access in the majority of patients (16 [73%]). Technical success was achieved in 21 (95%) patients. The mean hospital stay was 3 ± 2 days. There were no deaths or serious complications, and five (23%) patients experienced access site complications. The mean follow-up was 23 ± 11 months. The early primary and assisted primary patency rate was 91%. However, follow-up computed tomography angiography detected stent graft occlusion in six patients (27%).

CONCLUSIONS

Stent graft for PAA in patients with Behçet disease had a high early patency rate and minimal morbidity. However, the complication and reintervention rates were high during follow-up, with low surgical conversion.

Behcet's disease involved the root of aorta in the treatment with modified Bentall procedure: a case report

Background

Behcet’s disease (BD) is a multisystemic vasculitis of unknown etiology, the incidence of cardiovascular system involvement is rare, about1–5% (Sakane et al., N Engl J Med 341:1284–91, 1999). BD combined with aortic pseudoaneurysm and aortic valve regurgitation is usually need surgical treatment, but there is controversy about which surgical method to choose.

Case presentation

We report a case of BD combined with severe aortic valve regurgitation and two giant pseudoaneurysms of the aortic sinus. The patient underwent modified Bentall procedure (MBP) and use oral immunosuppressive as well as corticosteroid strictly, after 8 months follow-up, the patient recovered well.

Conclusion

For patient with aortic valve regurgitation and ascend aortic pseudoaneurysm caused by BD, we recommend modified Bentall procedure when rheumatism in a stable period. Corticosteroids and immunosuppressive drugs should be used before and after surgery.

Treating the Different Phenotypes of Behçet's Syndrome

Behçet's syndrome (BS) is a multisystemic vasculitis, characterized by different clinical involvements, including mucocutaneous, ocular, vascular, neurological, and gastrointestinal manifestations. Based on this heterogeneity, BS can be hardly considered as a single clinical entity. Growing evidence supports that, within BS, different phenotypes, characterized by clusters of co-existing involvements, can be distinguished. Namely, three major BS phenotypes have been reported: (a) the mucocutaneous and articular phenotype, (b) the extra-parenchymal neurological and peripheral vascular phenotype, and (c) the parenchymal neurological and ocular phenotype. To date, guidelines for the management of BS have been focused on the pharmacological treatment of each specific BS manifestation. However, tailoring the treatments on patient's specific phenotype, rather than on single disease manifestation, could represent a valid strategy for a personalized therapeutic approach to BS. In the present literature review, we summarize current evidence on the pharmacological treatments for the first-, second-, and third-line treatment of the major BS phenotypes.

Vascular Behçet's syndrome: an update

Behçet's syndrome (BS) is a complex vasculitis, characterised by peculiar histological, pathogenetic and clinical features. Superficial venous thrombosis (SVT) and deep vein thrombosis (DVT) are the most frequent vascular involvements, affecting altogether 15-40% of BS patients. Atypical thrombosis is also an important clinical feature of BS, involving the vascular districts of the inferior and superior vena cava, suprahepatic veins with Budd-Chiari syndrome, portal vein, cerebral sinuses and right ventricle. On the other hand, arterial involvement, although affecting only 3-5% of patients, represents a unique feature of BS, with aneurysms potentially affecting peripheral, visceral and pulmonary arteries. Vascular events in BS are promoted by inflammation, with neutrophils playing a key role in the pathogenesis of thrombotic events; in turn, coagulative components such as fibrinogen, thrombin, factor Xa and factor VIIa amplify the inflammatory cascade. Understanding the contribution of inflammatory and coagulation components in the pathogenesis of BS vascular events is crucial to define the most effective therapeutic strategy. Control of vascular thrombosis is achieved with immunosuppressants drugs rather than anticoagulants. In particular, use of azathioprine and cyclosporine in association with low-dose corticosteroids should be considered in DVT and SVT cases, while treatment with cyclophosphamide together with anti-TNF-α agents can be effectively used in arterial involvement. More recently, the anti-TNF-α drugs have also been reported as a valid alternative for the treatment also of venous events, especially DVT. An exception to the use of anticoagulant in BS could be represented by cerebral veins thrombosis. In this review, we will depict the main characteristics of the vascular involvement in BS, briefly describing histological and pathogenetic features, while focusing on the clinical and therapeutical approaches of the vascular manifestations of BS.

