Diagnostic approach and proposed criteria for the clinical diagnosis of Takayasu's arteriopathy

Surgical treatment of Takayasu's arteritis: case report and literature review

Surgical intervention during the early stages of Takayasu's arteritis is rarely necessary. In the chronic stages of this disease, however, surgeons may be faced with difficult decisions regarding the timing of complex arterial reconstructions. These issues can be especially challenging in the pediatric population. We report the case of an 8-year-old girl with chronic Takayasu's arteritis complicated by malignant hypertension. Despite aggressive medical therapy, her blood pressure remained uncontrolled. Imaging studies demonstrated infrarenal aortic and right common iliac artery aneurysms with concomitant segmental stenosis of the right common iliac artery. Since her transplant kidney was based off the right external iliac artery, it was felt that this high-grade stenosis was responsible for her severe hypertension. Immediate surgical reconstruction was therefore recommended. Intraoperatively, the aneurysmal aorta and iliac arteries were found to be densely calcified. The transplant kidney was perfused during aortic clamping by placement of a suprarenal aorta to the right external iliac artery shunt. Endoaneurysmorrhaphy was then performed to reconstruct the aorta after extensive endarterectomy. In the early postoperative period, antihypertensive medications were decreased to two oral agents. She was discharged on the seventh postoperative day and placed on two agents. At a 1-year follow-up visit, she is on one antihypertensive medication. Her right leg complaints have resolved. Ultrasound surveillance revealed no evidence of recurrent aneurysmal or occlusive disease. A brief review of complications related to Takayasu's arteritis in the children and indications for surgical intervention completes this report.

Enalapril and losartan augment endogenous nitric oxide release in Takayasu's arteritis--a case report

Prognosis in Takayasu's arteritis is limited owing to renovascular hypertension. The authors report a patient with Takayasu's arteritis who had been unilaterally nephrectomized and presented with malignant hypertension due to renal artery stenosis. Hypertension was refractory to conventional antihypertensive treatment, and stenosis was not accessible by interventional angioplasty. Initiation of enalapril and losartan therapy was successful in improving blood pressure without deterioration of renal function due to ischemic failure. Antihypertensive treatment resulted in dramatically stimulated endogenous nitric oxide (NO) synthesis, while elevated plasma endothelin-1 levels were unchanged. Renovascular hypertension in Takayasu's arteritis is associated with an imbalance of vasoconstrictor peptide endothelin-1 and vasodilator peptide NO. Successful treatment of hypertension by enalapril or losartan results in improved endogenous NO synthesis, which putatively counterbalances excessive vasoconstrictor actions and may retard the progression of renal failure.

Takayasu arteritis: diagnosis with MR imaging and MR angiography in acute and chronic active stages

Early diagnosis and treatment of Takayasu arteritis is important in prevention of serious complications. Spin-echo magnetic resonance imaging (MRI) can depict early wall thickening of the aorta and cine MRI can evaluate aortic valve function. Significant enhancement in and around the aorta and carotid arteries is observed on postcontrast MR images in acute phase Takayasu arteritis. In the chronic phase, contrast enhancement in the aortic wall stronger than in the myocardium suggests activity of the disease. Breath-hold contrast-enhanced three-dimensional MR angiography is very effective in noninvasive evaluation of luminal change of aortitis. Contrast-enhanced MRI and MR angiography have an important role in early diagnosis, activity determination, and follow-up of Takayasu arteritis. MRI and MR angiography can be utilized for initial diagnosis of Takayasu arteritis and replace catheterization angiography. J. Magn. Reson. Imaging 1999;10:751-757.

Monoclonal anti-endothelial cell antibodies from a patient with Takayasu arteritis activate endothelial cells from large vessels

OBJECTIVE

To create monoclonal anti-endothelial cell antibodies (mAECA) from a patient with Takayasu arteritis to evaluate their ability to activate human umbilical vein endothelial cells (HUVEC), and to characterize the mechanism of EC activation.

METHODS

A panel of mAECA was generated from peripheral blood lymphocytes of a patient with Takayasu arteritis, using Epstein-Barr virus transformation. Activity against macrovascular EC (HUVEC) and microvascular EC (human bone marrow EC immortalized by SV40) antigens was detected by enzyme-linked immunosorbent assay. Inhibition studies were used to select the monoclonal antibodies (mAECA) which share the same EC epitope binding specificity as the total IgG-AECA from the Takayasu arteritis patient. The binding of the mAECA to human aortic EC was studied by immunohistochemistry. The secretion levels of interleukin-6 (IL-6) and von Willebrand factor (vWF) were determined, to serve as markers for EC activation. The activated EC were examined for the adherence of a monocytic cell line (U937), as well as for expression of vascular cell adhesion molecule 1, intercellular adhesion molecule 1, and E-selectin. In addition, nuclear extracts of the mAECA-treated EC were analyzed for the induction of translocation of nuclear factor kappaB (NF-kappaB), using a specific NF-kappaB oligoprobe in an electrophoretic mobility shift assay.

