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

Recommendations for the management of the vascular involvement in Behçet's disease by the Japanese National Research Committee for Behçet's disease-secondary publication

OBJECTIVES

This study aimed to develop clinical guidelines for the management of vascular Behçet's disease (BD) by the Behçet's Disease Research Committee of the Ministry of Health, Labour and Welfare of the Japanese Government.

METHODS

A task force proposed clinical questions (CQs) concerning vascular BD based on a literature search. After screening, draft recommendations were developed for each CQ and brushed up in three blinded Delphi rounds, leading to the final recommendations.

RESULTS

This study provides recommendations for 17 CQs concerning diagnosis and differential diagnoses, assessment of disease activity, and treatment. The guidelines recommend immunosuppressive treatments, for both arterial and venous involvement with active inflammation. Anticoagulation is also recommended for deep vein thrombosis except in high-risk patients. Surgical and endovascular therapies can be optional, particularly in patients with urgent arterial lesions undergoing immunosuppression. In addition, two sets of algorithms for diagnosis and treatment are shown for arterial and venous involvement.

CONCLUSIONS

These recommendations are expected to serve as useful tools in the daily clinical practice of BD. This content has already been published in Japanese in the Guideline for the Management of Behçet's Disease 2020 and is submitted with permission from both the primary and secondary publishers.

Aortic sinus aneurysm invading ventricular septum and dissection caused by Behcet's disease: a case report and literature review

Few case reports have mentioned the aortic sinus aneurysm invading ventricular septum and dissection caused by Behcet's disease. Here, we reported a 36-year-old male patient with an aortic sinus aneurysm invading the ventricular septum and dissection caused by Behcet's disease, who manifested as recurrent chest tightness and shortness of breath. Cardiac ultrasound showed the rupture of the right aortic sinus and the formation of ventricular septal dissection. Ascending aortic valve prosthesis replacement, mitral valvuloplasty with ring implantation and tricuspid valvuloplasty were performed. Postoperatively, he was treated with hormones, hydroxychloroquine sulfate, mycophenolate mofetil tablets, thalidomide and warfarin, and his symptoms were relieved. This is a rare case easily being misdiagnosed and missed, early diagnosis and in-time treatment are crucial to avoid surgical complications. The diagnostic and therapeutic approaches of this patient were reported and related literature was reviewed in this case report.

Long Term Outcomes and Potential Risk Factors for Endovascular Repair of Aortic Pseudoaneurysms in Vascular Behçet's Disease

OBJECTIVE

This study aimed to analyse long term outcomes and risk factors for endovascular repair of aortic pseudoaneurysms in patients with vascular Behçet's disease (BD).

METHODS

Medical records of 26 aortic vascular BD patients who underwent endovascular treatment at the vascular department of Peking Union Medical College Hospital between January 2002 and December 2021 were reviewed retrospectively. Erythrocyte sedimentation rate (ESR) and C reactive protein were used to assess BD activity. Computed tomography angiography (CTA) was obtained pre- and post-operatively for almost all patients. Univariable logistic regression analysis was used to analyse risk factors for endovascular repair, such as inflammatory indicators, drug usage, and stent graft parameters.

RESULTS

The abdominal aorta (n = 17) was the most common site of 27 vascular BD pseudoaneurysms in this study. CTA also revealed one aortic arch pseudoaneurysm, seven descending thoracic aortic pseudoaneurysms, one thoraco-abdominal aortic pseudoaneurysm, and one pseudoaneurysm at the aortic bifurcation. Most of the pseudoaneurysms were treated with covered stent grafts. The technical success rate was 96% and no deaths occurred during hospital stay. The mean follow up was 5.8 ± 5.5 years and 31% (8/26) experienced post-operative complications. Overall one, three, and five year event free survival rates were 87%, 78%, and 74%, respectively. Univariable logistic regression analysis revealed that pre-operative ESR ≥ 16.0 mm/h (p = .040), pre-operative glucocorticoid (GC) use ≤ 11.5 days (p = .024), pre-operative immunosuppressant use ≤ 15.5 days (p = .028), and length of proximal landing zone ≤ 1.95 cm (p = .034) were associated with a worse prognoses following endovascular treatment. Proximal oversize ≥ 9.5% (p = .074) was also regarded as a risk factor, although not statistically significant.

CONCLUSION

This study further confirmed the feasibility of endovascular repair for aortic vascular BD patients. Risk factors predicting poor prognoses included elevated pre-operative ESR, insufficient pre-operative GC use or immunosuppressant use, inadequate proximal landing zone, and larger proximal oversize percentage.

