Outcome of takayasu arteritis with inactive disease at diagnosis: the extent of vascular involvement as a predictor of activation

Predictors of relapse in Takayasu arteritis

BACKGROUND

Takayasu arteritis (TAK) is a large-vessel vasculitis with high relapse rate. Longitudinal studies identifying risk factors of relapse are limited. We aimed to analyze the associated factors and develop a risk prediction model for relapse.

METHODS

We analyzed the associated factors for relapse in a prospective cohort of 549 TAK patients from the Chinese Registry of Systemic Vasculitis cohort between June 2014 and December 2021 using univariate and multivariate Cox regression analyses. We also developed a prediction model for relapse, and stratified patients into low-, medium-, and high-risk groups. Discrimination and calibration were measured using C-index and calibration plots.

RESULTS

At a median follow-up of 44 (IQR 26-62) months, 276 (50.3%) patients experienced relapses. History of relapse (HR 2.78 [2.14-3.60]), disease duration <24 months (HR 1.78 [1.37-2.32]), history of cerebrovascular events (HR 1.55 [1.12-2.16]), aneurysm (HR 1.49 [1.10-2.04], ascending aorta or aortic arch involvement (HR 1.37 [1.05-1.79]), elevated high-sensitivity C-reactive protein level (HR 1.34 [1.03-1.73]), elevated white blood cell count (HR 1.32 [1.03-1.69]), and the number of involved arteries ≥6 (HR 1.31 [1.00-1.72]) at baseline independently increased the risk of relapse and were included in the prediction model. The C-index of the prediction model was 0.70 (95% CI 0.67-0.74). Predictions correlated with observed outcomes on the calibration plots. Compared to the low-risk group, both medium and high-risk groups had a significantly higher relapse risk.

CONCLUSIONS

Disease relapse is common in TAK patients. This prediction model may help to identify high-risk patients for relapse and assist clinical decision-making.

Clinical course of 602 patients with Takayasu's arteritis: comparison between Childhood-onset versus adult onset disease

OBJECTIVES

To describe the clinical profile of Asian Indian patients with Takayasu's arteritis (TAK) and to compare clinical features and outcome of childhood-onset Takayasu's arteritis (cTAK) with adult-onset TAK (aTAK).

METHODS

Data related to clinical features and response to treatment of patients with cTAK (age of onset <16 years) and aTAK from a large observational cohort in our tertiary care teaching hospital were noted and compared.

RESULTS

Altogether, 602 patients (cTAK = 119; aTAK = 483) were studied. Patients with cTAK had a blunted female: male ratio; but fever, elevated acute phase reactants, involvement of abdominal aorta or its branches, hypertension, abdominal pain, elevated serum creatinine and cardiomyopathy were more common in cTAK as compared with aTAK. Patients with aTAK were more likely to have aortic-arch disease and claudication than cTAK. During follow-up, complete remission was more common in cTAK (87% vs 66%; P < 0.01), but subsequent relapses were equally common (30% vs 27%; P = 0.63). Independent associations of disease duration at presentation with disease extent [Disease Extent Index in TAK (DEI.Tak)] and damage [TAK Damage Score (TADS)] were observed (P ≤ 0.01). Moreover, 54% of patients with symptom duration of >5 years at presentation still continued to have elevated CRP suggesting continued and active inflammation warranting escalation or inititation of immunosuppression.

CONCLUSION

Patients with cTAK are more likely to have arterial disease below the diaphragm, systemic inflammation and achieve remission. Disease of the aortic arch is more common in patients with aTAK. Longer duration of symptoms prior to initiation of immunosuppression, thereby leading to extensive disease and damage, reflects ongoing disease activity as the rule rather than exception in untreated TAK.

Clinical Scenario and Long-Term Outcome of Childhood Takayasu Arteritis Undergoing 121 Endovascular Interventions: A Large Cohort Over a Fifteen-Year Period

OBJECTIVE

Evidence-based studies on endovascular approaches for childhood Takayasu arteritis (TAK) are limited. Our objective was to present the largest current real-world scenario for patients with childhood TAK undergoing interventions and their postinterventional outcomes.

METHODS

Data were collected for patients with childhood TAK admitted from 2002 to 2017. Complication/reintervention-free survival was projected by Kaplan-Meier methods. Associated factors for intervention and predictors for postinterventional complications/reinterventions were assessed via regression models.

RESULTS

Among 101 patients enrolled, 69 (68.3%) underwent 121 interventions (angioplasty 95, stenting 26) during a 3.1-year follow-up. Compared with the nonintervention group, the intervention group independently associated with a male population (odds ratio [OR] 0.27, P = 0.035) and type IV disease (OR 17.92, P = 0.001). Male sex also marginally indicated a risk for reintervention (hazard ratio [HR] 3.22, P = 0.05). Baseline retinopathy, delay in diagnosis, and descending thoracic aorta involvement were associated with stent insertion (P < 0.05). Hypertension secondary to renal artery stenosis (RAS; 59.4%) or mid-aorta stenosis (MAS; 14.5%), heart failure (21.7%), and claudication (21.7%) were leading clinical hints for interventions. The technical success rate was 96.7%. During a median 2.88-year of follow-up after intervention, 36 lesions occurred with complications in 28 patients, and 22 lesions in 17 patients, particularly on the renal artery or mid-aorta. The 5-year complication-free and reintervention-free survivals were 50.7% and 65.8%, respectively. Peri-interventional dual antiplatelet therapy (DAPT; HR 0.31), concurrent surgery (HR 26.5), and technical failure (HR 3.65) were independent predictors for complications (P < 0.05). Male sex (HR 2.52), retinopathy secondary to hypertension (HR 3.41), and pulmonary artery hypertension (PAH; HR 3.64) were baseline indicators for complications (P < 0.05).