RESULTS

Six mAECA were selected, the mixture of which produced 100% inhibition of binding of the original IgG (from the patient with Takayasu arteritis) to HUVEC. All mAECA possessed high activity against macrovascular EC, but none had significant antimicrovascular EC activity. The mAECA, but not normal human IgG, had anti-human aortic EC activity. Four of the 6 mAECA activated EC, manifested by increased IL-6 and vWF secretion. The 4 mAECA induced EC expression of adhesion molecules and increased adhesion of U937 monocytic cells to EC. In addition, these mAECA stimulated the nuclear translocation of the NF-kappaB transcription factor.

CONCLUSION

Our findings suggest that AECA may directly stimulate EC in Takayasu arteritis through elevation of adhesion molecule expression associated with NF-kappaB activation and adhesion of monocytes, and may therefore play a pathogenic role in the development of the vasculopathy in Takayasu arteritis.

Takayasu's arteritis accompanied with massive pericardial effusion--a case report

A 40-year-old woman who had been treated for Takayasu's arteritis was admitted to the hospital with fever, fatigue, malaise, and severe chest pain. Computed tomography of the chest demonstrated massive pericardial effusion and bilateral pleural effusion. In laboratory data, the C-reactive protein was high at 22.0 mg/dL, and erythrocyte sedimentation rate was also high at 80 mm/hr. The diagnosis was pericarditis with a recurrence of the systemic inflammatory process of Takayasu's arteritis. The patient was treated with methylprednisolone pulse therapy. Her massive pericardial effusion disappeared without pericardiocentesis.

Takayasu's arteritis: an unusual manifestation--a case report

Takayasu's arteritis is a rare entity. The authors describe a case of a middle-aged woman with an atypical form of Takayasu's arteritis. This manifestation has not been described previously.

Stenosis in the aorta caused by non-specific aortitis: results of treatment by percutaneous stent placement

AIM

To evaluate the short-term results of percutaneous stent placement in treating stenosis in the aorta caused by non-specific aortitis (Takayasu's disease).

METHOD

Five patients were treated by this method, all of whom had uncontrolled hypertension, haemodynamically significant stenosis in the aorta and a clinically inactive disease. Stents were placed to treat an obstructing dissection in four and recurrent stenosis in one patient. All procedures were carried out via the percutaneous transfemoral route, utilizing self-expanding stents.

RESULTS

The lesion was located in the thoracic aorta in three patients and in the abdominal aorta in two patients. The stenosis decreased from 81+/-2 to 7+/-3%, the pressure gradient fell from 97+/-5 to 9+/-2 mmHg, the blood pressure improved from 200+/-3/124+/-2 to 131+/-2/81+/-2 mmHg, and the drug requirement fell from 4+/-.2 to 1.3+/-.3 (P value for all <0.001). No complication was encountered. At follow-up at 13+/-4 months, all of the patients had improved clinically. Intimal hyperplasia within the stent was seen in two patients who underwent follow-up angiograms.

CONCLUSION

Percutaneous aortic stenting is useful in treating selected patients with non-specific aortitis. Further information about the long-term behaviour of intimal hyperplasia and the response of stented segments to the aging process needs to be understood before elective stenting in this young patient population can be advocated.

Increased levels of soluble forms of adhesion molecules in Takayasu arteritis

The present series of experiments were designed to determine if soluble forms of vascular cell adhesion molecule-1 and inter cellular adhesion molecule-1 are elevated in the setting of Takayasu arteritis. Plasma levels of these soluble adhesion molecules were measured by enzyme-linked immunosorbent assay in 73 Takayasu arteritis and 36 age-matched normal controls and examined with respect to the age of patients. Soluble vascular cell adhesion molecule-1 levels were significantly higher in Takayasu arteritis (mean 871.4 ng/ml, P<0.01) compared with controls (mean 607.9 ng/ml). No difference was found in soluble inter cellular adhesion molecule-1 levels between these two groups. Comparison of soluble vascular cell adhesion molecule-1 and inter cellular adhesion molecule-1 in these patients subdivided by age into three groups indicated significantly higher levels of these molecules in individuals over 50 years old compared to those under 39 years old (P<0.05). These data suggest that the measurement of soluble vascular cell adhesion molecule-1 may be clinically important in Takayasu arteritis. The correlation of soluble vascular cell adhesion molecule-1 and inter cellular adhesion molecule-1 levels with age may indicate some relationship with progression of this disease.

Surgical treatment for annuloaortic ectasia in Takayasu arteritis

Annuloaortic ectasia (AAE) associated with aortic regurgitation (AR) is a rare involvement in Takayasu arteritis. There are many difficult problems in surgical treatment of this lesion because of its inflammatory nature. We developed a composite graft repair technique to avoid complications associated with Bentall type procedures for treatment of AAE+AR. The technique consists of a double proximal suturing and direct coronary artery reimplantation as a Carrel patch without wrapping. Eight patients (one male, seven females) received this composite graft repair for treatment of AAE+AR due to Takayasu arteritis. Of them, two patients were in active phase. There was one hospital death probably due to ventricular arrhythmia, however, no late death occurred. And there were no late complications related to operative procedures. Thus, our composite graft repair technique for treatment of AAE+AR in Takayasu arteritis can prevent major complications associated with Bentall type procedures. However, close serial follow-up, careful control of inflammation, and early detection and treatment of other vascular involvements are necessary in the postoperative management of patients with Takayasu arteritis.