Early and Midterm Outcomes of Endovascular Treatment in Arterial Manifestations of Vascular Behcet Disease

BACKGROUND

Behcet's disease (BD), originally described by Hulusi Behcet in 1937, is a chronic relapsing inflammatory process of an immunologic syndrome and the involvement of the vascular system is called Vasculo-Behcet disease (VBD). This is a retrospective study evaluating 21 patients diagnosed with VBD who underwent endovascular treatment.

METHODS

This single-center study was conducted between January 2016 and January 2022. Early and mid-term endovascular outcomes of a total of 21 patients (16 males, 5 females with a median age of 42 years; range, 31 to 46 years), with a diagnosis of VBD, who underwent endovascular arterial repair in our hospital, were retrospectively analyzed. Follow-ups were scheduled for the first and sixth postoperative months and every 6 months thereafter. For symptomatic patients, imaging studies and additional interventions were planned. The primary outcomes were a procedural success and a requirement for reintervention. Secondary outcomes were complications and all causes of mortality.

RESULTS

Twenty-one patients underwent endovascular repair. In this study, 1 balloon-expandable stent for brachial artery aneurysm (4,8%), 1 viabahn graft for femoral artery aneurysm (4,8%), 2 tube endograft for ruptured iliac artery aneurysm (9,5%), 1 tube endograft (Thoracic endovascular aortic repair [TEVAR]) insertion at the aortic bifurcation for infrarenal abdominal aortic occlusion (4,8%), 1 chimney-TEVAR for saccular arcus thoracic aortic aneurysm (TAA) (4,8%) and 7 TEVAR for saccular TAA (33,3%), 1 EVAR for an intact and symptomatic infrarenal abdominal aortic aneurysm (AAA) (4,8%), 1 EVAR (aorto-uniiliac) for ruptured iliac artery aneurysm (4,8%), and 6 EVAR for ruptured AAA (28,5%) were deployed. The technical success rate was 100% with a mean follow-up period of 50. 4 ± 10.7 months (8-66 months). The mean aneurysm diameter was 10,7 ± 53 mm. In the follow-up period, 3 patients presented with a hematoma at the insertion site of the sheath (14.3%). There were no early mortalities. Three patients required reintervention (14,3%); 1 of these underwent open surgical repair due to a pseudoaneurysm of the access site (4,8%). The Kaplan-Meier analysis revealed freedom from reintervention rate as 94,1 ± 5,7% at 1 year, 85,6 ± 9,7% at 3 years, and 68,4 ± 17,1% at 5 years.

CONCLUSIONS

Awareness of the BD especially for vascular involvements in young ages is lifesaving. Endovascular therapy with proper medical treatment seems to be the treatment of choice according to the early and midterm successful results with low morbidity and mortality.

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.

Endovascular treatment in Behçet’s disease: an integrative review

Abstract Behçet’s Disease (BD) is a rare, chronic, relapsing, inflammatory, and multisystemic disease. There is no universally described test for confirming diagnosis, so it is made clinically, on the basis of its classic triad of signs: oral ulcers, genital ulcers, and uveitis (inflammation of the uveal tract of the eye). The aim of this study is to evaluate the importance of endovascular treatment in Behçet’s disease. The literature review conducted to achieve this objective covered 30 articles published between 2002 and 2021. Behçet’s Disease affects both the venous and arterial systems. Rupture of aneurysms is the main cause of death and thus requires treatment, which can be clinical, open surgical, or endovascular. Endovascular surgery has been gaining ground for surgical treatment of arterial aneurysms, including those related to BD, although the therapy of choice is still controversial.

Tratamento endovascular na doença de Behçet: uma revisão integrativa

Resumo A doença de Behçet (DB) é caracterizada por ser uma doença rara, crônica, recidivante, inflamatória e multissistêmica. Quanto ao diagnóstico, não existe nenhum teste universalmente descrito; logo, ele é feito de maneira clínica, por meio da presença da sua tríade clássica de sinais: úlceras orais, úlceras genitais e uveíte (inflamação do trato uveal do olho). O objetivo deste estudo foi avaliar a importância do tratamento endovascular na doença de Behçet, sendo que a revisão de literatura para obter essa resposta foi realizada a partir de 30 artigos publicados entre 2002 e 2021. A DB acomete tanto o sistema venoso quanto o arterial. A ruptura de aneurismas é a principal causa de morte e necessita de tratamento, podendo ser clínico, cirúrgico aberto ou por via endovascular. A cirurgia endovascular vem ganhando espaço no tratamento cirúrgico nos casos de aneurismas arteriais, inclusive nos relacionados com DB, apesar de a terapia de escolha ainda ser controversa.