Endovascular treatment for Behçet's disease: a case report

Behçet's disease (BD) is a multisystemic vasculitis of unknown etiology. Cardiovascular involvement has been thoroughly described in the literature and the major cause of death in BD is secondary to aneurysm complications. In this case report, a patient with BD presented with a recurrent abdominal aortic aneurysm, which was corrected using a custom-made endoprosthesis. The optimal treatment for patients with BD remains highly controversial and challenging because of technical difficulties and frequent recurrence. Endovascular intervention seems to be a feasible alternative with considerably less morbidity than conventional surgery.

Open surgical repair of abdominal aortic aneurysms in Behçet's disease

BACKGROUND

Behçet's disease (BD) is a multisystem chronic autoimmune inflammatory disorder that involves multiple organs. Arterial involvement in BD is rare. Aortic involvement is one of the most severe manifestations and is associated with a much higher mortality. In this article, we will present our experience in open surgical repair of abdominal aortic aneurysm combined with immunosuppressive therapy.

METHODS

Between January 2010 and December 2017, 7 patients were treated for abdominal aortic aneurysms (5 infra-renal and 2 supra-renal, in 1 woman and 6 men). All patients were Moroccan, the age range being 25-59 years, mean age 43.2 years. Three Dacron tube grafts, two Dacron aortobiiliac grafts and two patch closures were used. All 7 patients received immunosuppresive therapy after surgery.

RESULTS

All patients underwent successful open surgical repair without major complications during the 30 days immediately after the procedure. During a mean follow-up of 36 months, there was no recurrent aneurysmal localization, but one patient had lost their sight. Until now, we have been following 6 patients and they continue to receive immunosuppressive therapy.

CONCLUSION

Long-term immunosuppressive therapy after aneurysm repair is important to limit pseudoaneurysm recurrence. Through our serie, we describe the results of the combination of surgical treatment and adjunctive immunosuppressive therapy, with a literature review.

Rupture of multiple pseudoaneurysms as a rare complication of common iliac artery balloon occlusion in a patient with placenta accreta: A case report and review of literature

RATIONALE

Placenta accreta is the main cause of severe obstetric postpartum hemorrhage (PPH) and hysterectomy. Several hemostatic techniques have been performed in patients with placenta accreta to prevent PPH and reserve fertility. Abdominal aorta and pelvic arteries balloon occlusion are the only techniques which could be performed before cesarean section (CS) in patients who want to keep the fetus and reserve fertility. However, abdominal aorta and pelvic arteries balloon occlusion might lead to severe complications such as formation and rupture of pseudoaneurysm, angiorrhexis, etc.

PATIENT CONCERNS

We report a case diagnosed with pernicious placenta previa (PPP) combined with Rh(D) negative blood type, who was performed with bilateral common iliac arteries (CIA) balloon occlusion during CS. However, on the first day after CS, the patient caught sudden left-side lumbago and backache accompanied with palpitation and shortness of breath.

DIAGNOSES

Formation and rupture of multiple pseudoaneurysms in left CIA.

INTERVENTIONS

Covered stent was inserted into the proximal part of the left CIA and the ipsilateral internal iliac artery was embolized by coil to prevent endoleak.

OUTCOMES

The patient recovered and discharged from hospital in stable condition without other complications 9 days after CS.

LESSONS

It is of paramount importance that obstetricians and radiologists correctly estimate the appropriate occlusion volume and pressure of pelvic arteries before CS to avoid formation and rupture of a pseudoaneurysm. And if the rupture of a pseudoaneurysm occurred, it should be quickly identified and treated with endovascular intervention.

Management of tibioperoneal trunk aneurysm in a patient with Behçet disease

Only a few cases of infrapopliteal aneurysms are reported in the literature. These are commonly associated with trauma, infection, and iatrogenic injuries and mostly present as pseudoaneurysms. We report the case of a 44-year-old man with Behçet disease and an 8-cm tibioperoneal trunk aneurysm and discuss the management options of these aneurysms.

Alginate oligosaccharide indirectly affects toll-like receptor signaling via the inhibition of microRNA-29b in aneurysm patients after endovascular aortic repair

