Carotid artery involvement in Takayasu's arteritis: evaluation of the activity by ultrasonography

Cerebrovascular implications of takayasu arteritis: a review

PURPOSE

Takayasu arteritis (TA) is a rare, chronic, inflammatory large-vessel vasculitis that affects the aorta and its main branches, including the cerebrovascular system. This review analyzes current knowledge and patient outcomes concerning the cerebrovascular implications of TA.

METHODS

A literature search, with publications from 1994 to 2024, identified pertinent studies through PubMed. An illustrative case report details a 19-year-old female with Type 1 TA, illustrating the complex decision required in the absence of surgical or endovascular options.

RESULTS

Our results offer a demographic analysis of 1,698 TA patients, highlighting a female predominance of 89.99% and a mean symptom onset at 33 years. The clinical spectrum of cerebrovascular involvement presented varied symptoms, most notably dizziness, with significant incidences of ischemic events and bilateral stenosis primarily affecting the carotid and subclavian arteries. The most common type of TA was Type V, affecting 40% of patients studied. Endovascular treatment had a 95% initial success rate, with a 67% restenosis rate. Surgical treatment was successful in 84% of cases, but 21% had notable post-operative complications. Similar to the endovascular population, those treated with stand-alone conservative therapy saw a 93% initial remission rate with 52% having relapsed.

CONCLUSION

Assessing the disease activity of TA is crucial when planning vascular intervention due to its significant impact on treatment outcomes. Despite its greater initial invasiveness, surgical interventions showed lower restenosis rates compared to either endovascular interventions or standalone conservative management. We emphasize advancements in TA management and the pressing need for continued research into diagnostic and treatment protocols for improved patient outcomes.

Chinese guideline for the diagnosis and treatment of Takayasu's arteritis (2023)

Takayasu's arteritis (TAK) is a chronic granulomatous inflammatory disease that involves aorta and its primary branches. It is characterized by wall thickening, stenosis/obliteration or aneurysm formation of the involved arteries. In order to standardize the diagnosis and treatment of TAK in China, a clinical practice guideline with an evidence-based approach is developed under the leadership of National Clinical Medical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID). Eleven recommendations for 11 clinical questions that are important to the diagnosis and treatment of TAK are developed based on the latest evidence and expert opinions combined with real clinical practice in China.

A patient with Takayasu arteritis presenting with malignant hypertension: a case report

Background

Takayasu arteritis (TA) is a rare large-vessel vasculitis primarily affecting the aorta and its proximal branches. The manifestation of TA is variable, ranging from asymptomatic cases to severe organ dysfunction secondary to vascular damage, which often delays diagnosis.

Case summary

Here, we present a 37-year-old male patient suffering from visual impairment and malignant hypertension. Emergency fundoscopy showed large left subretinal bleeding and bilateral signs of hypertensive retinopathy. Echocardiographic and magnetic resonance imaging showed mildly reduced left ventricular ejection fraction and signs of hypertensive cardiomyopathy. Evaluation for secondary causes of arterial hypertension did not reveal an underlying disease, and the patient was discharged with optimal medical therapy. He was re-admitted after 11 days with fever of unknown origin, fatigue, and elevated inflammatory markers. The diagnosis of TA was finally established using ¹⁸F-fluorodeoxyglucose positron emission computed tomography scan and sonography of carotid and subclavian arteries. Anti-inflammatory combination therapy for active, severe TA with ophthalmologic involvement was initiated using high-dose glucocorticoids and the tumour necrosis factor alpha inhibitor adalimumab to minimize drug-related risks. The patient was scheduled for multidisciplinary follow-up appointments, including specialist consultation in rheumatology, angiology, cardiology, diabetology, and ophthalmology.

Discussion

This case highlights the diversity of initial symptoms, the challenges of TA diagnosis, and the importance of comprehensive evaluation for rare secondary causes of arterial hypertension. Individualized acute and long-term care necessitates multidisciplinary management of immunosuppressive therapy, secondary organ involvement, and concomitant diseases.

INCREASED ARTERIAL STIFFNESS AND ACCELERATED ATHEROSCLEROSIS IN TAKAYASU ARTERITIS

INTRODUCTION

Cardiovascular diseases are the leading causes of morbidity and mortality in patients with Takayasu arteritis (TAK). Arterial stiffness and accelerated atherosclerosis have been reported in TAK, however, morphological changes in the arterial wall have not been adequately addressed. Shear wave elastography (SWE) is a new, non-invasive, direct and quantitative method of ultrasonography (US) that evaluates elasticity of biological tissues.

METHODS

A total of 50 patients with TAK (44F/6 M; mean age: 39.8 ± 8.2 years), 43 with systemic lupus erythematosus (SLE) (38F/5 M; 38.0 ± 7.9 years) and 57 healthy controls (HCs) (50F/7M: 39.5 ± 7.1 years) were studied using carotid B mode US and SWE. Carotid artery intima-media thickness (CCA IMT) and SWE were measured and the atherosclerotic plaques were recorded. Clinical characteristics and cardiovascular risk factors were determined. Intra and inter observer reproducibility was assessed and found good agreement.

RESULTS

The mean IMT in the right and left carotid arteries was significantly higher only among patients with TAK when compared to SLE and HCs. Carotid artery plaques were significantly increased only in patients with TAK. On the other hand, the mean SWE value was significantly increased among both TAK and SLE patients when compared to HCs, whereas patients with TAK had the highest value. These were also true after adjustments were made for atherosclerotic risk factors and after all those with atherosclerotic plaques were excluded from the analysis. TAK itself, diastolic blood pressure levels and IMT were independently associated with SWE.