Subclavian artery pseudoaneurysm in vascular Behcet's disease repaired using endovascular treatment: A case report of the clinical course over 10 years

The vascular involvement in patients with Behcet's disease is defined as vascular Behcet's disease, which can greatly influence the prognosis. However, there are few reports on endovascular treatment (EVT) for subclavian pseudoaneurysms with long-term prognosis over 10 years. We present the case of a 42-year-old man with left subclavian artery pseudoaneurysm due to vascular Behcet's disease who was treated with EVT along with immunosuppressive therapies. Subsequently, 8 years after, the aneurysm recurred in the stent with stent fracture. Therefore, additional EVT was performed. We present the details of the patient's clinical course over 10 years after the EVT. <Learning objective: Vascular Behcet's disease can greatly influence the prognosis. Therefore, understanding its treatment and management is important. There are few reports on endovascular treatment (EVT) for subclavian pseudoaneurysms with long-term prognosis over 10 years. Long-term management and recurrence monitoring are required for vascular Behcet's disease even after EVT.>.

Behcet's disease and multiple arterial aneurysms: 4 case reports

Behcet's disease (BD) is a vasculitis of unknown origin. BD is rare in Western countries and the southern hemisphere and is mainly seen in countries along the Silk Road such as the Middle East and Mediterranean regions including Iran. We report four interesting cases of BD with multiple aneurysms three of which had subclavian aneurysms. We chose different surgical approaches for each of these patients due to the different presentations and unique circumstances of each case. Endovascular stent graft used for patients and we discussed open vs. endovascular treatment for BD aneurysms in the discussion.

[Unusual complication of Behcet's disease]

Arterial involvement in Behcet's disease is rare and the tibioperoneal trunk localisation is exceptional. We report the case of a young men with Behcet's disease and in whom the evolution to angiobehcet was unusual. The medical treatment and the therapeutic abstention were decided according to a bundle of argument.

Hepatic artery aneurysm: A case report of a novel approach to an age old problem

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Visceral artery aneurysms are a relatively uncommon but potentially devastating pathology.

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Endovascular therapy offers a treatment alternative to open surgery in visceral aneurysm rupture.

Introduction

Visceral artery aneurysms are a relatively uncommon but potentially devastating pathology. The most common site is the splenic artery followed by the hepatic (Stanley et al., 1986) [1]. In the event of rupture, mortality has been estimated at anywhere between 20% and 100% (Schweigert et al., 2011) [2]. Emergency surgery in such a scenario has previously been dependent on an open approach with high morbidity and mortality associated (Schweigert et al., 2011) [2]. The advent of endovascular techniques may improve both short and long term outcomes as highlighted in this case.

Presentation of case

We present the case of a ruptured common hepatic artery aneurysm presenting with acute abdominal pain and haemodynamic instability. Minimally invasive surgery in the form of endovascular repair via two covered stents from the coeliac trunk in to the splenic artery (excluding flow in to the common hepatic artery aneurysm) allowed for immediate management without the significant morbidity and mortality with which open surgery is associated.

Discussion

This resulted in resolution of acute haemorrhage while liver perfusion was maintained via the portal vein and arterial collaterals. Follow-up highlighted both short and medium term success.

Conclusion

This case highlights that endovascular management in the case of visceral artery aneurysm rupture is a viable option while also portraying several important anatomic considerations essential to hepatic perfusion.

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.

Isolated brachial artery aneurysm successfully treated with a covered stent in a patient with Behçet's disease

Behçet's disease is a vasculitic pathology characterized by skin lesions, genital ulcers, aphthous stomatitis, and uveitis. Arterial aneurysms are rare in this disease. Herein, we report a rare case of an isolated brachial artery aneurysm with a history of Behçet's disease treated with endovascular covered stenting of the brachial artery.

Prophylactic prosthetic wrapping for vascular anastomosis in patients with Behçet's aortic aneurysms: an experience from a resource-challenged setting

BACKGROUND

The objectives of the current study were to evaluate our technical and clinical results of surgical treatment of infrarenal Behçet's abdominal aortic aneurysm (AAA). In addition to the prosthetic wrapping of the constructed anastomosis as a prophylactic measure for patients with vasculo-Behçet's disease, together with the administration of per- and postoperative immunosuppressive therapy.

METHODS

A single-center retrospective case series included 16 patients with vasculo-Behçet's AAA who treated with open surgical repair, between January 2005 and December 2013. The administration of immunosuppressive treatment was done preoperatively to achieve complete remission of the disease activity before starting the surgical repair. Patients' data were retrieved and analyzed emphasizing the diagnostic procedures, the used surgical techniques, and suitable graft selection, as well as, graft-related complications. The patients were followed up for one month to a maximum of 72 months. The median follow-up period was 24.83±9.4 months.