Endovascular aortic repair (EVAR) is often followed by aneurysm recurrence. Alginate oligosaccharide (AOS) has potential antitumor properties as a natural product while the related mechanisms remain unclear. Toll-like receptor (TLR) signaling is associated with inflammatory activity of aneurysm and may be affected by miR-29b. Thus, inhibitory function of AOS on aneurysms was explored by measuring the important molecules in TLR4 signaling. After EVAR, a total of 248 aortic aneurysm patients were recruited and randomly assigned into two groups: AOS group (AG, oral administration 10-mg AOS daily) and control group (CG, placebo daily). The size of residual aneurysms, aneurysm recurrence, and side effects were investigated. Aneurysm recurrence was determined by Kaplan-Meier analysis. After 2 years, eight and two patients died in the CG and AG, respectively. The sizes of residual aneurysms were significantly larger in the CG than in the AG (P<0.05). The incidence of aneurysm recurrence was also significantly higher in the CG than in the AG (P<0.05). AOS treatment reduced the levels of miR-29b, TLR4, mitogen-activated protein kinase (MAPK), nuclear factor kappa B (NF-kappa B), interleukin 1 (IL-1) beta, and interleukin 6 (IL-6). Overexpression and silence of miR-29b increased and reduced the level of TLR4, phospho-p65 NF-kappa B, phospho-p38 MAPK, IL-1 beta, and IL-6. Spearman's rank correlation analysis shows that the level of miR-29b is positively related to the levels of TLR4, NF-kappa B, IL-1 beta, and IL-6 (P<0.05). Thus, AOS represses aneurysm recurrence by indirectly affecting TLR signaling via miR-29b.

The bronchial obstruction as a complication of endovascular repair of aortic pseudoaneurysm in Behçet's disease

Behçet's disease (BD) is an autoimmune disorder affecting multiple organs. Aortic pseudoaneurysm is the most catastrophic lesion in BD. This lesion type is considered as a complicated and challenging pathology by surgeons because of the technical operative difficulties and frequent recurrence. So, the endovascular repair of inflammatory aortic pseudoaneurysm has been used as an alternative to open surgical repair. It is particularly important in patients who are high-risk surgical candidates because of comorbidities. In this report, we present a case and treatment of bronchial obstruction, which caused progressive dyspnea after endovascular repair of aortic rupture, in patient with known history of BD.

Outcomes of surgery for patients with Behcet's disease causing aortic pseudoaneurysm: a shift from open surgery to endovascular repair

OBJECTIVES

Behcet's disease is a form of systematic vasculitis that affects vessels of various sizes. Aortic pseudoaneurysm is one of the most important causes of death among patients with Behcet's disease due to its high risk of rupture and associated mortality. Our study aimed to investigate the outcomes of Behcet's disease patients with aortic pseudoaneurysms undergoing open surgery and endovascular aortic repair.

METHODS

From January 2003 to September 2014, ten consecutive patients undergoing surgery for aortic pseudoaneurysm met the diagnostic criteria for Behcet's disease. Endovascular repair was the preferred modality and open surgery was performed as an alternative. Systemic immunosuppressive medication was administered after Behcet's disease was definitively diagnosed.

RESULTS

Eight patients initially underwent endovascular repair and two patients initially underwent open surgery. The overall success rate was 90% and the only failed case involved the use of the chimney technique to reach a suprarenal location. The median follow-up duration was 23 months. There were 7 recurrences in 5 patients. The median interval between operation and recurrence was 13 months. No significant risk factors for recurrence were identified, but a difference in recurrence between treatment and non-treatment with preoperative immunosuppressive medication preoperatively was notable. Four aneurysm-related deaths occurred within the follow-up period. The overall 1-year, 3-year and 5-year survival rates were 80%, 64% and 48%, respectively.

CONCLUSIONS

Both open surgery and endovascular repair are safe and effective for treating aortic pseudoaneurysm in Behcet's disease patients. The results from our retrospective study indicated that immunosuppressive medication was essential to defer the occurrence and development of recurrent aneurysms.

Endovascular Treatment of Behcet Disease With Recurrent Infrainguinal Arterial Pseudoaneurysms: A Case Report and Literature Review

Aneurysm or pseudoaneurysm formation is one of the vascular complications of Behcet disease. At present, the optimal treatment for the disease has not been established.The authors report a case of vasculo-Behcet disease (v-BD) with recurrent pseudoaneurysms in the left infrainguinal arteries (common femoral artery, superficial femoral artery, and popliteal artery), as well as thrombosis in the popliteal vein and posterior tibial vein. The patient underwent 3 rounds of surgery, but developed a new pseudoaneurysm several months after each surgery. Eventually, the patient was successfully treated with a combination of endovascular repair, using a fully covered stent graft, and prednisone. The pseudoaneurysm regressed without recurrence for more than 1 year.For v-BD, treatment with immunosuppressive therapy alone may not be sufficient to prevent the recurrence of pseudoaneurysms. For the endovascular treatment of pseudoaneurysms affecting the infrainguinal arteries in v-BD, a fully covered stent graft without oversizing is essential to prevent the recurrence of pseudoaneurysms.

