Clinical, angiographic profile and percutaneous endovascular management of Takayasu’s arteritis – A single centre experience.
- 1Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, Karnataka, India. Electronic address: firstname.lastname@example.org.
- 2Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, Karnataka, India.
Aim of the study was to evaluate clinical, angiographic profile and percutaneous endovascular management of Takayasu’s arteritis.
Takayasu’s arteritis is a chronic inflammatory vasculitis affecting the aorta and its major branches. Although it is more prevalent in Asia, the distribution of the disease is worldwide with different vascular involvement patterns and clinical manifestations.
In this prospective study a total of 50 consecutive patients who were reported as having Takayasu’s arteritis between January 2010 and April 2016 were evaluated. Detailed clinical presentation and angiograms of all patients were analysed.
50 patients were analysed during study period. Among 50 patients, 43(86%) were female and 7 (14%) were male. Average age of presentation was 26.92years. Most common clinical presentation was claudication (74%) followed by, musculoskeletal symptoms (48%), fatigue (46%), weight loss (22%), headache (22%), visual disturbances (16%), syncope (10%), dyspnoea (20%). Most common features were absent/diminished pulses (80%), difference in blood pressure (80%), followed by bruit (70%)hypertension (64%), cerebrovascular accident (8%),heart failure (8%) and aortic regurgitation (4%). According to the new angiographic classification, angiographic type I (40%) was encountered most frequently, followed by type III (30%), type V (16%), type IIb (8%), type IIa (2%), and type IV is (4%). Angioplasty was the main stay of treatment in 66% of the patients, remaining 34% of them were treated medically either with corticosteroids or methotrexate.
Takayasu’s arteritis is a rare disease, affects mainly women, manifestations range from asymptomatic disease, found as a result of impalpable pulses or bruits, to catastrophic neurological impairment. Takayasu’s arteritis is the common cause of renovascular hypertension. Angiography remains the gold standard for diagnosis. Angiographic evaluation and percutaneous transluminal angioplasty with stenting is useful in selected cases.
KEYWORDS: Angiographic profile; Clinical profile; Takayasu’s arteritis
- PMID:27420344; DOI:10.1016/j.ijcard.2016.06.194
VASCULAR INTERVENTIONS IN NONSPECIFIC AORTOARTERITIS [TAKAYASU’S]
Dr H.S. Natraj Setty MD, DM, FICC; Dr B.C Srinivas MD,DM; Dr. Rahul Patil MD,DM; Dr. Shivanand S Patil MD,DM; Dr C.N.Manjunath MD, DM.
Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, Karnataka, India
Dr. H.S. Natraj Setty MD, DM, FICC.
Assistant Professor of Cardiology,
Sri Jayadeva Institute of Cardiovascular Sciences and Research,
Bangalore, Karnataka, India.
Mobile No. – 9845612322
Telephone No. – 080-26580051
#493, 4th Cross, 7th Main,
J.P. Nagar 3rd Phase.
Bangalore – 69
Takayasu arteritis is an inflammatory disease of large and medium-size arteries involving the aorta and its branches, and occasionally, pulmonary arteries and coronary arteries. Predominantly seen in young women with onset in the second or third decade. However, rare cases may present in early age groups. Etiology is still unclear although autoimmunity has been shown to play a major role. It differs in clinical manifestations based on ethnicity and geographical distributions. Management of Takayasu arteritis is challenging because of the variations in its clinical and anatomical and angiographic findings. Endovascular intervention has emerged as the major modality management of Takayasu arteritis.
Management of Takayasu arteritis depends on the clinical manifestations, disease activity, stage and its complications. Medical treatment is usually provided during the active phase and the chronic phase is managed by the surgical or endovascular procedure.
Procedures to re-establish flow in stenotic or occluded vessels include surgical use of synthetic grafts or autologous vessel bypass, endarterectomy, and percutaneous transluminal angioplasty (PTA), with or without stenting. Although often initially successful, vascular interventions in TA patients are prone to failure due to the ongoing inflammatory process, degree of vessel fibrosis, and length of lesions. Selecting the best intervention for the lesion in question remains a very difficult area and requires the evaluation of an experienced cardiac or vascular surgeon.