RESULTS

This study included 16 patients, 10 (63%) males, and 6 (37%) females, with the median age of (30.50 years, range: 21-37 years). Moreover, all patients were anticoagulated and discharged on warfarin and aspirin therapy. All surgical procedures were done on an elective basis except for only one emergency laparotomy, which was performed for a life-threatening ruptured aneurysm. The vascular anastomoses were performed using either interposition tube graft (for isolated AAA), or Y-shaped graft (for concomitant aorto-iliac aneurysms). Furthermore, prophylactic prosthetic wrapping was applied encircling the graft to the host artery. In addition, all patients received systemic immunosuppressive therapy post-surgical intervention to prevent anastomotic site complications. Technical success was obtained in 100% of cases. Moreover, the patients were followed up for a period of 12-72 months. Two anastomotic pseudoaneurysms were developed postoperatively. More interesting is that both were infected (one low-virulent that was conservatively treated and one overt that was surgically repaired). Furthermore, there was no aneurysm-related mortality.

CONCLUSIONS

Prophylactic prosthetic wrapping of vascular anastomosis in patients with Behçet's AAA in resource-challenged settings, where the proximal anastomoses were all end-to-end with wrapping, is an affordable, simple, reliable, and feasible technique, and commonly associated with a lower incidence of anastomotic site false aneurysms and different complications related to the implanted graft, where endovascular procedures might not be applicable. Moreover, the proper preoperative medical preparation for controlling the activity of Behçet's disease, with the administration of immunosuppressive agents, followed by immediate postoperative therapy, may have a good impact on the operative technical success and the prevention of the development of serious postoperative complications; especially anastomotic pseudoaneurysms (which may be complicated by fatal hemorrhage), as well as other graft-related complications.

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.

Incomplete intestinal obstruction as the possible main complaint in Behcet's disease after surgery for recurrent abdominal aortic pseudoaneurysms: a case report and literature review

Background

Behcet’s disease (BD) is a systemic vasculitis characterized by oral and genital aphthosis, and ocular and skin lesions. The disease is involved in vascular, gastrointestinal, and central nervous systems. Vasculitis may exacerbate fatal problems, such as anastomotic pseudoaneurysms. If the mesenteric vessels are involved, severe abdominal symptoms such as intestinal obstruction may occur.

Case presentation

This case report describes a young female patient who suffered from BD with recurrent abdominal aortic pseudoaneurysms, as well as deep venous thrombosis and subsequent complications of incomplete intestinal obstruction. This patient first underwent stent grafting, which was followed by rupture of two newly formed anastomotic pseudoaneurysms within six months. Emergency open surgical repair (OSR) was then performed on the ruptured pseudoaneurysms. Thrombosis and incomplete ileus occurred five months after surgery. This case was unique due to the presence of incomplete intestinal obstruction being the possible main complaint for a patient with Behcet’s disease, and it is the first ever case to be reported.

Conclusion

Intestinal obstruction may present as the possible main complaint in BD. Careful and attentive strategy should be carried out to prevent fatal outcomes.

Pulmonary vasculitis: diagnosis and endovascular therapy

Pulmonary vasculitides are caused by a heterogeneous group of diseases with different clinical features and etiologies. Radiologic manifestations depend on the predominant type of vessel involved, which are grouped into large, medium, or small-sized vessels. Diagnosing pulmonary vasculitides is a challenging task, and radiologists play an important role in their management by providing supportive evidence for diagnosis and opportunities for minimally invasive therapy. This paper aims to present a practical approach for understanding the vasculitides that can affect the pulmonary vessels and lungs. We will describe and illustrate the main radiologic findings, discussing opportunities for minimally invasive treatment.

Multiple Recurrent Pseudoaneurysms after Endovascular Repair of Abdominal Aortic Aneurysm in a Patient with Behçet's Disease

In Behçet’s disease (BD) patients, endovascular repair is a reasonable alternative treatment for aortic aneurysms to avoid postoperative anastomotic pseudoaneurysms. However, there are some complications that may occur after endovascular repair. We herein report the case of a 40-year-old man with active BD developed recurrent aortic pseudoaneurysms at the proximal and distal margins of the stent graft and a femoral puncture site pseudoaneurysm 3 months after endovascular abdominal aortic aneurysm (AAA) repair. The aortic pseudoaneurysms were treated endovascularly, including the use of the chimney technique for the proximal pseudoaneurysm close to the renal arteries and the femoral pseudoaneurysm with surgical excision and reconstruction. Intensive immunosuppressive therapy was initiated immediately after the operation. The patient is in good condition without any complications at 8-month follow-up. This case suggests the utility of the chimney technique and postoperative immediate intensive immunosuppressive therapy in treating recurrent aortic pseudoaneurysms in emergency, active BD patients.

