Outcomes after endovascular treatment of symptomatic patients with Takayasu's arteritis

Clinical Characteristics and Outcomes of Aortic Arch Emergencies: Takayasu Disease, Fibromuscular Dysplasia, and Aortic Arch Pathologies: A Retrospective Study and Review of the Literature

Non-atherosclerotic aortic arch pathologies (NA-AAPs) and anatomical variants are characterized as rare cardiovascular diseases with a low incidence rate, below 1 case per 2000 population, but enormous heterogeneity in terms of anatomical variants, i.e., Takayasu disease (TAK) and fibromuscular dysplasia (FMD). In specific clinical scenarios, NA-AAPs constitute life-threatening disorders.

METHODS

In this study, 82 (1.07%) consecutive patients with NA-AAPs (including 38 TAKs, 26 FMDs, and 18 other AAPs) out of 7645 patients who underwent endovascular treatment (EVT) for the aortic arch and its side-branch diseases at a single institution between 2002 and 2022 were retrospectively reviewed. The recorded demographic, biochemical, diagnostic, operative, and postoperative factors were reviewed, and the functional outcomes were determined during follow-up. A systematic review of the literature was also performed.

RESULTS

The study group comprised 65 (79.3%) female and 17 (21.7%) male subjects with a mean age of 46.1 ± 14.9 years. Overall, 62 (75.6%) patients were diagnosed with either cerebral ischemia symptoms or aortic arch dissection on admission. The EVT was feasible in 59 (72%) patients, whereas 23 (28%) patients were referred for medical treatment. In EVT patients, severe periprocedural complications occurred in two (3.39%) patients, including one periprocedural death and one cerebral hyperperfusion syndrome. During a median follow-up period of 64 months, cardiovascular events occurred in 24 (29.6%) patients (5 deaths, 13 ISs, and 6 myocardial infarctions). Repeated EVT for the index lesion was performed in 21/59 (35.6%) patients, including 19/33 (57.6%) in TAK and 2/13 (15.4%) in FMD. In the AAP group, one patient required additional stent-graft implantation for progressing dissection to the iliac arteries at 12 months. A baseline white blood count (odds ratio [HR]: 1.25, 95% confidence interval [CI]: 1.11-1.39; p < 0.001) was the only independent prognostic factor for recurrent stenosis, while a baseline hemoglobin level (HR: 0.73, 95%CI: 0.59-0.89; p = 0.002) and coronary involvement (HR: 4.11, 95%CI: 1.74-9.71; p = 0.001) were independently associated with a risk of major cardiac and cerebral events according to the multivariate Cox proportional hazards regression analysis.

CONCLUSIONS

This study showed that AAPs should not be neglected in clinical settings, as it can be a life-threatening condition requiring a multidisciplinary approach. The knowledge of prognostic risk factors for adverse outcomes may improve surveillance in this group of patients.

Carotid Restenosis Rate After Stenting for Primary Lesions Versus Restenosis After Endarterectomy With Creation of Risk Index

PURPOSE

Carotid artery stenting (CAS) is an option for carotid restenosis (CR) treatment with favorable outcomes. However, CAS has also emerged as an alternative to carotid endarterectomy (CEA) for the management of patients with primary carotid stenosis. This study aimed to report CR rates after CAS was performed in patients with primary lesions versus restenosis after CEA, to identify predictors of CR, and to report both neurological and overall outcomes.

MATERIALS AND METHODS

From January 2000 to September 2018, a total of 782 patients were divided into 2 groups: The CAS (prim) group consisted of 440 patients in whom CAS was performed for primary lesions, and the CAS (res) group consisted of 342 patients with CAS due to restenosis after CEA. Indications for CAS were symptomatic stenosis/restenosis >70% and asymptomatic stenosis/restenosis >85%. A color duplex scan (CDS) of carotid arteries was performed 6 months after CAS, after 1 year, and annually afterward. Follow-up ranged from 12 to 88 months, with a mean follow-up of 34.6±18.0 months.

RESULTS

There were no differences in terms of CR rate between the patients in the CAS (prim) and CAS (res) groups (8.7% vs 7.2%, χ²=0.691, p=0.406). The overall CR rate was 7.9%, whereas significant CR (>70%) rate needing re-intervention was 5.6%, but there was no difference between patients in the CAS (prim) and CAS (res) groups (6.4% vs 4.7%, p=0.351). Six independent predictors for CR were smoking, associated previous myocardial infarction and angina pectoris, plaque morphology, spasm after CAS, the use of FilterWire or Spider Fx cerebral protection devices, and time after stenting. A carotid restenosis risk index (CRRI) was created based on these predictors and ranged from -7 (minimal risk) to +10 (maximum risk); patients with a score >-4 were at increased risk for CR. There were no differences in terms of neurological and overall morbidity and mortality between the 2 groups.