In two American longitudinal cohorts, intervention for either vessel stenosis or aortic regurgitation was required in one-half to two-thirds of TA patients over mean periods of 3 to 5 years [1-2]. Several large TA cohorts have confirmed superior patency rates following bypass grafting as compared to stenting for TA lesions, with follow up extending out to 6.5 years.[3-5] However, advances in surgical techniques such as the use of stent grafts may eventually lead to improved outcomes for endovascular procedures in these patients.
Revascularization should ideally be performed during periods of disease remission. In a retrospective review of 79 TA patients undergoing revascularization, inflammation at the time of intervention was independently associated with arterial complication. There appears to be a clear benefit to achieving good control of disease activity with the use of immune suppression both pre- and postoperatively.
Treatment of late inactive stage TA lesions with angioplasty alone or with angioplasty and stenting results in excellent to good clinical improvement of symptoms in the majority of patients
Endovascular Treatment Indication:
- Clinically significant ischemic symptoms such as renovascular hypertension.
- Clinical features of cerebrovascular ischemia.
- Critical stenosis of at least three cerebral vessels.
- Angiographically demonstrable stenosis over 75% of diameter and focal stenosis than diffuse long segment lesion, which is compatible with clinical symptoms.
- Clinically inactive state.
The current approach using endovascular therapy (angioplasty and stenting) to treat chronic inactive lesions has shown excellent revascularization in the majority of patients. In a Prospective study, Clinical outcomes expressed as cumulative primary success (71.4%) and secondary successes (77.1%) were excellent, with an average follow-up of 46.8 months.
Endovascular therapy does not offer a definitive cure in patients with chronic inactive TA, and its long-term durability remains to be defined. It can be performed with reasonable safety and success, especially in chronic cases, in which the active versus the inactive status is unclear. Early application of endovascular therapy in patients with chronic TA appears to be a good treatment option, especially in situations in which the risk of recurrence and reactivation of the disease remain high, thus making open surgical bypass a much less attractive treatment option.
There are no clear guidelines regarding the selection of endovascular versus open surgical intervention in TA patients with chronic inactive disease. Endovascular therapy may be used for palliation of severe symptoms in these patients. On the other hand, with regard to open surgical intervention, identification of a disease-free area of artery is required for the bypass graft anastomosis. This is extremely important to prevent the development of anastomotic stricture and/or pseudoaneurysm formation following bypass surgery . Endovascular retrieval of artery tissue for histologic evaluation may be helpful in planning open bypass surgery. Endoluminal artery wall biopsy may miss areas of hidden or dormant inflammatory activity in an area where a bypass anastomosis is planned. Therefore, if there is any doubt, endovascular intervention could be used initially, reserving the open bypass surgery for a later time.
In general, open surgical bypass or endovascular intervention should be avoided during the active inflammatory phase of TA, unless the presence of an acute life-threatening condition outweighs the risk of the intervention . Even in life-threatening situations, endovascular therapy appears to be the treatment modality that carries the lowest risk of morbidity and mortality to the patient and should be considered first before open surgical therapy.
Open surgical therapy is generally preferred over endovascular therapy when treating lesions with long segmental stenoses or occlusions and in patients with end-stage disease with complete fibrosis of the arterial wall.
For situations in which critical ischemia is unresponsive to medical therapy and endovascular therapy is neither applicable nor indicated, such as uncontrollable hypertension, severe cerebral ischemia, renal insufficiency secondary to severe renal artery stenosis, aortic stenosis, or chronic intestinal ischemia, surgical revascularization should be considered without delay .