Subclavian steal syndrome secondary to Takayasu arteritis

We present a case of 'subclavian steal syndrome' secondary to Takayasu arteritis, in a 32-year-old, Japanese woman, whose clinical manifestations result from severe ocular and brain ischemia, refractory to high dose systemic corticosteroids. Surgical management using two bypass-grafts was carried out. The first one, a GoreTex, 8 mm in diameter, thin wall, stretch type with ring-bypass graft, from the left external iliac artery to the ipsilateral axillary artery. The second one, an autologous reverse saphenous vein graft from the left subclavian artery to the ipsilateral common carotid artery. The result was a remarkable improvement of the patient's general condition and symptoms. Patency of the extra-anatomic conduits was established by digital subtraction angiography (DSA), and transcranial Doppler evaluation, as well as flow velocity assessment revealed an objective improvement of the blood supply to the ischemic areas. The present surgical approach was justified since the inflammatory process extended to the aortic arch. The development of new and efficient operatory techniques, and continuous improvement of the graft-materials provide better expectations for the long-term outcome of refractory syndromes.

Atypical Takayasu arteritis: late onset and arthritic manifestations: report of two cases

We recently experienced two cases of Takayasu arteritis rendered atypical by late onset (over 60 years of age) of disease, involvement of distal branch arteries, and association with rheumatoid arthritis. In both cases, roentgenologic examination revealed typical appearance of the abdominal aorta and stenosis of the subclavian artery entirely compatible with Takayasu arteritis. In addition, Case 1 had occlusive lesions of the superficial femoral arteries and Case 2 manifested occlusion of the axillary artery. Laboratory findings showed increased ESR and CRP but negative HLA B52 locus. Both cases showed arthritis symptoms with swelling, pain, and tenderness in joints. Case 1 did not manifest erosive lesions and positive RA test; Case 2 showed roentgenologic erosive lesions in hand joints with positive RA test. A surgical specimen from the femoral artery of Case 1 showed lesions suggesting Takayasu arteritis. Based upon these findings, we diagnosed the two patients as having atypical Takayasu arteritis with late middle age onset and arthritic manifestations.

Magnetic resonance imaging diagnosis of Takayasu arteritis

Conventional angiography has been used for diagnosis of Takayasu arteritis (TA). In early stage of TA, subtle inflammatory wall thickening of the aorta and its branches without significant stenosis may be the only morphologic change of TA. Magnetic resonance (MR) imaging appears to be useful in the diagnosis of early stage TA by visualizing concentric wall thickening of the vessels. T2-weighted images may show bright signal of edema in and around the inflamed vessel. Contrast media-enhanced MR shows enhanced wall of vessels even in chronic stage, which may indicate the activity of TA at the tissue level. MR angiography allows us noninvasive assessment of the vascular tree and it may replace conventional angiography.

Diagnosis and management of stenotic aorto-arteriopathy in childhood

Stenotic aorto-arteriopathy is an uncommon vascular lesion characterized by segmental arterial stenoses. We reviewed the experience with several management algorithms to define the most effective management course. The clinical records of 14 pediatric patients with acquired SAA who presented over a 16-year period were reviewed. Most patients presented with a mid-thoracoabdominal coarctation and were diagnosed with Takayasu arteritis. Differentiating between Takayasu arteritis and fibromuscular dysplasia was difficult on clinical grounds or by angiography. Medical management of the end-organ disease and renovascular hypertension was only palliative. Selective percutaneous transluminal balloon angioplasty of the stenotic renal arteries had only transient benefits; renal autotransplantation had slightly better success. Dilation of stenosed aortic segments with balloon-expandable endovascular stents and subsequent renal autotransplantation proved useful. Distinguishing SAA resulting from fibromuscular dysplasia caused by Takayasu arteritis in the chronic vaso-occlusive phase may be unnecessary for effective treatment. Therapy should focus on interventions to minimize the end-organ damage caused by the vaso-occlusive manifestations of the disorders.

Carotid tenderness: an ominous sign of giant cell arteritis?

Giant cell (temporal) arteritis is a systemic vasculitis involving medium and large-sized vessels. Despite the high frequency of involvement of cranial arteries, pain on examination of the external carotid artery itself has been exceptionally reported. We describe 3 patients with biopsy-proven giant cell arteritis (GCA) and wincing pain on palpation over the external carotid. The presence of this sign may be a harbinger of the existence of severe vascular involvement in patients with GCA.

Results of renal angioplasty in nonspecific aortoarteritis (Takayasu disease)

PURPOSE

To evaluate the long-term results of percutaneous transluminal renal angioplasty (PTRA) in the management of renovascular hypertension caused by nonspecific aortoarteritis (Takayasu disease).

MATERIALS AND METHODS

The results of 96 stenoses in 66 patients were retrospectively studied. The indications for PTRA included hypertension uncontrolled by single-drug therapy, evidence of greater than 70% diameter stenosis in the renal artery with a peak systolic gradient of greater than 20 mm Hg, and clinically inactive disease.