What Is Vascular Behçet's Disease?

Vascular Behçet's disease (BD) would keep risk of anastomotic pseudoaneurysm due to deterioration of the disease even after vascular surgery was successfully done. Therefore, it is one of the least-welcome diseases for vascular surgeons. There still exist several points on a concept and criteria of the vascular BD which not only general practitioners but also the vascular surgeons do not understand. Clinical findings strongly suspecting vascular BD are follows; saccular aneurysms without atherosclerosis developed in younger than 50-year-old patients, superior vena cava syndrome or deep vein thrombosis in bilateral legs without apparent causes, and multiple superficial thrombophlebitis, etc. It is very difficult to make a diagnosis of BD in the patients whose onset of the disease is a vascular lesion, because vascular BD combines few ocular lesions. In such case, it is very important to find out not only oral and genital ulceration, but also past history of arthritis. To establish the vascular BD, we vascular surgeons have to collect cases of the vascular BD and to revise criteria of the disease. (This is a translation of Jpn J Vasc Surg 2017; 26: 19-23.).

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.

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.

[Peripheral arterial pseudo-aneurysm in Behçet's disease: Report of two cases]

Behçet's disease is a systemic vasculitis of unknown etiopathogenesis. Arterial events such as pseudo-aneurysms are rare and may be the mode of occurrence of the disease. These pseudo-aneurysms tend, regardless of size, to progress rapidly to life-threatening rupture. We report two cases of arterial pseudo-aneurysms that ruptured. Treatment consisted of surgical repair in one case and arterial ligation in the other; the postoperative course was uneventful in both cases.

Outcomes of vascular intervention and use of perioperative medications for nonpulmonary aneurysms in Behçet disease

BACKGROUND

Aneurysms attributable to Behçet disease (BD) are not common but are associated with a poor prognosis because of a high risk of rupture. Special considerations are required for vascular intervention, because the intense local inflammation may increase complications. The aim of this study was to assess the outcome of operative intervention and the use of perioperative medical therapy for aneurysms in patients with BD.

MATERIALS AND METHODS

We reviewed retrospectively the medical records of patients with BD admitted to Peking Union Medical College Hospital between January 1995 and January 2015.

RESULTS

Among 874 patients diagnosed with BD, 176 patients had vascular involvement, of whom 59 had arterial aneurysms. Thirty-six patients with 51 arterial aneurysms underwent operative intervention. The 51 primary operative interventions included 20 open operations and 31 endovascular interventions. Eleven (22 %) recurrent aneurysms developed in 10 patients and 5 (10%) thrombosis occurred in 5 patients. Of the 19 endovascular stents placed for aortic aneurysms, 1 type I endoleak, 1 graft occlusion, 3 recurrent aneurysms, and 1 recurrent aneurysmal rupture occurred. Among the revascularization procedures for extremity arteries, there were more complications with endovascular intervention than with open surgery. The cumulative risk of recurrent aneurysmal formation at the operative site was significantly less in patients treated with operative intervention combined with use of immunosuppressants than those treated with operative intervention alone (P = .01).

CONCLUSION

In patients with BD, an endovascular approach is feasible and effective for aortic aneurysms, whereas bypass surgery appears to provide better outcomes for extremity arterial aneurysms than placement of endovascular stents. The administration of corticosteroids combined with cyclophosphamide perioperatively decreases the cumulative risk of recurrent aneurysm.

Correção endovascular de pseudoaneurisma toracoabdominal em paciente com Doença de Behçet

Resumo A Doença de Behçet é uma doença inflamatória caracterizada por úlceras genitais e orais recorrentes, uveítes e lesões cutâneas. O envolvimento arterial é raro, sendo mais comuns as degenerações aneurismáticas do que as oclusivas. Neste caso clínico, paciente do sexo feminino, em tratamento de doença de Behçet havia 20 anos, iniciou com dor abdominal progressiva por dois meses, com piora súbita importante, foi submetida à tomografia computadorizada, que mostrou pseudoaneurisma toracoabdominal. A paciente foi submetida a tratamento endovascular com sucesso.

Durability of aneurysm treatments in patients with active Behcet's disease

OBJECTIVE

Aneurysms in Behcet's disease are rare, serious, and recurrent. To achieve durable treatment, patients should receive immunosuppressive therapy before intervention to induce remission. We present early and long-term results of emergency cases of active Behcet's disease, which did not permit waiting for suppressive treatment.