CONCLUSIONS

Markedly increased CCA IMT and SWE values appear to be uniquely associated with TAK, suggesting that they could be used as diagnostic tools. Arterial stiffness occurs independently from atherosclerosis and is associated with arterial thickening. Further studies should investigate whether CCA SWE values could predict cardiovascular morbidity and mortality. Strong association with premature atherosclerosis could be also considered as a unique feature of TAK.

Overview of Imaging Modalities in Stroke

PURPOSE OF THE REVIEW

This article reviews common imaging modalities used in diagnosis and management of acute stroke. Each modality is discussed individually and clinical scenarios are presented to demonstrate how to apply these modalities in decision-making.

RECENT FINDINGS

Advances in neuroimaging provide unprecedented accuracy in determining tissue viability as well as tissue fate in acute stroke. In addition, advances in machine learning have led to the creation of decision support tools to improve the interpretability of these studies.

SUMMARY

Noncontrast head computed tomography (CT) remains the most commonly used initial imaging tool to evaluate stroke. Its exquisite sensitivity for hemorrhage, rapid acquisition, and widespread availability make it the ideal first study. CT angiography (CTA), the most common follow-up study after noncontrast head CT, is used primarily to identify intracranial large vessel occlusions and cervical carotid or vertebral artery disease. CTA is highly sensitive and can improve accuracy of patient selection for endovascular therapy through delineations of ischemic core. CT perfusion is widely used in endovascular therapy trials and benefits from multiple commercially available machine-learning packages that perform automated postprocessing and interpretation. Magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) can provide valuable insights for outcomes prognostication as well as stroke etiology. Optical coherence tomography (OCT), positron emission tomography (PET), single-photon emission computerized tomography (SPECT) offer similar insights. In the clinical scenarios presented, we demonstrate how multimodal imaging approaches can be tailored to gain mechanistic insights for a range of cerebrovascular pathologies.

Multiple occlusions in extracranial arteries in patients with aortic arch syndrome: is minimally invasive treatment still possible? Technical aspects of the treatment based on our own experience and a review of the literature

Takayasu arteritis is a large vessel vasculitis of granulomatous nature and unknown aetiology affecting predominantly the aorta and its major branches, which may lead to ischaemic symptoms of many organs including the central nervous system. To decrease the risk of neurological complications and improve the quality of life, an arterial revascularisation may be necessary. The treatment options include pharmacotherapy as well as both open surgical and endovascular procedures, which has to be carefully chosen to obtain clinical success. There is an ongoing debate on the advantages, possibilities, and indications for implementing endovascular and open surgical methods, especially in high-risk patients. In this article we present our own experience in the treatment of an unusually complex and high-risk patient with multiple occlusion of supra-aortic branches, focusing on the technical aspects of the procedures and the decision-making process, as well as to confront with contemporary medical knowledge.

Serum leptin, a potential predictor of long-term angiographic progression in Takayasu's arteritis

Aim

In patients with Takayasu's arteritis (TA), current biomarkers that properly reflect the progression of the vascular structure remain absent. We aimed to determine the serum leptin level to investigate its relationship with imaging changes and assess its value as a predictor for long‐term radiological progression.

Method

This study included 34 untreated TA patients and 40 age‐matched healthy controls. At baseline and during the 5‐year follow‐up, we assessed disease activity using Kerr's criteria and Indian Takayasu Clinical Activity Score (ITAS2010) and monitored laboratory biomarkers as well as imaging findings. Serum leptin levels were measured by enzyme‐linked immunosorbent assay.

Results

The baseline serum leptin levels were significantly higher in TA patients than in healthy controls. Leptin was significantly positively correlated with triglyceride and high‐density lipoprotein cholesterol levels and negatively correlated with fibrinogen and C‐reactive protein levels. Patients were subdivided into three groups based on their baseline leptin level. During a 5‐year follow‐up, patients in the high and medium leptin groups showed more radiological progression compared to those in the low leptin group. Cox proportional hazard regression analysis showed that a high serum leptin level was a positive predictor of radiological progression.

Conclusion

Leptin is a potential biomarker for assessing TA structural progression. Untreated patients with elevated serum leptin levels are at a higher risk of progression in the aorta. Thus, the leptin level can be a predictor of long‐term radiological progression.

Value of contrast-enhanced ultrasonography of the carotid artery for evaluating disease activity in Takayasu arteritis

AIMS

To assess the value of contrast-enhanced ultrasonography (CEUS) for monitoring disease activity of Takayasu arteritis (TA).

METHODS

TA patients were recruited in a Chinese TA clinical center from January 2016 to September 2017. The physician global assessment was used as the referential standard for disease activity. Clinical data, acute phase reactants, and CEUS scans were simultaneously recorded at baseline and after a 3-month therapy.

RESULTS

A total of 84 TA patients were enrolled, and 47 (55.95%) cases were active at baseline. Macaroni sign and entire artery involvement were characteristic findings of CEUS in TA. The average vascular full thickness of the carotid artery in active TA patients was significantly higher than that in inactive patients (2.36 ± 0.86 vs. 1.79 ± 0.49 mm; p = 0.001). Severe neovascularization (grade 2) was observed in 29 active cases (61.70%) and in 9 inactive cases (24.32%) (p = 0.001). Receiver operating characteristic analysis showed that the combination of CEUS parameters (cutoff of thickness was 1.75 mm or neovascularization grade 2) and erythrocyte sedimentation rate (ESR) (cutoff of 20 mm/H) could help differentiate between active and inactive TA patients with a sensitivity and specificity of 81.1% and 81.5%, respectively. Youdon's index was 0.626. Furthermore, our study found that patients with decreased ESR and C-reactive protein (CRP) still had a progression of vascular wall inflammation at 3 months of follow-up.