RESULTS

Technical success was obtained in 91 (95%) stenoses in 62 patients. Clinical success was seen in 59 (89%) and included "cure" in 14 and "improvement" in 45 patients. The stenosis decreased from 88% +/- 6% (range, 70%-100%) to 11% +/- 12% (range, 0%-40%), systolic pressure gradient decreased from 95 mm Hg +/- 22 (range, 30-140 mm Hg) to 9 mm Hg +/- 8 (range, 0-30 mm Hg), blood pressure improved from 181 +/- 16 (range, 150-220)/115 +/- 10 (range, 90-146) to 136 +/- 25 (range, 130-210)/86 +/- 16 (range, 80-130) mm Hg, and the drug requirement decreased from 3.9 +/- .6 (range, 2-5) to 1.1 +/- .9 (range, 0-3) (P value for all < .001). Complications included transient intrarenal arterial spasm in three patients, groin hematoma in two patients, and ipsilateral renal vein injury in one patient. At 22 months +/- 17 (range, 4-84 months) follow-up, the restenosis rate, as determined by recurrence of hypertension and angiographic demonstration of restenosis, was 16%.

CONCLUSION

Despite some technical problems, PTRA is safe and effective in treating renovascular hypertension caused by nonspecific aortoarteritis. The complication rate is low.

Anastomotic aneurysms after surgical treatment of Takayasu's arteritis: a 40-year experience

PURPOSE

To evaluate the clinical characteristics of anastomotic aneurysms that develop in surgically treated patients with Takayasu's arteritis.

METHODS

Among 103 patients with Takayasu's arteritis treated surgically over 40 years, 91 patients with 259 anastomoses (allowing for exclusion of 12 operative deaths) participated in follow-up study from 1 month to 37.3 years with a mean value +/- SEM of 17.3 +/- 1.1 years with a follow-up completion rate of 93% at 30 years. The clinical characteristics of anastomotic aneurysms were clarified, and the influences of several factors (sites of anastomoses, occlusive or aneurysmal disease, suture material, preoperative systemic inflammation, and administration of corticosteroids) on formation of anastomotic aneurysms were analyzed by means of life-table method and Cox regression analysis.

RESULTS

Twenty-two uninfected anastomotic aneurysms were found among 14 patients (22 of 259 anastomoses, 8.5%). The interval between the previous operation and diagnosis varied from 1.6 to 30 years with a mean value +/- SEM of 9.8 +/- 1.8 years. The cumulative incidence of anastomotic aneurysm at 20 years was 12.0%. Systemic inflammation or steroid administration had little influence on formation of anastomotic aneurysm. Instead, anastomotic aneurysm tended to occur after operations for aneurysmal lesions.

CONCLUSIONS

Anastomotic aneurysm can occur anytime after operations for Takayasu's arteritis. The development of anastomotic aneurysm is not influenced by any factor specific to this disease except the presence of an aneurysmal lesion.

Psoriatic arthritis associated with dilated cardiomyopathy and Takayasu's arteritis

A 40-year-old Japanese man with psoriatic arthritis (PA) involving the spine, sacroiliac and peripheral joints presented with dyspnoea and ankle oedema. Blood pressure was 180/110 and 114/80 mmHg in the right and left upper arms, respectively. Examinations showed left ventricular dilatation and diffuse hypokinesis of the left ventricle, with no involvement of the coronary arteries. Aortography detected total occlusion of the left subclavian artery and stenosis of the origin at the right renal artery. Dilated cardiomyopathy and Takayasu's arteritis associated with PA was diagnosed. A few cases of PA have been reported in association with cardiovascular diseases, but the association of these three diseases has not been documented in the literature to date. Dermatologists need to be aware of cardiovascular manifestations in patients with PA, because cardiovascular diseases are not rare in other seronegative spondyloarthropathies.

Morphological mural changes in the aorta in non-specific aortoarteritis (Takayasu's arteritis): assessment by intravascular ultrasound imaging

OBJECTIVE

Non-specific aortoarteritis (Takayasu's arteritis) is a panarteritis of unknown aetiology which primarily involves the vessel walls. The imaging morphology of wall abnormalities has been infrequently studied and their intravascular ultrasound appearance is not reported in the literature.

METHOD

We studied this morphology by intravascular ultrasound in nine patients in whom the diagnosis of Takayasu's arteritis was made by clinical and angiographic criteria. Intravascular ultrasound was performed by the transfemoral route. Images of the aorta were obtained in each patient. Qualitative and quantitative analysis was performed.

RESULTS

All procedures were successful, without complication. Typical findings included thickening and altered echogenicity of the media, adventitia and peri-arterial tissues. The inner echogenic layer was thin. Pliability of aortic walls was lost in stenotic segments. Aortic calcification was seen in one patient. The aortic wall thickness was 0.17-0.58 cm. Angiograms showed skip areas of aortic involvement. Intravascular ultrasound showed wall changes even in the skip areas which were normal at angiography.

CONCLUSION

Intravascular ultrasound shows changes in the aortic wall morphology in non-specific aortoarteritis. Our findings suggest that this disease involves contiguous aortic segments, producing wall and luminal changes in some areas and only wall changes in intervening areas.