PATIENTS AND METHODS

The study was undertaken on all cases admitted to the vascular unit, King Fahd Hospital of University for aneurysm treatment in patients with active Behcet's disease over about 10 years. All patients had exclusion of the aneurysm either by open surgery or endovascular intervention. Morbidities and mortality were recorded within the hospital admission and on the follow-up.

RESULTS

During the study period, three cases were included. All interventions were successful and lifesaving. However, two cases, treated with surgical interposition grafts, were blocked in the intermediate term follow-up (2-12 months) and one case, treated with endovascular treatment, complicated with pseudoaneurysm at femoral puncture site after six months.

CONCLUSION

Although early results were good, intermediate ones were not satisfactory because of progressive graft thrombosis and formation of new aneurysms. Awareness of these rare cases help for early identification and proper immunosuppressive before emergency vascular intervention is warranted.

Successfully treated isolated renal artery pseudoaneurysm in a patient with Behçet's disease

Renal artery aneurysms and pseudoaneurysms are an uncommon clinical problem with a low incidence rate. They are abnormal dilatations of the vessel lumen with some different natures. However, the rupture of an aneurysm and pseudoaneurysm is the most dreaded complication because it causes death of the patient. There are many causes of renal artery aneurysm and pseudoaneurysm, including Behçet's disease; however, renal involvement in Behçet's disease is less frequent. We report a case of renal artery pseudoaneurysm induced by Behçet's disease and treated successfully with coil embolization. A 56-year-old woman with Behçet's disease presented with an incidental left renal artery pseudoaneurysm measuring 18 mm. We successfully performed endovascular treatment with coil embolization instead of surgical treatment.

Urgent Surgical Management of Deep Femoral Artery Aneurysm in a Patient with Pre-Vasculo-Behcet Status

We report a case of deep femoral artery (DFA) aneurysm associated with pre-vasculo-Behcet status. A 34-year-old man with a history of recurring oral and genital ulcers was admitted complaining of worsening left thigh pain over the previous 30 days. Computed tomography showed a left DFA aneurysm (60 mm × 70 mm), concomitant aneurysms in the popliteal and carotid arteries, and deep vein thrombosis. Active pre-vasculo-Behcet status was diagnosed, and DFA ligation was performed urgently. Remission was achieved with postoperative prednisolone and colchicine without vascular complications. DFA aneurysm and vascular pathologies were successfully managed by ligation surgery and medical therapy.

Gastrointestinal Behçet's disease: A review

Behçet’s disease (BD) is an idiopathic, chronic, relapsing, multi-systemic vasculitis characterized by recurrent oral and genital aphthous ulcers, ocular disease and skin lesions. Prevalence of BD is highest in countries along the ancient silk road from the Mediterranean basin to East Asia. By comparison, the prevalence in North American and Northern European countries is low. Gastrointestinal manifestations of Behçet’s disease are of particular importance as they are associated with significant morbidity and mortality. Although ileocecal involvement is most commonly described, BD may involve any segment of the intestinal tract as well as the various organs within the gastrointestinal system. Diagnosis is based on clinical criteria - there are no pathognomonic laboratory tests. Methods for monitoring disease activity on therapy are available but imperfect. Evidence-based treatment strategies are lacking. Different classes of medications have been successfully used for the treatment of intestinal BD which include 5-aminosalicylic acid, corticosteroids, immunomodulators, and anti-tumor necrosis factor alpha monoclonal antibody therapy. Like inflammatory bowel disease, surgery is reserved for those who are resistant to medical therapy. A subset of patients have a poor disease course. Accurate methods to detect these patients and the optimal strategy for their treatment are not known at this time.

Transcatheter Arterial Coil Embolization of Ruptured Common Hepatic Artery Aneurysm in a Patient with Behçet's Disease

Hepatic artery aneurysm is a rare and potentially life-threatening entity. We report a case of ruptured common hepatic artery aneurysm in a patient with Behçet's disease. The ruptured aneurysm was treated successfully with transcatheter arterial coil embolization. Transcatheter arterial embolization is the preferred treatment modality in patients at high risk of surgical intervention.

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.

Outcome measures used in clinical trials for Behçet syndrome: a systematic review

Behçet syndrome (BS) is a multisystem vasculitis that is most active during young adulthood, causing serious disability and significant impairment in quality of life. Differences in the disease course, severity, and organ involvement between patients, depending on the age at presentation and sex, makes it impossible to determine a single management strategy. The diversity and variability in the outcome measures used in clinical trials in BS makes it difficult to compare the results or inform physicians about the best management strategy for individual patients. There is a large unmet need to determine or develop validated outcome measures for use in clinical trials in BS that are acceptable to researchers and regulatory agencies. We conducted a systematic review to describe the outcomes and outcome measures that have been used in clinical trials in BS. This review revealed the diversity and variability in the outcomes and outcome measures and the lack of standard definitions for most outcomes and rarity of validated outcome tools for disease assessment in BS. This systematic literature review will identify domains and candidate instruments for use in a Delphi exercise, the next step in the development of a core set of outcome measures that are properly validated and widely accepted by the collaboration of researchers from many different regions of the world and from different specialties, including rheumatology, ophthalmology, dermatology, gastroenterology, and neurology.