CONCLUSIONS

The evaluation of vascular inflammation by CEUS is more sensitive than acute phase reactants. Neovascularization can still be observed in the vascular lesion sites of those who have reached clinical remission after treatment. Thus, CEUS can be used as an alternative method to assess disease activity for TA patients.

The use of ultrasound to assess giant cell arteritis: review of the current evidence and practical guide for the rheumatologist

Colour duplex sonography (CDS) of temporal arteries and large vessels is an emerging diagnostic tool for GCA. CDS can detect wall oedema, known as a halo, throughout the length of the vessel and shows higher sensitivity compared with biopsy. Specificity reaches 100% in case of bilateral halos. A positive compression sign has been demonstrated to be a robust marker with excellent inter-observer agreement. The assessment of other large vessels, particularly the axillary arteries, is recognized to further increase the sensitivity and to reliably represent extra-cranial involvement in other areas. Nevertheless, CDS use is still not widespread in routine clinical practice and requires skilled sonographers. Moreover, its role in the follow-up of patients still needs to be defined. The aim of this review is to provide the current evidence and technical parameters to support the rheumatologist in the CDS evaluation of patients with suspected GCA.

Updates in Pathophysiology, Diagnosis and Management of Takayasu Arteritis

BACKGROUND

Takayasu arteritis (TA) is a rare, systemic, inflammatory vasculitis of granulomatous nature, and still of unknown etiology. It mainly involves the aorta and its major branches and is more commonly seen in women of childbearing age and Asians. TA leads to stenosis, occlusion, or aneurysmal degeneration of large arteries, and its pathogenesis seems to be mainly due to an abnormal cell-mediated immunity, although other molecular and genetic abnormalities may contribute. The diagnosis and treatments lie on clinical and arteriographic findings. Because of its fluctuating course, both clinical scores and biomarkers are currently evaluated. The aim of this review is to report a comprehensive and methodologically robust state of the art about Takayasu arteritis, including the latest data and evidences in the definition, epidemiology, pathogenesis and etiology, clinical manifestations and classification, diagnosis, assessment of disease activity and progression, biomarkers, and treatment.

METHODS

We searched all publications addressing definition, epidemiology, pathogenesis, etiology, classification, diagnosis, biomarkers, and treatment of TA. Randomized trials, cohort studies, and reviews were contemplated to give a breadth of clinical data. PubMed and Scopus were searched from August 2010 to November 2015.

RESULTS

Of the 3,056 records found, 267 matched our inclusion criteria. After reading the full-text articles, we decided to exclude 169 articles because of the following reasons: (1) no innovative or important content; (2) no multivariable analysis; (3) insufficient data; (4) no clear potential biases or strategies to solve them; (5) no clear end-points; and (6) inconsistent or arbitrary conclusions. The final set included 98 articles.

CONCLUSIONS

This review presents the last updates in all fields of Takayasu arteritis. Still today, large areas of TA pathogenesis and disease-activity assessment need to be further investigated to better treat patients with TA.

Vessel Wall Inflammation of Takayasu Arteritis Detected by Contrast-Enhanced Magnetic Resonance Imaging: Association with Disease Distribution and Activity

AIMS

The assessment of the distribution and activity of vessel wall inflammation is clinically important in patients with Takayasu arteritis. Magnetic resonance imaging (MRI) is a useful tool, but the clinical utility of late gadolinium enhancement (LGE) in Takayasu arteritis has yet to be determined. The aim of the present study was to evaluate the utility of LGE in assessing vessel wall inflammation and disease activity in Takayasu arteritis.

METHODS AND RESULTS

We enrolled 49 patients with Takayasu arteritis who had undergone 1.5 T MRI. Patients were divided into Active (n = 19) and Inactive disease (n = 30) groups. The distribution of vessel wall inflammation using angiography and LGE was assessed by qualitative analysis. In 79% and 63% of patients in Active and Inactive groups, respectively, greater distribution of vessel wall inflammation was observed with LGE than with conventional angiography. MRI values of pre- and post-contrast signal-to-noise ratios (SNR), SNR increment (post-SNR minus pre-SNR), pre- and post-contrast contrast-to-noise ratios (CNR), and CNR increment (post-CNR minus pre-CNR) were evaluated at arterial wall sites with the highest signal intensity using quantitative analysis of post-contrast LGE images. No statistically significant differences in MRI parameters were observed between Active and Inactive groups. Contrast-enhanced MRI was unable to accurately detect active disease.

CONCLUSION

Contrast-enhanced MRI has utility in detecting the distribution of vessel wall inflammation but has less utility in assessing disease activity in Takayasu arteritis.

Outcome assessment in Takayasu arteritis

Takayasu arteritis (TAK) is a systemic granulomatous large-vessel vasculitis with a phenotype that overlaps with GCA and defined by the 1993 and 2012 Chapel Hill Consensus Conference statements. However, the diagnosis of TAK is often delayed since TAK patients may be asymptomatic or have non-specific symptoms. Once a diagnosis is made, it is difficult to judge remission or recurrence since there are no reliable assessment tools. With the availability of newer agents, such as cytokine blockade, which are being evaluated in GCA, there is the potential for real advances in TAK patient management. Without reliable assessment tools it will be difficult to introduce newer agents in an organized way or to optimally benefit patients in the future. In this article we review the use and performance of disease indicators in TAK clinical trials as a basis for the further development of assessment tools for this disease.