Classification and epidemiology of the vasculitides

The systemic vasculitides are rare inflammatory conditions of blood vessel walls. A number of different classification schemes have been published since the first in 1952. The important developments have been the recognition of dominant blood vessel size, the distinction between primary and secondary vasculitis and the incorporation of pathogenic markers such as anti-neutrophil cytoplasmic antibodies. In 1990 the American College of Rheumatology (ACR) published criteria for the diagnosis of polyarteritis nodosa, Churg-Strauss syndrome, Wegener's granulomatosis, hypersensitivity vasculitis, Schönlein-Henoch purpura, giant cell arteritis and Takayasu arteritis. Sensitivity and specificity rates varied considerably: 71.0-95.3% for sensitivity and 78.7-99.7% for specificity. The criteria were not tested against the general population or against patients with other connective tissue diseases or rheumatic conditions. Four years later the Chapel Hill Consensus Conference (CHCC) produced definitions for the major types of vasculitis, however, these have proved controversial. Comparison in unselected patients with systemic vasculitis (in particular polyarteritis nodosa and microscopic polyangiitis) has shown that the ACR criteria and CHCC definitions identify different patients. The systemic vasculitides are somewhat more common than previously believed. The overall annual incidence approaches 40/million adults. The most common form of primary systemic vasculitis is giant cell arteritis; Wegener's granulomatosis, microscopic polyangiitis and Churg-Strauss syndrome have similar incidences. Classical polyarteritis nodosa and Takayasu arteritis are very rare in the UK.

CT angiography of Takayasu arteritis: comparison with conventional angiography

PURPOSE

To compare computed tomography (CT) angiography with conventional angiography in the evaluation of the extent of disease in the aorta and its major branches in patients with Takayasu arteritis.

MATERIALS AND METHODS

Both conventional (digital subtraction) and CT angiography were performed in 10 patients with Takayasu arteritis. The luminal abnormalities were assessed with both conventional angiography and maximum intensity projection (MIP) CT angiography. Transverse images from CT angiography also were used to assess mural changes, which were not assessed with conventional angiography.

RESULTS

Conventional angiography revealed 51 sites of luminal abnormalities. In five patients (50%), both conventional and MIP CT angiography depicted the same number of involved sites. At 36 of the 51 sites (71%), the estimation of luminal changes was the same for both modalities. In all patients, the transverse images provided additional mural findings in the aorta and its major branches. The integrated information provided by CT angiography, including MIP and transverse images, depicted more extensive disease than conventional angiography.

CONCLUSION

CT angiography including MIP and transverse images has advantages over conventional angiography in the evaluation of disease extent by providing additional mural information in Takayasu arteritis.

Ultrasonographic study and long-term follow-up of Takayasu's arteritis

BACKGROUND AND PURPOSE

Takayasu's arteritis is an inflammatory vasculopathy involving the aorta and its major branches. Little information is available on the natural history and temporal profile of changes in the carotid vessels, the major vessels involved in Takayasu's arteritis. Duplex ultrasonography may provide a reliable and efficient tool for the characterization and follow-up of the brachiocephalic vascular changes in Takayasu's arteritis.

METHODS

Sixteen female patients fulfilling the clinical diagnostic criteria for Takayasu's arteritis were studied. Mean age at onset was 23.6 years (SD = 6.0), and mean duration of follow-up was 17.1 years (SD = 11.9). The clinical features were analyzed. Only one patient had had a stroke. They had undergone at least one duplex scanning examination to evaluate the brachiocephalic vessels, including the extracranial carotid, vertebral, and subclavian arteries. Six patients underwent sequential duplex examination and long-term clinical follow-up.

RESULTS

All the studied patients had subclavian artery involvement, and 11 (69%) had common carotid artery involvement. The percentage of bilateral concomitant involvement was 100% in the common carotid artery and 33% in the subclavian artery. Homogeneous circumferential intima-media thickening was commonly seen in stenotic common carotid arteries (89%). Four patients had internal carotid artery involvement (all on the left side). In the serial duplex follow-up study, 2 of 6 patients had progressive vascular stenosis with concentric thickening, rather than longitudinal spreading, in the bilateral common carotid arteries. Left-side lesions were more prominent. Most were clinically stationary, despite severe stenosis or occlusion of the common carotid arteries.

CONCLUSIONS

The characteristic vascular lesions and progression changes in Takayasu's arteritis detected by duplex ultrasonography are quite different from those seen in ordinary atherosclerosis. Homogeneous circumferential intima-media thickening of the common carotid arteries is a highly specific ultrasonographic finding in patients with Takayasu's arteritis, particularly young women. Sequential duplex scanning showed vascular progression to be unpredictable and unrelated to medication in our patients. Further clinical investigations of vascular progression are warranted, and duplex scanning may provide a simple, safe, and accurate long-term means of follow-up.

Anti-endothelial cell antibodies in Takayasu arteritis

BACKGROUND

Although a specific etiology for Takayasu arteritis has not been found, the bulk of evidence favors an autoimmune mechanism. We examined the sera of 19 patients with Takayasu arteritis for antineutrophil cytoplasmic antibodies (ANCA), antinuclear antibodies (ANA), anti-DNA antibodies, antibodies to extractable nuclear antigens (ENA), anti-Ro anti-bodies, anticardiolipin antibodies, circulating immune complexes, and anti-endothelial cell antibodies (AECA).

METHODS AND RESULTS

We used enzyme-linked immunoassays, immunofluorescence, counterimmunoelectrophoresis, fluorescent-activated cell sorter (FACS) analysis, and confocal microscopy. We found that although no patient had positive ANCA, ANA, anti-DNA antibodies, ENA antibodies, anti-Ro antibodies, or anticardiolipin antibodies, 18 of the 19 patients had AECA. The AECA titers of the patients were 2561 +/- 1458 compared with 126 +/- 15 arbitrary units in a normal group of control subjects (P < .001). To verify the specificity of AECA, we performed cytofluorimetry on human endothelial cells with the sera from patients and control subjects. Two entirely separate patterns of fluorescence intensity were identified. We next performed immunocytochemistry and confocal microscopy with human endothelial cells subjected to patients' sera and to sera from normal subjects. The cells subjected to sera from patients with Takayasu arteritis demonstrated specific immunofluorescent staining of their plasma membrane and cytosol.