Evidence-based practice in Behçet's disease: identifying areas of unmet need for 2014

BACKGROUND

Behçet's Disease (BD) is characterized by a relapsing-remitting course, with symptoms of varying severity across almost all organ systems. There is a diverse array of therapeutic options with no universally accepted treatment regime, and it is thus important that clinical practice is evidence-based. We reviewed all currently available literature describing management of BD, and investigated whether evidence-based practice is possible for all disease manifestations, and assessed the range of therapeutic options tested.

METHODS

We conducted an internet search of all literature describing management of BD up to August 2013, including pharmacological and non-pharmacological interventions. We recorded treatment options investigated and disease manifestations reported as primary and secondary study outcomes. Quality of data was assessed according to the Scottish Intercollegiate Guideline Network (SIGN) hierarchy of evidence.

RESULTS

Whilst there is much literature describing treatment of ocular and mucocutaneous disease, there is little to guide management of rheumatoid, cardiovascular and neurological disease. This broadly reflects the prevalence of disease manifestations of BD, but not the severity. Biologic therapies are the most commonly investigated intervention. The proportion of SIGN-1 graded studies is declining, and there are no SIGN-1 graded studies investigating neurological or gastrointestinal manifestations of BD.

CONCLUSIONS

This is the first study to investigate trends in published literature for management of BD over time. It identifies neurological, cardiovascular and gastro-intestinal disease as particular areas of unmet need and suggests that overall quality of evidence is declining. Future research should be designed to address these areas of insufficiency to facilitate evidence-based practice in BD.

[Cardiovascular involvement in Behçet's disease]

Vascular involvement is a common complication of Behçet's disease (BD) and affects up to 40% of BD patients. These complications worsen the prognosis of BD. The concept of vasculo-Behçet has been adopted for cases in which vascular complications dominate the clinical features. Vascular manifestations affect particularly young men, during the first years following onset of the disease. Venous complications are the most frequent vascular complications, affecting 14 to 40% of BD patients. Superficial and deep lower limb thrombosis is the most frequent venous complications but one third of venous thrombosis concern large vessels (such as cerebral venous thrombosis, pulmonary embolism, and inferior or superior vena cava, etc.). Budd-Chiari syndrome is the worst prognostic factor increasing mortality by 9 times. Arterial complications (2 to 17% of BD patients) include aneurysms and occlusions/stenosis. Main locations of arterial lesions are aortic (abdominal and thoracic), femoral, pulmonary and iliac arteries. Aneurysms are the most severe arterial complications, particularly pulmonary aneurysms associated with a high risk of massive bleeding. Cardiac complications (up to 6% of BD patients) include pericarditis, endocardial lesions (aortic regurgitation and less often mitral insufficiency), myocardial lesions (myocardial infarction, myocarditis and endomyocardial fibrosis) and intracardiac thrombosis (right ventricle and atrium). Coronary lesions complicated to myocardial infarction are the most severe cardiac complications. Treatment is based on corticosteroids and immunosuppressive drugs. The use of anticoagulation in venous thrombosis is still controversial.

[A saccular aneurysm of the abdominal aorta revealing Behçet disease: when to operate?]

L'atteinte vasculaire est fréquente au cours de la maladie de Behçet. Elle est essentiellement représentée par les thromboses veineuses alors que l'atteinte artérielle est plus rare. Elle peut être isolée ou multifocale et peut toucher tous les territoires avec prédilection pour l'aorte abdominale, les artères pulmonaires et les artères des membres inférieurs. L'atteinte anévrysmale de l'aorte abdominale est trompeuse se manifestant par une symptomatologie atypique responsable d'un retard diagnostique favorisant la rupture. Dans notre cas, des douleurs abdominales paroxystiques ont incité le patient à consulter rapidement. L'enquête étiologique a conclue à un angio Behcet. Rarement, l'anévrysme de l'aorte abdominale est révélé par une complication telle que la rupture dans le rétro péritoine ou le tube digestif. Les indications chirurgicales des anévrysmes de l'aorte sont discutées ici. Un traitement immunosuppresseur au long cours s'impose en post opératoire pour limiter le risque de récidive.