High-sensitivity C-reactive protein predicts adverse cardiovascular events in patients with Takayasu arteritis with coronary artery involvement

The study aimed to assess the association of high-sensitivity C-reactive protein (hsCRP) and N-terminal pro-brain natriuretic peptide (NT-proBNP) to major adverse cardiovascular events (MACE) in Takayasu arteritis (TA) patients with coronary artery disease (CAD). Data on 60 TA patients with CAD and 60 age- and severity-matched patients with CAD hospitalized in Fuwai Hospital from 2005 to August 2014 were assessed. The clinical features, laboratory data, coronary angiographic findings, treatment, and follow-up outcomes were summarized retrospectively. MACE were defined as death from cardiac causes, myocardial infarction, nonfatal target vessel revascularization, or rehospitalization due to unstable or progressive angina. CAD patients had more atherogenic lipid and lipoprotein profiles such as lower levels of high-density lipoprotein cholesterol (HDL-C) (1.0 ± 0.2 vs. 1.3 ± 0.3 mmol/L, p = 0.01) and higher levels of low-density lipoprotein cholesterol (LDL-C) (2.5 ± 0.9 vs. 2.2 ± 1.1 mmol/L, p = 0.04) in contrast with TA-CAD patients. During a mean follow-up period of 3.2 years, 31 patients with Takayasu coronary arteritis reached the endpoint. Multivariate Cox proportional hazards model demonstrated that log(hsCRP) (HR = 5.3, 95 % CI = 1.1-27.8, p = 0.04) was a significant and independent predictor of MACE in patients with Takayasu coronary arteritis. Elevated baseline levels of hsCRP predict cardiovascular events, independent of other prognostic markers in TA-related CAD patients.

Evaluation of echogenicity of the heart in Kawasaki disease

Pathologic studies of the heart in patients with Kawasaki disease (KD) revealed vasculitis, valvulitis, myocarditis, and pericarditis. However, there have been no studies on the quantitative determination of multi-site echogenicity of the heart in KD patients. It is also undetermined whether the degree of echogenicity of each site of the heart in patients with KD might be related to the response to intravenous immunoglobulin (IVIG) treatment. In 81 KD patients and 30 control subjects, we prospectively analyzed echogenicity of the heart. Echogenicity was measured in four sites: coronary artery wall (CAW), mitral valve (MV), papillary muscle (PM), and ascending aortic wall (AAo wall) by the calibrated integrated backscatters (cIBs). The cIB values of all measurement sites at acute phase in KD patients were significantly higher than those in control subjects (KD patients vs control subjects; CAW, 19.8 ± 6.2 dB vs 14.5 ± 2.0 dB, p < 0.05; MV, 23.3 ± 5.3 dB vs 16.0 ± 3.3 dB, p < 0.05; PM, 22.4 ± 5.1 dB vs 12.7 ± 1.9 dB, p < 0.05; AAo wall, 25.3 ± 5.6 dB vs 18.3 ± 3.4 dB, p < 0.05). The cIB values of CAW at the acute phase in IVIG nonresponders were significantly higher than those in responders. Conclusion: Echogenicity of the heart in KD patients at the acute phase increased not only in the coronary artery wall but also in other parts of the heart. Echogenicity of CAW might be helpful in determining the unresponsiveness of IVIG treatment.

The triple line pattern on carotid intima media thickness imaging and its relationship to cardiovascular risk factors in patients on lipid lowering therapy

Background

Carotid intima media thickness (CIMT) infrequently identifies a triple line pattern (TLP) in the visualization of the internal elastic lamina. We examined the prevalence and predictors of the TLP among a consecutive series of subjects enrolled in a CIMT clinical trial, and also the effects of lipid lowering therapy.

Methods

Baseline CIMT studies of subjects with known heart disease, or high risk for heart disease, were evaluated from a single site of the Arterial Biology for the Investigation of the Treatment Effects of Reducing Cholesterol 6-HDL and LDL Treatment Strategies in Atherosclerosis trial (N=120). One sonographer obtained four views of the right and left far wall common CIMT, using a 13 MHz ultrasound probe. Images were blindly reviewed for the presence of the TLP. The TLP was defined as absent (0), possible (1), or definite (2). A composite score from all four views was calculated. A patient was defined as having the TLP if the composite score was ≥4. Univariate predictors of the TLP were explored. Follow-up ultrasounds at 14 months were also reviewed for presence of the TLP.

Results

The prevalence of the TLP at baseline was 22.5%. Among cardiovascular risk variables, systolic blood pressure was significantly higher in subjects displaying the TLP (141.3±15.6 mmHg versus 133.1±18.4 mmHg; P=0.036). There were no differences among those with, and without, the TLP, with respect to other cardiovascular risk variables (age, sex, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, C-reactive protein, glucose, weight, waist girth, tobacco use, medications, quantitative CIMT), or image quality. During ongoing lipid lowering therapy, the prevalence of the TLP increased to 54.2% (P<0.001). However, it was unrelated to changes in lipid concentrations or cardiovascular risk variables.