CONCLUSIONS

AECA are frequently present in patients with Takayasu arteritis. They may play a role in the pathogenesis. Furthermore, they may be useful as an additional diagnostic tool.

Direct role of HLA-B5 in influencing susceptibility to Takayasu aortoarteritis

To investigate genetic factors involved in the pathogenesis of Takayasu arteritis (TA), North Indian patients belonging to the states of Punjab, Haryana, Uttar Pradesh and Delhi were examined for HLA-class I and class II antigens and the data compared with healthy controls from the same ethnic group. Additionally, DNA typing was performed using polymerase chain reaction/sequence specific oligonucleotide probe (PCR-SSOP) technique to evaluate the distribution of molecular alleles in the healthy Indian population as compared to orientals and Western caucasoids. The frequency of HLA-B5 was significantly increased in patients as compared to controls (chi 2 = 32.5, corrected P value, Pc = 3 x 10(-6), relative risk = 4.3). Serological splitting of B5 into B51 and B52 did not reveal an association with any of the two subtypes. Weak association was also noticed with DR8 in the patient group (chi 2 = 8.2, Pc = 0.05). Distribution of the molecular subtypes of various HLA-B and DR alleles indicated that although the Indian population is essentially caucasoid, it comprises of an admixture of both caucasoid as well as oriental alleles/haplotypes. The observations clearly suggest that (a) HLA-linked genes are involved in the development of Takayasu arteritis, and (b) rather than a subtype of B5, the whole molecule or its closely linked gene(s) influence susceptibility to TA.

Current status of Takayasu arteritis in India

The clinical features of 106 patients of Takayasu arteritis (TA) seen over a period of 16 years are documented (65 females and 41 males). The mean age was 27.3 +/- 9.2 years. Hypertension was the commonest mode of presentation (51.3%) and was detected in 82 patients (77.4%) at the time of presentation. Vascular bruits were heard in 72 patients (67.9%) and 13 patients (12.3%) were in congestive heart failure. Aortography was performed in 95 patients. Based on the extent of involvement, Type I (branches of aortic arch) was seen in 7 (6.6%) patients, Type II (aortic arch, its branches and descending thoracic aorta) in 7 (6.6%) patients, Type III (descending thoracic aorta and abdominal aorta) in 4 (3.8%) patients, Type IV (abdominal aorta only) in 29 (27.3%) patients and Type V (aortic arch, descending thoracic aorta and abdominal aorta) in 59 (55.7%) patients. Therapeutic modalities included antihypertensive drug therapy in 81 patients, antitubercular drugs in 8 patients, steroids in 16 patients and cyclophosphamide in one patient. Response to steroids was satisfactory in 5 of these 16 patients while the lesions of vasculitis healed in the patient who was treated with cyclophosphamide. Surgical interventions included nephrectomy and autotransplantation of kidney in 3 patients each and revascularization in 4 patients and angioplasty in 4 patients. In the area of pathogenesis of this disease, a high activity of protein kinase C(PKC), an increased intracellular calcium and inositol 1,4,5 triphosphate in both unstimulated and stimulated T cells of TA was observed. These findings suggest an activation of PKC-calcium pathway in TA.

Diagnostic criteria for Takayasu arteritis

Diagnosis of Takayasu arteritis (TA) is often delayed because of a non-specific clinical presentation. Ishikawa's criteria (1988) has been widely used for the diagnosis of this disease. Few modifications have been proposed in Ishikawa's criteria for the diagnosis of TA. The proposed modifications include: (a) removal of the obligatory criteria of age less than 40 years; (b) inclusion of characteristic signs and symptoms as a major criteria; (c) removal of age in defining hypertension; (d) deletion of the absence of aorto-iliac lesion, in defining abdominal aortic lesion; and (e) an addition of coronary artery lesion in absence of risk factors. The criteria proposed consists of three major criteria including left and right mid subclavian artery lesions and characteristic signs and symptoms of at least one month duration and ten minor criteria-a high erythrocyte sedimentation rate, carotid artery tenderness, hypertension, aortic regurgitation or annuloaortic ectasia, pulmonary artery lesion, left mid common carotid lesion, distal brachiocephalic trunk lesion, descending thoracic aorta lesion, abdominal aorta lesion and coronary artery lesion. Presence of two major or one major and two minor criteria or four minor criteria suggests a high probability of TA. When applied to 106 Indian patients of angiographically proven TA and 20 control subjects, it had a sensitivity of 92.5% and specificity of 95% that was higher than that of Ishikawa's criteria (sensitivity 60.4%, specificity 95%) and American college of Rheumatology criteria (sensitivity 77.4%, specificity 95%). Similarly, this criteria had a 96% sensitivity and 96% specificity in 79 Japanese patients of TA and 79 control subjects. Adoption of these criteria is expected to prevent the possibility of an under diagnosis of TA.