Outcomes of endovascular treatment for aortic pseudoaneurysm in Behcet's disease

OBJECTIVE

To evaluate the effectiveness of endovascular stent grafting for surgical management of aortic pseudoaneurysm in patients with Behcet's disease (BD).

METHODS

We present a single-institution retrospective cohort of patients with aortic pseudoaneurysm and BD treated with aortic stent grafting. Computed tomography imaging was obtained preoperatively in all patients and once within 2 weeks postoperatively, and then annually. Clinical follow-up and erythrocyte sedimentation rate were used to follow BD activity. Immunosuppressant therapy was instituted prior to endovascular treatment unless a contraindication existed.

RESULTS

From 1998 to 2012, 10 patients (eight male, two female; median age, 39) with BD and aortic pseudoaneurysm were treated with endovascular stent grafting at this institution. Ninety percent of these patients received immunosuppressive therapy before and after surgical treatment. The median follow-up period was 57 months (interquartile range, 43-72). The locations of the 12 pseudoaneurysms treated in this cohort were infrarenal abdominal aorta (seven), descending thoracic aorta (four), and aortic arch (one). Median pseudoaneurysm size was 4.5 cm (interquartile range, 3.4-5.9). At long-term follow-up, complete resolution of the aortic pseudoaneurysm was noted in all patients. No endoleaks occurred. Newly developed pseudoaneurysm at the distal margin of the stent graft was noted in one patient 17 months after the stent graft procedure. One patient required a subsequent stent graft placement for an expanding pseudoaneurysm of the subclavian artery. No patient deaths occurred during the follow-up period.

CONCLUSIONS

Endovascular treatment of aortic pseudoaneurysm with stent-grafting in patients with BD is safe and effective with long-term durability.

Behcet's Disease: New Concepts in Cardiovascular Involvements and Future Direction for Treatment

Behcet's disease (BD) is the only systemic vasculitis involving both arteries and vein in any sizes. It frequently encounters in rheumatology clinics. It has some major morbidities and even fatal outcomes in some cases. The aim of this paper is to analyze the main concepts on pathophysiology and treatment options in BD, focusing on cardiovascular aspects, thrombosis, and potential future treatment.

Surgical treatment of peripheral aneurysms in patients with Behcet's disease

INTRODUCTION

Our aim was to report our experience with 23 patients presenting with 32 peripheral aneurysms secondary to Behcet's disease (BD) and their outcome after vascular surgery.

METHODS

The study was retrospective in nature. Except for those presenting with aneurysm rupture, patients underwent surgery after treatment of acute inflammatory lesions. All aneurysms appeared to be pseudo-aneurysms. Graft interposition with polytetrafluoroethylene or saphenous vein was most commonly employed. Postoperatively, all patients were put on immunosuppressive and antiplatelet therapy. Follow-up was done every 6-12 months, complications recorded and managed appropriately.

RESULTS

All the patients were males. The mean age at diagnosis of a peripheral aneurysm was 41.0 ± 9 years. There were 17 (53%) femoral, 8 (25%) popliteal, two carotid, two external iliac, two brachial and one internal iliac aneurysms. Fourteen (61%) patients had a single peripheral aneurysm while nine had two. Surgery was performed for all initially presenting 23 aneurysms. Six patients with multiple peripheral aneurysms had surgery for their second asymptomatic aneurysm. The mean follow-up period was 84 ± 62 months. Of 29 aneurysms operated on, 7 (24%) anastomotic pseudo-aneurysms and 11 (38%) graft occlusions developed. Five (22%) patients underwent major lower extremity amputations. Six (26%) mortalities were recorded.

CONCLUSION

Surgery for peripheral aneurysms in BD is warranted in many instances. Results of operation can be improved by prolonged monitoring. However, despite all efforts, peripheral aneurysm involvement in BD worsens the prognosis.

Major vessel involvement in Behçet's disease: an update

PURPOSE OF REVIEW

Large vessel vasculitis occurs in a subgroup of patients with Behçet's disease who are at high risk for disease-related morbidity and mortality. Recognition of patients at risk, early detection of vasculitis, and aggressive treatment are essential for optimal care of these patients. We review the expanding knowledge on large vessel problems in Behçet's disease, highlighting recent contributions.

RECENT FINDINGS

Vasculo-Behçet patients are at risk for multiple vessel-related complications including thromboses, stenoses, occlusions, and aneurysms. The primary reason for clot seems to be an inflammatory process in the vessel wall. Less invasive endovascular procedures are increasingly used to treat aneurysms in Behçet patients.

SUMMARY

Because of earlier recognition, aggressive medical treatment, and novel surgical procedures, the morbidity and mortality of large vessel vasculitis in Behçet's disease are improving.