Conclusion

The TLP in CIMT imaging is commonly identifiable using high-frequency ultrasound, and appears to be associated with higher systolic blood pressure. Its prevalence and incidence is unrelated to lipid parameters.

Ultrasonography is convenient and useful for assessment and follow-up of Takayasu's arteritis

A 20-year-old woman first came to our hospital complaining of high fever and pain affecting the whole body. Takayasu's arteritis (TA) was diagnosed. Following full-body examination, many vessels between the bilateral neck and iliac arteries were found to be impaired. Ultrasonography (US) showed the characteristic wall thickening of TA in the left common carotid artery. After starting prednisolone treatment (40 mg/day), symptoms improved quickly and vessel walls gradually became thinner. However, chest pain recurred when prednisolone was tapered to 20 mg/day. Blood tests showed no signs of recurring inflammation, and US revealed worsened wall thickening only in the left carotid artery. We therefore diagnosed local recurrence of activation of TA. Assessing local recurrence of TA with a blood test is difficult, particularly after prescribing steroids. In this case, US identified the local changes attributable to TA before any other diagnostic modality. US can be useful in assessing inflammation and offers a good strategic tool for initial diagnosis of TA.

Common carotid artery intima-media thickness is useful for diagnosis of the acute stage of Kawasaki disease

Background

This study aimed to investigate intima-media thickness (IMT) of the common carotid arteries in children with acute Kawasaki disease (KD).

Methods

Between 2009 and 2011, patients fulfilling the criteria for KD, including a fever lasting >5 days, were prospectively enrolled in this study. Laboratory data, echocardiography, and IMT were measured and compared with matched controls.

Results

A total of 70 common carotid IMTs were measured in 35 children. We studied 21 patients aged 3–60 months old with acute KD and 14 febrile patients aged 3–194 months old with acute infection and similar characteristics to those of KD patients. Children with KD had a significantly higher IMT compared with the controls (0.550 ± 0.081 mm vs. 0.483 ± 0.046 mm, P = 0.01).

Conclusions

IMT during the acute stage of KD is increased, suggesting that IMT could be a useful diagnostic tool in the early diagnosis of KD.

Takayasu arteritis: criteria for surgical intervention should not be ignored

Takayasu aortoarteritis is a rare, chronic granulomatous panarteritis with significant morbidity amongst young patients. Current challenges include a lack of awareness about the condition, delays in diagnosis due to its varied presentation, and suboptimal methods for assessing disease activity. The development of noninvasive imaging including magnetic resonance angiography and positron emission tomography is aiding earlier diagnosis. Early initiation of immunosuppressive treatment is crucial to control active inflammation and minimize arterial injury. Recent studies investigating biological agents such as tumour necrosis factor-α antagonists are encouraging. Surgical revascularization should only be undertaken following careful consideration, as restenosis is common. The indications for considering intervention include uncontrolled hypertension due to renal artery stenosis, severe symptomatic coronary artery or cerebrovascular disease, severe aortic regurgitation, stenotic or occlusive lesions resulting in critical limb ischemia, and aneurysms at risk of rupture. In these cases, the risk benefit ratio for intervention is good. Open surgery, at present, has better outcomes compared to endovascular techniques. However, technological advances in endovascular treatment are continually improving. Controlling disease activity prior to and following revascularization is key to preventing complications. A multidisciplinary approach to the diagnosis and management of Takayasu arteritis is essential to achieve satisfactory patient outcomes.

Advances in the diagnosis, assessment and outcome of Takayasu's arteritis

Takayasu's arteritis (TAK) is a rare, chronic large-vessel vasculitis (LVV) that predominantly affects aorta, its major branches, and the pulmonary arteries. Segmental stenosis, occlusion, dilatation, or aneurysm formation may occur in the vessel wall during the course of the disease. The vascular involvement can be shown with different imaging modalities to make the diagnosis of TAK. Conventional angiography, the gold standard method for initial diagnosis, seems to be replaced with the new imaging modalities such as magnetic resonance angiography (MRA) and (18)F-fluorodeoxyglucose positron emission tomography (FDG-PET) in recent years. The data coming from the new studies support that MRA and FDG-PET are also promising for the assessment of disease activity. Prognosis is possibly getting better with lower mortality in recent years; however, it is difficult to assess the widely different vascular intervention rates among the clinical series. Leflunomide, TNF-α antagonists, and tocilizumab are new options in patients resistant to conventional therapies. There is a clear need to develop a validated set of outcome measures for use in clinical trials of TAK. The OMERACT Vasculitis Working Group has taken on this task and aims to develop a core set of outcomes for LVV.

Prevalence and predictors of carotid wall triple line pattern in a general population sample

OBJECTIVE

Carotid intima-media thickness (IMT) and plaques are markers of atherosclerosis and predict cardiovascular events. A specific sonographic triple line pattern (TLP) of the carotid wall has been identified in different conditions, but its origin and clinical significance are unclear. We examined the prevalence and predictors of TLP in a general population.

METHODS AND RESULTS

The study was conducted in random sample of the general population of Novosibirsk, Russia, within the international Health, Alcohol and Psychosocial Factors in Eastern Europe project. In a subsample of 418 men (aged 45 to 69), carotid IMT, the presence of atherosclerotic plaques, and the presence of TLP were assessed by ultrasound. The prevalence of TLP was 21%. It was associated with IMT (odds ratio = 9.53 per 1 SD, P<0.001) and the presence of plaques (odds ratio = 2.42, P = 0.002). Other predictors of TLP in multivariate models included age, systolic blood pressure, total cholesterol, and smoking. In addition, infrequent consumption of high amounts of alcohol approximately doubled the risk of triple pattern.