Common carotid artery wall properties in Takayasu's arteritis

The vessel wall properties of the common carotid artery have been noninvasively and quantitatively assessed with an ultrasonic instrument. Stiffness parameter beta, which represents the mechanical properties of the vessel, was calculated from the relationship between blood pressure and the diameter of the artery. There are no reports that quantitatively assess wall properties in Takayasu's arteritis. The authors compared, in vivo, the vessel wall properties of the common carotid artery in 14 patients with Takayasu's arteritis versus those in 60 normal subjects (controls). They measured changes in the inner diameter of the artery between systole and diastole with an ultrasonic, phase-locked, echo-tracking system. Beta was significantly higher in Takayasu's arteritis than in normal subjects (better than a 99% confidence interval). The findings for each decade were as follows: 3rd decade (20s): 35.7 +/- 28.9 vs 5.01-6.46, P=0.0001; 4th decade (30s): 19.5 +/- 9.71 vs 6.09-7.80, P=0.02; 5th decade (40s): 26.2 +/- 11.3 vs 7.26-9.28, P = 0.0001; 6th decade (50s): 19.1 +/- 4.27 vs 8.66-11.25, P = 0.0001. Takayasu's arteritis significantly impaired the mechanical performance of the common carotid artery. Thus, beta shows promise as a useful diagnostic indicator of Takayasu's arteritis.

Arterial wall thickness measurements by B mode ultrasonography in patients with Takayasu's arteritis

OBJECTIVE

To assess the feasibility and potential diagnostic usefulness of arterial ultrasonography in Takayasu's arteritis.

METHODS

The total wall, intimal + medial, and adventitial thickness of the common carotid, subclavian and common femoral arteries, and of the abdominal aorta, were examined by B mode ultrasonography in 16 patients with Takayasu's arteritis and 16 healthy control subjects.

RESULTS

The mean total wall and intimal + medial thickness of all arteries other than the common femoral were significantly increased in Takayasu's arteritis. Long segments of homogeneous circumferential wall thickening in multiple vessels were characteristic. When the common carotid and subclavian arteries and the abdominal aorta were examined, each individual with Takayasu's arteritis had at least one artery with total wall thickness exceeding the reference range in controls.

CONCLUSIONS

B mode ultrasonography is able to expose the widespread arterial wall thickening characteristic of Takayasu's arteritis and may provide a useful tool for the detection and follow up of this disease.

Transvenous procurement of pulmonary artery smooth muscle and endothelial cells using a novel endoarterial biopsy catheter in a canine model

OBJECTIVES

The aim of this study was to evaluate the performance of a new arterial biopsy catheter in obtaining pulmonary endovascular samples in a canine model.

BACKGROUND

Percutaneous endomyocardial biopsy is a widely used and valuable procedure in the management of posttransplant rejection and selected cardiomyopathies. A similar method of obtaining endoarterial biopsy samples would aid in the study, diagnosis and management of arterial diseases.

METHODS

Catheterization was performed in 19 dogs, each weighing 20 to 30 kg, through an 8F sheath in the external jugular vein to obtain pulmonary endoarterial samples. The catheter consists of two sliding tubes: an inner one with a beveled opening that accommodates endoarterial tissue by means of a vacuum and an outer tube with a sharp distal edge that cuts the tissue when activated.

RESULTS

Overall, a total of 266 separate biopsy attempts were performed, and 161 tissue samples were obtained (success rate 61%). With modifications in technique in the last nine dogs, 54 (93%) of 58 attempts were successful. There were no deaths, extravasation of contrast material on angiography or thrombi. Of 20 vessels with prebiopsy and postbiopsy angiograms, 1 developed transient spasm (5%). On microscopic examination of cross sections of 50 separate pulmonary endoarterial biopsy samples, all had smooth muscle cells and 30 contained endothelial cells (60%). The arteries of origin showed small intimal and medial tears and mild perivascular hemorrhage. Angiographic and pathologic examination of previously biopsied arterial segments 2 weeks (two dogs) and 8 weeks (two dogs) after the procedure showed patent vessels and no thrombi. Histologically, the biopsy sites revealed mild neointimal and medial proliferation.

CONCLUSIONS

This new endoarterial biopsy catheter is safe and effective in obtaining pulmonary artery samples in normotensive dogs.

Vasculitis

The systemic vasculitides are a group of rare inflammatory conditions resulting in inflammation and necrosis of blood vessel walls. They are somewhat commoner than previously believed with an annual incidence approaching 40 per million. Furthermore the annual incidence of rheumatoid vasculitis is 12.5 per million and Wegener's granulomatosis is 8.5 per million. The first useful classification system for systemic vasculitis was published in 1952, since then a number of different schemes have been published. The major changes have been the recognition of the importance of dominant blood vessel size, the distinction between primary and secondary vasculitis and the incorporation of pathogenetic markers such as ANCA (see Table 6). Until relatively recently there were no widely agreed diagnostic or classification criteria. In 1990 the ACR published criteria for the diagnosis of polyarteritis nodosa, Churg-Strauss syndrome, Wegener's granulomatosis, hypersensitivity vasculitis, Henoch-Schönlein purpura, giant cell arteritis and Takayasu's arteritis. The criteria were provided in both traditional and tree format. Sensitivity and specificity rates varied considerably: 71.0-95.3% for sensitivity and 78.7-99.7% for specificity. The criteria were not tested against the general population or against patients with other connective tissue diseases or rheumatic conditions. In 1993/94 the Chapel Hill Consensus Conference developed and published definitions for the nomenclature of systemic vasculitis based on clinical features. These have not met with universal acceptance. However, they are a useful addition, since their use should result in different centres studying more homogeneous populations of patients and facilitate comparison of data between different centres. Assessment of vasculitis comprises an activity score (BVAS), damage index and quality of life/health status (SF-36). These are recent developments which are still undergoing validation.