Multiple Right and Left Pulmonary Arteries and Subdivisions of Inferior Mesenteric Artery Aneurysms in Behcet's Disease Case: A Rare Clinical Presentation

Behcet's disease is a multi-systemic inflammatory disorder with cutaneous acneiform eruptions, orogenital aphthae, uveitis, arthritis and systemic vascular inflammation. One of the rare vascular manifestations is thoraco-abdominal aortic and pulmonary aneurysm that is associated with high risk of morbidity and mortality. We report a 36-year-old man with chronic cough, hemoptysis, significant weight loss, and orogenital ulcers from one year before referral. Initial assessments revealed multiple parahillar nodules in chest X-ray, chronic inflammatory anemia, erythrocyte sedimentation rate more than 100, and positive Human Leukocyte Antigen B5 and B51. Evaluation for infection and malignancies was unremarkable. Open exploratory lung study showed multiple pulsatile nodules in both lungs. AMIGO computed tomogram confirmed multiple right and left pulmonary artery aneurysms and impending to rupture aneurysm at subdivision of inferior mesenteric artery. After beginning of three methylprednisolone and cyclophosphamide pulse doses, the clinical aspect of the patient dramatically improved. Although pulmonary aneurysm is a rare manifestation of Behcet's disease and it is more infrequent in the distal branches, it can be seen in patients presenting with inflammatory disease and respiratory manifestations and with Behcet's disease diagnosis. Corticosteroid pulse-therapy could be considered as the first line of medical treatment in these patients.

New Evidence-Based Treatment Approach in Behçet's Disease

Behçet's disease (BD) is a chronic, relapsing, and debilitating systemic vasculitis of unknown aetiology with the clinical features of mucocutaneous lesions, ocular, vascular, articular, neurologic, gastrointestinal, urogenital, and pulmonary involvement. The disease is much more frequent along the ancient “Silk Route” extending from Eastern Asia to the Mediterranean basin, compared with Western countries. The disease usually starts around the third or fourth decade of life. Male sex and a younger age of onset are associated with more severe disease. Although the treatment has become much more effective in recent years, BD is still associated with severe morbidity and considerable mortality. The main aim of the treatment should be the prevention of irreversible organ damage. Therefore, close monitoring, early, and appropriate treatment is mandatory to reduce morbidity and mortality. The treatment is mainly based on the suppression of inflammatory attacks of the disease using immunomodulatory and immunosuppressive agents. In this paper, current state of knowledge regarding the therapeutic approaches is outlined. To provide a rational framework for selecting the appropriate therapy along the various treatment choices, a stepwise, symptom-based, evidence-based algorithmic approach was developed.

Effectiveness and safety of endovascular aneurysm treatment in patients with vasculo-Behçet disease

PURPOSE

To compare long-term outcomes of endovascular and surgical treatment of arterial aneurysms in patients with vasculo-Behçet disease (VBD).

METHODS

The medical records of 912 patients with Behçet disease who were seen between May 1995 and January 2007 were reviewed. Among them, 34 (3.7%) patients with 39 non-cerebral aneurysmal lesions were diagnosed with VBD. Between February 1998 and November 2006, 16 VBD patients (14 men; mean age 39.2+/-9.2 years, range 25-63) were treated for 20 arterial aneurysms with an endovascular technique (stent-graft and/or coil embolization). All patients received immunosuppressive therapy (prednisolone 60 mg/d) before endovascular therapy to induce remission. From February 1993 to January 2007, 8 arterial aneurysms in 7 patients (all men; mean age 33.0+/-7.9 years, range 25-51) were treated with surgical graft interposition over 31.5+/-23.2 months.

RESULTS

The endovascular procedure was successful in all lesions. The mean follow-up was 47.6+/-41.8 months, during which 4 complications in 3 patients (3/16, 18.8%) occurred (2 occluded stent-grafts and 2 access site pseudoaneurysm). There were no deaths. The cumulative primary patency rate in the endovascular group was 89% at 24 months. In the 7 patients undergoing graft interposition for 8 arterial aneurysms, 3 (42.9%) events occurred in follow-up: 2 recurrent pseudoaneurysms and 1 aneurysm-related death.

CONCLUSION

In Behçet disease, aneurysm treatment is performed whenever possible because of the high risk of rupture. Endovascular treatment of arterial aneurysms was effective and safe, with an acceptable vascular complication rate and excellent patency of the treated site.