CONCLUSIONS

Our findings showed high prevalence of TLP of carotid wall in a general male population sample from a typical Russian city. This sonographic pattern was strongly associated with cardiovascular risk factors and diseases, bioimaging indicators of atherosclerosis, and episodic heavy drinking.

Takayasu arteritis--advances in diagnosis and management

Takayasu arteritis, a rare granulomatous vasculitis affecting young people, is associated with considerable morbidity and premature mortality. In most patients the diagnosis is delayed until after the development of substantial arterial injury. Studies of noninvasive imaging techniques suggest that these approaches might facilitate earlier diagnosis and have a role in monitoring disease progress; however, they remain limited in their ability to accurately quantify inflammatory disease activity in the arterial wall. A lack of controlled clinical trial data complicates the choice of therapy for Takayasu arteritis, and clinical indices for monitoring disease activity are currently suboptimal. Increasing knowledge of the pathogenesis of the large vessel vasculitides might eventually lead to novel targeted therapies. Preliminary data from open-label trials of anti-tumor necrosis factor therapy are encouraging, but there is an urgent need for controlled clinical trials to establish optimum therapeutic approaches for this disease. These trials should include a prospective assessment of the use of noninvasive imaging modalities in the diagnosis and subsequent management of Takayasu arteritis.

Diagnosis of a 65-year-old male patient with Takayasu's arteritis by 18F-FDG PET/CT

Takayasu's arteritis (TA) is characterized by a chronic inflammatory arteriopathy with unknown etiology affecting large vessels. As TA occurs mostly in young females, elderly males with this disease may be under-diagnosed. A 65-year-old Chinese male with a 6-week history of fever, fatigue, low appetite, night sweats, and a 5-kg weight loss did not experience symptoms of jaw claudication, localized headache, sudden visual change, upper or lower extremity claudication, arthralgia, and rashes. On physical examination and laboratory findings, there was no evidence of infectious disease or malignancy. (18)F-Fluorodeoxyglucose positron emission tomography/computed tomography ((18)F-FDG PET/CT) was performed which suggested TA. The patient was treated with methylprednisolone and clopidogrel. His symptoms subsided gradually and hematological examination showed decreases of erythrocyte sedimentation rate and high-sensitivity C-reactive protein. We reported here a patient who presented with fever of unknown origin and was diagnosed with TA using PET/CT. Although elderly males are beyond the predominant population of TA, TA should be considered when there is no evidence of infectious disease and malignancy.

Endovascular Management of Takayasu Arteritis: Is It a Durable Option?

Interim outcome of endovascular management of Takayasu arteritis (TA) was determined retrospectively to assess the efficacy of angioplasty and/or stenting in 24 patients with 35 lesions in the chronic inactive stage. The renal ( n = 16), subclavian/innominate ( n = 11), and carotid ( n = 5) arteries and abdominal aorta ( n = 3) were treated. Twenty-six lesions achieved excellent to good target lesion revascularization with no residual or only minimal residual stenosis, whereas five had a moderate result. Thirty lesions achieved satisfactory hemodynamic correction. Restenosis was observed in 8 lesions treated with angioplasty alone ( n = 18) and in 3 lesions treated with angioplasty and stenting ( n = 17). All recurrent stenoses underwent successful reintervention without significant complication. Treatment of inactive stage TA lesions with angioplasty alone or with angioplasty and stenting results in excellent to good clinical improvement in the majority of patients (follow-up at 46.8 months). Endovascular therapy is a durable treatment option in patients with chronic inactive stage TA.

Arterite de Takayasu: aspectos clínicos e terapêuticos em 36 pacientes

CONTEXTO: A arterite de Takayasu é uma vasculite crônica, geralmente com diagnóstico tardio devido à pouca especificidade dos sintomas durante a fase inicial do acometimento vascular. A terapêutica de eleição é o uso de imunossupressores. O procedimento cirúrgico, quando necessário, é sempre evitado na fase aguda. OBJETIVO: Descrever alterações clínicas, laboratoriais e vasculares de arterite de Takayasu no período de 1977 a 2006. MÉTODO: A amostra compreendeu 36 pacientes - 10 brancos, 35 mulheres, idade média de 31,7 anos (±13,7), com prevalência significante na quarta década (p < 0,005). Evolução de 3 anos e período até o diagnóstico de 7,9 anos. Velocidade de hemossedimentação (VHS) e proteína C reativa (PCR) avaliaram atividade da doença, e o duplex scan aferiu a espessura médio- intimal da artéria carótida. RESULTADOS: Hipertensão arterial sistêmica e claudicação de membros superiores e inferiores foram ressaltados em 85,2, 69,5 e 30,5%, respectivamente. O resultado da VHS foi > 60 mm em 50% da amostra (p < 0,005). PCR mg/dL foi realizado em 18, variando de 0,4-25 na admissão para 0,11-1,9 na evolução. Doença auto-imune, tuberculose e HIV correlacionaram-se em 19,4, 8,3 e 2,7%, respectivamente. Lesões aórticas foram significativas em 22% (quatro oclusões, dois aneurismas infra-renais, um torácico). Em 19,4%, foram acometidas artérias renais e subclávias uma oclusão bilateral de carótidas, e em 25% os membros inferiores. A espessura médio-intimal da carótida comum foi estratificada em: > 3 mm, < 3 e > 1,7, < 1,7 e > 1,2 e < 1,2 mm, representando 41,6, 19,4, 8,37 e 30,50%, respectivamente (p < 0,005). Glicocorticóides foram utilizados em 61,1%, azatioprina em 16.6%, e associada a ciclofosfamida em 8,3%. Procedimento cirúrgico ou endovascular foi realizado em 30,5% com dois óbitos por complicações cardiovasculares. CONCLUSÕES: A VHS, PCR, e a espessura médio-intimal nas carótidas são importantes marcadores de acompanhamento da arterite de Takayasu. O período entre os sintomas e o diagnóstico deve ser abreviado, com redução da morbimortalidade.