CONCLUSIONS

There was no difference in CR rate after CAS between the patients with primary stenosis and restenosis after CEA. A CRRI score >-4 is a criterion for identifying high-risk patients for post-CAS CR that should be tested in future randomized trials.

2021 American College of Rheumatology/Vasculitis Foundation Guideline for the Management of Giant Cell Arteritis and Takayasu Arteritis

OBJECTIVE

To provide evidence-based recommendations and expert guidance for the management of giant cell arteritis (GCA) and Takayasu arteritis (TAK) as exemplars of large vessel vasculitis.

METHODS

Clinical questions regarding diagnostic testing, treatment, and management were developed in the population, intervention, comparator, and outcome (PICO) format for GCA and TAK (27 for GCA, 27 for TAK). Systematic literature reviews were conducted for each PICO question. The Grading of Recommendations Assessment, Development and Evaluation methodology was used to rate the quality of the evidence. Recommendations were developed by the Voting Panel, comprising adult and pediatric rheumatologists and patients. Each recommendation required ≥70% consensus among the Voting Panel.

RESULTS

We present 22 recommendations and 2 ungraded position statements for GCA, and 20 recommendations and 1 ungraded position statement for TAK. These recommendations and statements address clinical questions relating to the use of diagnostic testing, including imaging, treatments, and surgical interventions in GCA and TAK. Recommendations for GCA include support for the use of glucocorticoid-sparing immunosuppressive agents and the use of imaging to identify large vessel involvement. Recommendations for TAK include the use of nonglucocorticoid immunosuppressive agents with glucocorticoids as initial therapy. There were only 2 strong recommendations; the remaining recommendations were conditional due to the low quality of evidence available for most PICO questions.

CONCLUSION

These recommendations provide guidance regarding the evaluation and management of patients with GCA and TAK, including diagnostic strategies, use of pharmacologic agents, and surgical interventions.

2021 American College of Rheumatology/Vasculitis Foundation Guideline for the Management of Giant Cell Arteritis and Takayasu Arteritis

OBJECTIVE

To provide evidence-based recommendations and expert guidance for the management of giant cell arteritis (GCA) and Takayasu arteritis (TAK) as exemplars of large vessel vasculitis.

METHODS

Clinical questions regarding diagnostic testing, treatment, and management were developed in the population, intervention, comparator, and outcome (PICO) format for GCA and TAK (27 for GCA, 27 for TAK). Systematic literature reviews were conducted for each PICO question. The Grading of Recommendations Assessment, Development and Evaluation methodology was used to rate the quality of the evidence. Recommendations were developed by the Voting Panel, comprising adult and pediatric rheumatologists and patients. Each recommendation required ≥70% consensus among the Voting Panel.

RESULTS

We present 22 recommendations and 2 ungraded position statements for GCA, and 20 recommendations and 1 ungraded position statement for TAK. These recommendations and statements address clinical questions relating to the use of diagnostic testing, including imaging, treatments, and surgical interventions in GCA and TAK. Recommendations for GCA include support for the use of glucocorticoid-sparing immunosuppressive agents and the use of imaging to identify large vessel involvement. Recommendations for TAK include the use of nonglucocorticoid immunosuppressive agents with glucocorticoids as initial therapy. There were only 2 strong recommendations; the remaining recommendations were conditional due to the low quality of evidence available for most PICO questions.

CONCLUSION

These recommendations provide guidance regarding the evaluation and management of patients with GCA and TAK, including diagnostic strategies, use of pharmacologic agents, and surgical interventions.

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.

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.

Factors Associated with Increased Risk of Unplanned Hospital Readmission after Endovascular Aortoiliac Interventions