Endovascular treatment of aortic pseudoaneurysm in Behçet disease

OBJECTIVE

This study evaluated the feasibility, efficacy, and outcome of endovascular therapy combined with immunosuppressive therapy for aortic pseudoaneurysms in patients with Behçet disease.

METHODS

Between April 2002 and April 2008, 12 pseudoaneurysms (9 involving the intrarenal abdominal aorta, 1 at the suprarenal level, and 2 in the supraceliac aorta) in nine men and one woman with Behçet disease were evaluated at Peking Union Medical Center (PUMC). Three bifurcated stent grafts and seven tubular stent grafts, including two fenestrated stent grafts, were deployed. All 10 patients received immunosuppressive therapy after the implant procedure.

RESULTS

All patients underwent successful endovascular therapy without major complications during the 30 days immediately after the procedure. One patient with two aneurysms had treatment of only the larger infrarenal symptomatic aneurysm, but the smaller suprarenal pseudoaneurysm was not addressed because of its proximity to mesenteric branches. During a mean follow-up of 25.8 months (range, 6-50 months), nine aneurysms resolved completely in eight patients. The only untreated aneurysm, which coexisted with a treated lesion, remained stable under imaging observation. Three aneurysms recurred in two patients. At 6 months, one patient presented with a new aneurysm at the femoral artery access site for stent graft introduction and another formed at the proximal margin of the stent graft. Despite medical advice, he had stopped immunotherapy. He died from aneurysm rupture 8 months after stent deployment. Another patient with recurrent aneurysmal disease at the distal margin of the primary stent was successfully treated with an additional stent graft. These two were the only patients who did not adhere to taking immunosuppressant medicine after discharge.

CONCLUSION

Endovascular stent graft placement combined with immunosuppressive treatment for aortic pseudoaneurysms in Behçet disease is a feasible and effective management option. Long-term immunosuppressive therapy after endovascular repair is important to limit pseudoaneurysm recurrence.

Surgical outcomes and risk factors for postoperative complications in patients with Behcet's disease

This study aims to investigate surgical outcomes in patients with Behcet's disease (BD) and to identify risk factors for the occurrence of postoperative complications. The medical records of 37 patients with newly diagnosed BD were reviewed retrospectively. All patients fulfilled the International Study Group criteria for diagnosis of BD and underwent surgeries after diagnosis. Demographic, clinical, and laboratory data at the time when surgeries were performed were collected and surgical modalities, postoperative complications, and postoperative medical treatments were evaluated. Forty-three surgeries were performed in 37 patients. During mean follow-up duration of 78.2 +/- 50.3 months, 14 surgeries (32.6%) were complicated by wound dehiscence, infection, and graft occlusion or failure with the mean lag time of 6.0 +/- 4.6 months from surgeries. Cumulative incidence of postoperative complications was 7.7% at 3 months, 25.6% at 6 months, 33.3% at 12 months, and 35.9% at 18 months. Postoperative complications occurred more frequently after surgeries that were performed in patients with positive pathergy test (P < 0.001) and after vascular surgeries than after nonvascular surgeries (P < 0.05). Moreover, surgeries that were followed by glucocorticoids with immunosuppressive agents showed a significantly lower postoperative complication rate compared to those that were followed by glucocorticoids alone and those that were not followed by medical treatment (P < 0.05). Multivariate analysis showed that a positive pathergic reaction (P < 0.05, hazard ratio = 1.91) at the time of surgery and surgeries that were not followed by treatment with glucocorticoids and immunosuppressive agent (P < 0.01, hazard ratio = 2.11) was an independent risk factor for the occurrence of postoperative complications. Our findings suggest that the occurrence of postoperative complications can be reduced when postsurgical immunosuppressive treatment was implemented and that the pathergy test can be used as screening methods for occurrence of postoperative complications in patients with BD.

Progression of abdominal aortic aneurysm after endovascular stent-grafting in a patient with Behçet's disease: report of a case

A 53-year-old man with Behçet's disease was admitted to our hospital for investigation of back and lower abdominal pain. Computed tomography (CT) showed a projecting saccular aneurysm below the right renal artery. We placed a stent-graft just below the right renal artery, successfully excluding the abdominal aortic aneurysm (AAA). His C-reactive protein level and white blood cell count remained elevated after stent-grafting. About 5 months later, he was readmitted with recurrent back and lower abdominal pain and CT showed progression of the AAA. Thus, we performed straight grafting using a woven Dacron graft just below the right renal artery. The patient had an uneventful postoperative course. We discuss the controversial issue of treating AAA in patients with Behçet's disease, focusing on the indications and timing of surgery.