Follow-up CT evaluation of the mural changes in active Takayasu arteritis

Objective

We wanted to evaluate the mural changes by CT on the follow-up examination of patients with active Takayasu arteritis.

Materials and Methods

The study included 18 patients, (4 males and 14 females), with active Takayasu arteritis. A total of 44 CT examinations were done during the follow-up period (mean: 55.6 months). At the time of the last follow-up CT, the disease, on the basis of the erythrocyte sedimentation rate (ESR), was found to be inactive in five patients and the disease was active and persistent in 13 patients. The thickness and CT attenuation of the aortic wall on the precontrast, arterial and venous phases were measured on the initial and the follow-up CT examinations. The ratio of the mural attenuation over that of the back muscle on the initial CT was compared with the ratio found on the follow-up CT.

Results

The initial CT findings included high density and calcifications of the aortic wall in the precontrast images and a thickened wall with enhancements in the arterial and the venous phases. A low-attenuation ring was demonstrated in the venous phase in 15 patients (83%). On the follow-up evaluation, the mean mural thickness decreased significantly from 4.1 mm to 2.4 mm. The mean mural attenuation ratio in the venous phase decreased significantly from 1.9 to 1.3 (p = 0.001). The low attenuation ring was identified in seven patients (39%) who had only with active, persistent Takayasu arteritis.

Conclusion

The mural changes demonstrated by the follow-up CT evaluations for the patients with active Takayasu arteritis included a decrease of the mural thickness and enhancement, disappearance of the low-attenuation ring on the venous phase, and an increase of the mural attenuation and calcification on the precontrast phase.

Atherosclerosis in Takayasu arteritis

OBJECTIVE

Chronic inflammatory diseases such as systemic lupus erythematosus (SLE) and rheumatoid arthritis are associated with accelerated atherosclerosis. We hypothesised that atherosclerosis may also be increased in Takayasu arteritis.

METHODS

The frequency of atherosclerotic plaques and the intima-media thickness (IMT) were investigated in 30 female patients with Takayasu arteritis (mean age (standard deviation), 35.4 (8.0) years), along with 45 sex-matched and age-matched patients with SLE (37.4 (6.8)) and 50 healthy controls (38.2 (5.7)). Plaques were scanned and IMT was measured at both sides of the common carotids, carotid bulb, and internal and external carotid arteries by B-mode ultrasonography. Traditional risk factors for atherosclerosis were also assessed.

RESULTS

Most of the atherosclerotic risk factors were comparable between patients with Takayasu arteritis and SLE. More atherosclerotic plaques were observed among patients with Takayasu arteritis (8/30; 27%) and those with SLE (8/45; 18%) than among the healthy controls (1/50; 2%; p = 0.005). Logistic regression analyses showed that the presence of a plaque was associated only with age in both Takayasu arteritis and SLE (p = 0.04 and 0.02, respectively). The mean overall IMT was significantly higher among patients with Takayasu arteritis (0.95+/-0.31 mm) than among the patients with SLE (0.58+/-0.10 mm) and the healthy controls (0.59+/-0.08 mm; p<0.001).

CONCLUSION

Patients with Takayasu arteritis have a high rate of atherosclerotic plaques, at least as frequent as that observed among patients with SLE.

La TEP au 18FDG au cours de l'artérite de Takayasu : un marqueur d'activité de la maladie

INTRODUCTION

Takayasu arteritis (TA) is an inflammatory arteritis affecting large vessels, predominantly the aorta, its main branches, and the pulmonary arteries. Up to now, arteriography was considered as the "gold standard". But others exams are emerging in the management of TA: vascular ultrasound, angio-scanner, magnetic resonance imaging and 18FDG positron emission tomography (18FDG PET). Such investigations allow a study of the lumen but also of the arterial walls. However, at the time, no biological or radiological test is able to determine the activity of TA. 18FDG PET could be effective to estimate the disease activity.

EXEGESIS

We report the case of a young woman for who 18FDG PET permit to assert a relapse of TA.

CONCLUSION

18FDG PET could be effective to estimate the disease activity.

Carotid intima–medial thickness as a marker of disease activity in Takayasu's arteritis

BACKGROUND

Assessment of disease activity in patients with Takayasu's arteritis (TA) is difficult due to absence of definitive tests. Presence of carotid intima-medial thickening has been suggested as a possible marker of inflammation and disease activity.

METHODS

We evaluated common carotid artery carotid intima-medial thickness (CCA-IMT) in 56 common carotid arteries (CCAs) in 28 healthy controls and 74 CCAs in 37 patients of TA. We correlated these findings with the presence of activity as assessed by the National Institutes of Health (NIH) criteria.