Objectives   Readmissions to hospital after surgical procedures are considered as reflective of poor quality of healthcare provided during the index hospitalization and are associated with increased costs of healthcare. Aortoiliac occlusive disease represents an aggressive form of atherosclerotic disease and has been traditionally treated with open surgical bypasses. Endovascular interventions for aortoiliac occlusive disease are associated with comparable outcomes to open surgical procedures. The purpose of this study is to review the factors associated with hospital readmission after aortoiliac endovascular interventions. Methods The 2015 procedure targeted American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database and general and vascular surgery NSQIP participant user file (PUF) were used for this analysis. Patient, diagnosis and procedure characteristics of patients undergoing aortoiliac endovascular interventions were reviewed. Bivariate analysis was used to identify the relationship between the independent variables and 30-day readmission. The significant variables from the bivariate analysis were used to generate a multivariable logistic regression model. The predicted probability of readmission was calculated. Results Out of 823 patients, 86 were readmitted. Readmission was related to the principal procedure in 48 (73.9%) patients. A total of 61 (7%) patients underwent an unplanned operation within 30 days after the index procedure. A multivariable logistic regression model identified the following variables to be significantly associated with 30-day risk of readmission: the use of pre-procedural beta blocker (OR = 2.06, 95% CI = 1.23 - 3.45, P < 0.01), external/internal iliac intervention (OR = 1.95, 95% CI = 1.18 - 3.20, P <0.01), critical limb ischemia (OR = 1.80, 95% CI = 1.10 - 2.94, P <0.05), and unplanned return to the operating room (OR = 11.65, 95% CI = 6.35 - 21.35, P <0.01). The predicted probability of readmission was as follows: 5.5% for critical limb ischemia, 5.9% for external iliac artery angioplasty/stenting, 6.2% for preoperative beta blockers, 17.7% for patients with cardiac arrest, 27% for unplanned return to the operating room, and 94.7% for patients with all of these risk factors. Conclusion Readmissions after endovascular interventions for severe atherosclerotic disease can be used as a quality metric. Several factors place a patient at a high risk for readmission. Unplanned return to the operating room, cardiac arrest, preoperative beta blockers, location of disease, and preoperative symptoms are independent risk factors for hospital readmission. Unplanned return to the operating room is associated with 11.65-fold increase in the risk of hospital readmission.

The "Eternal Recurrence" of Arteritis. Suggesting Autoimmunity Underlining Friedrich Nietzsche's Challenging Clinical Case

Friedrich Wilhelm Nietzsche (Röcken 1844 -Weimar 1900), the philosopher who theorized the concept of "eternal recurrence", suffered a lifelong multifaceted chronic illness that started in pediatric age with severe headaches and ended up with stroke at the age of 56. Even though many hypothetical diagnosis have been proposed in recent years, they all failed to explain the totality of clinical conditions that co-occurred in the philosopher's extremely challenging case, and debate on the matter is still open. In this report, we suggest an autoimmune condition, specifically Takayasu's arteritis, as a possible etiology of the philosopher's illness, which could not only potentially fit all available clinical data but also be the medical counterpart of Nietzsche's philosophical thought: could eternal recurrence of arteritis explain Zarathustra's destiny? If so, could a vascular surgeon, at this time in future, be so superhuman to change it?

Open and Endovascular Management of Severe Cerebral Ischemia in Takayasu's Arteritis

BACKGROUND

Severe cerebral ischemia in patients with Takayasu's arteries was caused by occlusion of most supra-aortic arteries. Arterial revascularization is necessary to decrease the incidence of stroke and improve the quality of life but may be complicated with multiple occlusive lesions and inflammation condition of this disease. This study was to assess options and long-term outcomes of surgical and endovascular treatment.

METHODS

Twenty-nine patients with severe cerebral ischemic symptoms underwent surgical or endovascular treatment from January 1991 to July 2015. Demographic characteristics, surgical and endovascular procedures, and follow-up outcomes were reviewed. Risk factors associated with primary patency of surgical treatment and assisted primary patency of endovascular treatment was identified by Cox regression analyses.

RESULTS

There were 29 patients with a median age of 24 (range 9-37 years), 9 in active and 20 in inactive phase. Seventeen patients underwent a variety of bypass procedures. Fourteen endovascular procedures were performed in 12 patients. No death occurred within 30 days after both procedures. Complications within 30 days after bypass included stroke in 1 patient, infection in 2 patients, and heart failure in 1 patient. Nine patients developed brain hyperperfusion after bypass. Transient hemiplegic paralysis occurred in 1 patient during dilation of the carotid artery. During a median follow-up time of 41 months, primary and secondary patency rate of bypass at 1 and 3 years was 93.75% and 100% and 87.5% and 100%, respectively. Assisted primary and secondary patency rate of endovascular treatment at 1 and 3 years was 85.71% and 92.86% and 68.18% and 75.66%, respectively. There was no independent risk factor associated with either primary patency of surgical treatment or assisted primary patency of endovascular treatment. Disease activity was independent risk factor associated with combined rate of primary patency of surgical treatment and assisted primary patency of endovascular treatment (HR: 0.17, 95% CI: 0.03-0.93, P = 0.04).

CONCLUSIONS

Bypass is the preferred treatment in majority of patients with good long-term patency, even has a higher propensity for postoperative complications. Endovascular treatment should be preserved for short lesions in inappropriate or high-risk surgical patients but needs more reintervention and close monitoring of lesion for better outcomes. Long-term patency of surgical and endovascular treatment is related with disease activity. Combination of surgical or endovascular treatment and medical therapy may improve the efficacy of interventions.

Outcomes of different treatments on Takayasu's arteritis

BACKGROUND

Takayasu's arteritis (TA) is a nonspecific chronic inflammation of the aorta and its branches. This study compared the outcomes of surgical treatments including bypass surgery, cutting balloon angioplasty and conventional balloon angioplasty to TA patients exhibiting supra-aortic arterial (SAA).