CONCLUSION

Over two-thirds of patients with childhood TAK require interventions, and the 5-year complication-free survival is 50.7%. Male sex, retinopathy, and PAH at baseline indicate the possibility of unfavorable outcomes. Interventions on MAS or RAS in childhood TAK raise specific concerns. DAPT peri-intervention appears to protect patients with childhood TAK from postinterventional complications.

18F-FDG PET/CT plays a unique role in the management of Takayasu arteritis patients with atypical manifestations

OBJECTIVE

The present study aimed to evaluate the value of ¹⁸F-fluorodeoxyglucose positron emission tomography/computed tomography (¹⁸F-FDG PET/CT) aiding in diagnosing and evaluating disease activity in Takayasu arteritis (TA) patients with atypical clinical manifestations.

METHODS

A retrospective study of 22 TA patients was conducted. All the participants were classified into two groups. Group one including 12 patients, who did not fulfill American College of Rheumatology (ACR) criteria, were diagnosed by modified Ishikawa criteria. Group two involving ten patients, who did not satisfy the modified Ishikawa criteria or ACR criteria, were clinically diagnosed as TA after panel discussion by a combination of clinical data, excluding other diagnoses. PET/CT results were analyzed using quantitative and qualitative metrics. Disease activity was evaluated using the US National Institutes of Health (NIH) criteria.

RESULTS

In group one, nine patients in active stage and two patients in inactive stage had active FDG uptake. One patient in inactive stage had inactive PET/CT results. In group two, five patients in active stage had active FDG uptake and five patients in inactive stage had inactive FDG uptake with SUVmax values of several vascular lesions slightly lower than livermean in each person. The sensitivity of PET/CT scans for evaluating disease activity was 100.0%, specificity was 75.0%, positive predictive value was 87.5%, and negative predictive value was 100.0% compared to NIH criteria.

CONCLUSIONS

PET/CT plays a unique role in diagnosing these TA with atypical manifestation and assisting in evaluating disease activity. Key Points • Diagnosis of these TA patients with atypical manifestations may be difficult. • PET/CT plays a unique role in diagnosing these TA patients and assisting in evaluating disease activity.

[Possibility of complex medicamental and endovascular treatment of pulmonary hypertension in Takayasu arteritis with predominant pulmonary arteries' lesion]

Takayasu arteritis (TA) is a systemic vasculitis with predominatly lesions of aorta and its large branches. In some cases pulmonary arteries (PA) are involved in the pathological inflammatory process and lead to the formation of pulmonary hypertension and significantly worse the prognosis. Timely development of lesion of PA, appointment of adequate therapy and surgical treatment can prevent irreversible damage of blood vessels and improve the prognosis. Perioperative administration of interleukin-6 inhibitor inhibitor (tocilizumab) in at patients with indications for vascular surgery, including angioplasty PA, should be considered as a promising approach to control the inflammatory activity of TA, reduce the dose of glucocorticoids and the risk of postoperative complications. We present the clinical experience of significant improvement in the patients condition was achieved by using two-stage balloon angioplasty on the background of control of the disease activity with interleukin-6 tocilizumab intravenously and specific therapy with riociguat and iloprost.

A Long-term Survival after Surgical Treatment for Atypical Aortic Coarctation Complicating Takayasu Arteritis with Inactive Disease at the Diagnosis: An Appropriately Treated Autopsy Case

The number of Takayasu arteritis (TAK) cases being diagnosed at an advanced age has increased, including some who develop ischemic lesions without inflammation of the involved arteries long after the onset of TAK. However, few histopathological analyses of such patients without immunosuppressive therapy have been reported. We herein report a 92-year-old woman with atypical aortic coarctation complicating TAK who underwent bypass graft surgery and survived for 23 years without immunosuppressive therapy. Microscopic findings at the autopsy revealed clear differences between the affected and unaffected arteries. This case suggests that inflammation severe enough to destroy the structure of the aorta may not inherently be sufficient to promote systemic atherosclerosis.

Unmet Needs in the Pathogenesis and Treatment of Vasculitides

Despite the progress in the last years on the field of vasculitides, there are several unmet needs regarding classification, disease activity assessment, predictors of flares and complications, and type of treatment for the different forms. The 1990 American College of Rheumatology (ACR) classification criteria currently used to define giant cell arteritis and Takayasu arteritis were designed to discriminate between different types of vasculitides but not to differentiate vasculitis from other disorders. Recently, efforts have been made to overcome the shortcomings of the ACR criteria. The lack of an accepted definition of disease activity in large-vessel vasculitides presents a major challenge in creating useful and valid outcome tools for the assessment of disease course. Identification of predictors of flares can aid in optimizing therapeutic strategies, minimizing disease flares, and reducing treatment-related side effects. It is furthermore important to recognize and characterize the risk factor that might predict the manifestations associated with poor outcome and prognosis. Two RCTs have evidenced the efficacy of tocilizumab in addition to glucocorticoids (GCs) in the treatment of giant cell arteritis (GCA). However, the role of tocilizumab or other biological agents without GCs needs to be investigated. Recent observational studies have suggested that rituximab is also effective in patients with eosinophilic granulomatosis with polyangiitis and in antineutrophil cytoplasmic antibodies (ANCA)-negative patients with granulomatosis with polyangiitis and microscopic polyangiitis. Rituximab or anti-TNF alfa may represent a possible alternative therapy in case of refractory or difficult to treat polyarteritis nodosa (PAN) patients. The new International Criteria for Behçet's Disease have shown a better sensitivity and a better accuracy compared to the older International Study Group on Behçet's Disease criteria. The EULAR recommendations for the management of Behçet's disease (BD) have been recently updated. However, the treatment of refractory disease is still a real challenge.