RESULTS

CCA-IMT was increased (>0.8 mm) in 59% of the patients with TA. In patients with disease activity, the CCA-IMT was more than in those without activity (1.5+/-0.16 vs. 0.9+/-0.2 mm, P<0.005). This is presumably because of ongoing inflammation causing abnormal thickening. Even among patients without active disease, CCA-IMT was more than in controls (0.9+/-0.2 vs. 0.6+/-0.1 mm, P<0.05) possibly due to a milder degree of inflammation or healing with fibrosis. All patients with angiographic carotid obstruction had increased CCA-IMT irrespective of whether they were active or not. However, in patients with angiographically normal carotid arteries, CCA-IMT was increased only among the patients who were active (1.4+/-0.2 vs. 0.7+/-0.04, P<0.05). Abnormal CCA-IMT as marker of disease activity had a sensitivity of 82% and specificity of 60%. On excluding patients with increased CCA-IMT who had angiographic carotid stenosis (because the increase in CCA-IMT cannot be attributed entirely to activity alone in these patients), the specificity increased to 70%.

CONCLUSION

Increased CCA-IMT is a reliable marker of active disease, especially in the absence of angiographically visible carotid disease.

Takayasu's arteritis: A case report and a brief review of the literature

Takayasu’s arteritis primarily affects young women. The current case report focuses on a Caucasian middle-aged woman who complained of weakness, malaise, and fatigue for as many as 19 years. Delayed diagnosis and lack of specific treatment could explain the extent and the clinical severity of the disease at time of hospital admission. Angiography showed focal narrowings of the abdominal and thoracic aorta and occlusion of both the subclavian arteries, of the right coronary artery and severe stenosis of the first marginal obtuse. Takayasu’s arteritis is not limited to women of Japanese origin but is present worldwide. Early diagnosis and treatment is warranted. Outcome appears to be favorable when the disease is quiescent.

Les aortites inflammatoires

PRINCIPLE AND OTHER CAUSES: Takayasu's arteritis, giant cell arteritis and Behçet's disease are the three main causes of inflammatory aortitis. More rarely, aortitis can be observed in Cogan's syndrome, atrophic polychondritis, sarcoidosis, ankylosing spondylitis and in rheumatoid arthritis. RISKS OF PROGRESSION: Takayasu's arteritis is distinct with the development of stenotic lesions of the aorta. With the other causes, aortitis can be complicated by ectasia or even aneurysm, with the risk of rupture. Indeed, during giant cell arteritis, patients are 17 times more likely to develop thoracic aortic aneurysm. Aortic regurgitation is a frequent complication of inflammatory aortitis. Sometimes, aortitis is only manifested by general signs such as fever or an inflammatory syndrome. SUPPLEMENTARY EXPLORATIONS: Recent advances in diagnosis and follow-up of patients with inflammatory aortitis concern the use of non-invasive imaging techniques: Doppler ultrasonography, computed tomography with injection of a contrast product and magnetic resonance imaging, which currently replace the aortography.

DIAGNOSTIC PROBLEMS

Infectious aortitis, inflammatory atheromatous aneurysm and retroperitoneal fibrosis are sometimes misleading differential diagnoses.

Use of imaging studies in the diagnosis of vasculitis

Imaging studies are necessary to determine disease extension and disease activity in the small-vessel vasculitides. Computed tomography (CT) and magnetic resonance imaging (MRI) increase the number of pathologic findings compared with conventional radiography. MRI delineates mucosal inflammation and granulomas in the paranasal sinuses, whereas CT provides information about osseous lesions. CT is superior to MRI for the detection of pulmonary lesions. Radiograph angiography has been the gold standard for medium- and large-vessel vasculitides for decades. Echocardiography and MRI correspond well with conventional angiography to assess cardiac involvement in Kawasaki disease. MRI, CT, and CT angiography are alternative noninvasive techniques to delineate vasculitic lesions in polyarteritis nodosa, Takayasu's arteritis, and large-vessel giant cell arteritis. Duplex ultrasonography has the greatest resolution. It delineates typical artery wall swelling in temporal arteritis and Takayasu's arteritis. Positron emission tomography can assess inflammatory activity of large arteries.

Diagnostic imaging in Takayasu arteritis

PURPOSE OF REVIEW

New imaging modalities may help accurately diagnose and monitor Takayasu arteritis (TAK). Examination of the published literature on arterial imaging studies other than conventional angiography will help guide appropriate use of these studies in TAK. MRI, magnetic resonance angiography (MRA), Doppler ultrasound, CT, and positron emission tomography (PET) are all potentially useful for evaluation of TAK.

RECENT FINDINGS

MRI/A avoids the risks of arterial puncture, iodinated contrast load, and radiation exposure, while providing information on arterial wall anatomy and obtaining a generalized arterial survey in TAK. Ultrasound can be helpful in detecting sub-millimeter changes in wall thickness of the carotid arteries and in differentiating TAK from atherosclerotic disease based on minimal plaque content, concentric and long segmental involvement, and location of lesion. Like MRI, CT angiography can be used to detect areas of aortic wall thickening and obtain a generalized survey of the aorta and its proximal branches for areas of stenosis and without the risks associated with arterial puncture. However, CT provides less detailed resolution than ultrasound and incurs the risks of contrast administration. Finally, PET scanning may provide valuable information about cellular activity within an inflamed arterial wall before morphologic changes on other imaging studies.

SUMMARY

Although it is still unclear how often early arterial wall changes lead to stenotic lesions, use of these modalities in combination, for both routine monitoring and evaluation of new symptoms, may facilitate the detection of TAK disease activity at a more treatable stage.