METHODS

This retrospective study was conducted on 42 TA patients, obtained from hospital database, who underwent surgical therapy due to SAA lesions from January 2010 to March 2015. Ten patients were reconstructed using cutting balloon angioplasty, 16 patients received conventional balloon angioplasty and 16 patients from bypass surgery. The primary patency, recurrent symptoms, re-intervention, early (<30 days) and late complications associated with treatment were evaluated.

RESULTS

In the conventional balloon angioplasty group, two patients were converted to bypass surgery as the guidewire could not traverse the lesions. The follow-up at 30.07±17.96 months (range, 1-60 months) showed restenosis or occlusion development in 40.9% arteries in conventional balloon angioplasty, compared with 6.3% after bypass surgery (P=0.018). The restenosis or occlusion rate between cutting balloon angioplasty and conventional balloon angioplasty groups were insignificant (P=0.738). In the re-intervention, three out of four (75%) treated by cutting balloon angioplasty were patent as compared to the three out of nine arteries (33.3%) dealt with by conventional angioplasty that was patent (P=0.266). Intracerebral hemorrhage (n=1) was developed in the bypass surgery group. Mortality was not observed in any of the groups.

CONCLUSIONS

Cutting balloon angioplasty can be considered as a safe, effective, and less-invasive alternative for non-diffuse SAA lesions, especially in young TA patients. However, bypass surgery has better primary patency rate than endovascular treatment.

Diagnosis and assessment of disease activity in takayasu arteritis: a childhood case illustrating the challenge

Takayasu Arteritis (TA) is a rare, debilitating large vessel vasculitis occurring in patients of all ages, including infants, but the disease most commonly presents in the third decade. Diagnosis is often delayed and consequently TA is associated with significant morbidity and mortality. Accurate methods of monitoring disease activity or damage are lacking and currently rely on a combination of clinical features, blood inflammatory markers, and imaging modalities. In this report we describe a case of a 14-year-old boy with childhood-onset TA who, despite extensive negative investigations, did indeed have on-going active large vessel vasculitis with fatal outcome. Postmortem analysis demonstrated more extensive and active disease than originally identified. This report illustrates and discusses the limitations of current modalities for the detection and monitoring of disease activity and damage in large vessel vasculitis. Clinicians must be aware of these limitations and challenges if we are to strive for better outcomes in TA.

Reocclusion and stroke due to immediate plaque protrusion following endovascular treatment of carotid artery successfully treated with intra-arterial urokinase and stent in stent in a patient with Takayasu arteritis with severe disease of all arch vessels

Endovascular treatment is becoming a safe and efficacious modality in the management of carotid artery stenosis in Takayasu arteritis (TA). A 24-year-old woman of TA presented with blurred vision, recurrent syncope and upper limb claudication. Angiography revealed right CCA 95 %, left CCA 90 % stenosis and occlusion of other arch vessels. She underwent right CCA angioplasty and stenting. She developed left-sided hemi paresis. Check angiogram revealed plaque protrusion in the proximal part of the stented segment. Intra-arterial urokinase bolus was given and overlapping stenting done. Re-occlusion by plaque protrusion immediately after stenting like in our case is not reported.

Outpatient (Same-day care) Neuroangiography and Neurointervention

Purpose

There have been few reports regarding same-day discharge following uncomplicated procedures such as cerebral angiography and neurointervention. We present same-day experience with cerebral angiography and neurointervention during the past three years.

Materials and Methods

Four hundred and fifty-three patients underwent cerebral angiography or neurointervention at Asan Medical Center between January 2009 and December 2011. Of these patients, 249 (55%) underwent diagnostic catheter cerebral angiography and 204 patients (45%) underwent neurointerventional procedures as same-day procedures. We analyzed any complications, the modified patient-care process, the yearly trend in patient increases, disease categories, and the additional duration of admission for these procedures.

Results

The number of overall patients increased by an average of 51% annually. The disease categories included aneurysm (51%), atherosclerosis (11%) and arteriovenous malformation (10%), etc. for which the patient underwent angiography, and aneurysm (42%), venous malformation (28%), and arteriovenous malformation (17%), etc. for which patients underwent neurointervention. Same-day care patients were admitted to the intermediary care unit in the angiosuite. Neurointervention patients were sent to the neurology intensive unit after the procedure. The same-day care patients stayed in angiosuite for six hours following the transfemoral procedure. The mean admission duration for neurointervention was 2.4 days. There were no reported complications for the same-day care procedures.

Conclusion

Our study revealed an increasing tendency toward same-day care for patients who require angiography and neurointervention. Further studies will be required to better define the cost-minimization effects of outpatient practice as well as the patient perception of this fast-tracking method. We propose that outpatient angiography and neurointervention will undoubtedly continue to increase over the next decade.