Surgical bypass arteries reconstruction has been shown to be superior to endovascular treatment in TA . However, this relates usually to lower limb and renal arteries. The higher risk of serious early and post procedural surgical complications should also be considered [10-12] With intensive technological development, endovascular treatment has been introduced as an alternative to surgery for arterial stenotic lesions in most vascular territories. Endovascular treatment of symptomatic TA has been found to be safe and very effective with an acceptable 30-day complication rate of 7.1% as reported by Wrotniak et al.. However, it has been shown that in-stent stenosis remains the main issue in both the surgical and the endovascular approach. Different mechanisms of artery stenosis development in non-atherosclerotic vasculitis, such as TA, including chronic intramural inflammation, suggest that the use of drug-eluting systems might be an optimal way to deal with severe intimal hyperplasia, leading to early and late restenosis affecting > 30% of treated vessels . Besides typical in-stent stenosis, external stent compression by progressive vessel wall fibrosis and calcification has been described In fact, there is insufficient information on the optimal endovascular treatment of TA, especially concerning use of drug-eluting devices in the supra-aortic territory.
We used DEB before stent implantation in the RCCA because there have been no drug-eluting self-expanding stents available on the market so far. This strategy gives a higher probability of restenosis avoidance. On the other hand, the use of drug-eluting stents has been shown to increase the risk of early and late in-stent thrombosis, which in the carotid territory might have devastating sequelae. The experience acquired in coronary interventions supports the strategy of at least 6 months dual antiplatelet therapy, as it was implemented in the described case. Coherent systemic treatment with steroids and antiproliferative drugs is crucial in terms of disease inhibition as withdrawal of drugs might be associated with in-stent stenosis.
Rigorous follow-up may not be mandatory after carotid angioplasty for atherosclerotic lesion. For the carotid territory, self-expanding stent implantation is associated with 5–7% risk of significant in-stent stenosis, and it is observed mainly during the first year of follow-up. In TA the risk of restenosis is significantly higher, reaching > 50% at 5 years, and probably it does not decrease with time. The risk of symptomatic disease progression related to a new stenotic lesion is also very high and exceeds 70% at 5 years..
Outcomes of vascular intervention in TA may be improved by detailed preoperative assessment including measurement of disease activity, and by ensuring optimal immunomodulatory therapy before and after the procedure.
PERCUTANEOUS TRANSLUMINAL RENAL ANGIOPLASTY (PTRA)
Stenotic obstructive lesions of renal artery is seen in 34-85% of patients, in majority of cases there is localised or diffuse involvement of the ostia and proximal segment of renal arteries. The results of PRTA in aortoarteritis reported in literature are comparable to those in atherosclerosis and fibromuscular dysplasia. Cutting balloon angioplasty is found to be even better due to the toughness of the lesion and has been considered as approach of choice while dealing with renal vessels in takayasu arteritis. Obstructive dissection and unsatisfactory response to PTRA can be safely treated by stent implantation with excellent results
ANGIOPLASTY OF ARCH VESSELS :
Left subclavian artery is the most commonly involved artery. Carotid involvement can give rise to syncope, dizziness, CVA. PTBA of arch arteries can be successfuly performed in most cases having a focal stenosis and short segmental occlusion.
A primary success rate of 73 – 100 % and a complication rate of 0 -10 % and no mortality is reported in literature. carotid angioplasty can be performed with relative security., because the inflammatory non ulcerative nature of the lesions in aortoarteritis decreases the the potential of embolic complicationsas compared with atherosclerotic carotid artery stenosis.
ANGIOPLASTY OF MESENTRIC AND ILIAC ARTERIES :
In patients with abdominal angina due to stenosis of celiac or superior mesentric artery angioplasty or stenting gives effective result
CORONARY ANGIOPLASTY AND STENTING :
There are isolated case reports describing excellent immediate and long term results of angioplasty with or without stenting of coronary artery stenosis in aortoarteritis.
Figure 1: Aortogram showing left subclavian artery aneurysm.
Figure 2A: Renal angiography showing right renal artery stenosis.
Figure 2B: Renal angiography post PTA with stenting to right renal artery.
Figure 3: CT Aortogram showing coarctation of aorta.
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