Acute myocardial infarction in a young adult due to solitary giant cell arteritis of the coronary artery diagnosed antemortemly by primary directional coronary atherectomy

It has been reported sporadically that several types of coronary arteritis can result in myocardial infarction. Recently, we treated a 27-year-old with acute anterior myocardial infarction. Primary directional coronary atherectomy was performed in order to recanalize the totally occluded coronary artery. The atherectomized tissue consisted of thrombi and intima infiltrated with inflammatory cells and multinucleated giant cells. Underlying diseases which can result in giant cell arteritis were excluded. This report documents that coronary arteritis can induce acute myocardial infarction, and that directional coronary atherectomy can be an effective tool in the diagnostic method for coronary arteritis.

Long-term outcome for 120 Japanese patients with Takayasu's disease. Clinical and statistical analyses of related prognostic factors

BACKGROUND

Patients with Takayasu's disease, a chronic inflammatory arteriopathy of unknown cause, have variable clinical courses, and predictors of the long-term outcome are not well understood. We studied prognostic factors of this disease, based on follow-up results, and a new prognostic classification was proposed.

METHODS AND RESULTS

Life-table methods and Cox regression analyses were applied to clinical data on 120 patients who had been prospectively followed for a median of 13 years (range, 1 month to 34 years). The overall survival rate at 15 years after the diagnosis was 82.9% and remained the same for the remainder of the follow-up period. Univariate Cox analyses revealed that of the six dichotomous variables evaluated at diagnosis, four were statistically significant predictors, including complications (Takayasu's retinopathy, hypertension, aortic regurgitation, and aneurysm), pattern of the past clinical course, age of the patient, and calendar year of diagnosis. Thus, the 15-year survival was 66.3% versus 96.4% for patients with and without a major complication, 67.9% versus 92.9% for patients with and without a progressive course, 58.3% versus 92.7% for age > 35 years and < or = 35 years, and 79.9% versus 96.5% for patients diagnosed in 1957 through 1975 and in 1976 through 1990, respectively. The delay in diagnosis and the erythrocyte sedimentation rate (ESR) were of marginal significance. The multivariate Cox analysis showed that only two of the above variables were statistically independent predictors, ie, the major complication and the progressive course. In addition to these two factors, ESR was the third predictor, if the Cox stepwise elimination procedure was performed. These three predictors used in various combinations made a total of 1822 classifications theoretically feasible. Of these, a three-stage classification was selected as the best one, based on the Akaike information criterion. The presence of both major complication and progressive course (stage 3) was the worst prognostic indicator (43% survival at 15 years). In contrast, no patient died who had neither of these manifestations or who had a progressive course but an elevated ESR as well (stage 1).

CONCLUSIONS

The long-term outcome for patients with Takayasu's disease seems best predicted by two major prognostic factors, ie, complications and the pattern of the past clinical course, as well as by ESR. Aggressive medical and surgical treatment may be considered for patients with a major complication and a progressive course (stage 3).

Percutaneous transluminal angioplasty of the subclavian artery in nonspecific aortoarteritis: results of long-term follow-up

PURPOSE

The results of percutaneous transluminal angioplasty (PTA) of the subclavian artery in nonspecific aortoarteritis (Takayasu disease) are analyzed.

PATIENTS AND METHODS

Twenty-four patients (15 men, nine women; age range, 18-47 years; mean, 37.1 years) with occlusive disease in 26 subclavian arteries, had symptoms due to vertebrobasilar insufficiency, upper limb claudication, or both. Aortography revealed stenosis in 19 arteries and occlusion in seven. The lesions were focal in 14 arteries (< 3 cm) and extensive in 12. Associated lesions involved the brachiocephalic artery in three patients, carotid arteries in five patients, and renal arteries in five patients.

RESULTS

Initial technical and clinical success was achieved in 21 of 26 arteries (81%, 17 of 19 stenoses and four of seven occlusions). The maximum follow-up was 82 months (mean, 26 months), during which time restenosis occurred in six arteries, all of which had extensive lesions. The cumulative primary, secondary, and overall patencies were 64%, 82%, and 65%, respectively, as analyzed by means of the life-table method. The cumulative patencies for short- and long-segment lesions were 100% and 50%, respectively (P = .0113). Minor complications were observed in four of 26 procedures (15%) and included vasospasm (three patients) and transient loss of consciousness (one patient). There were no major complications.

CONCLUSIONS

PTA is useful for treatment of occlusive disease of the subclavian artery in nonspecific aortoarteritis. The procedure is simple and associated with minimal morbidity. Long-term results are excellent in focal lesions but are less durable in the presence of more extensive disease.

Concentric left ventricular hypertrophy in patients with Takayasu arteritis

Although aortic regurgitation (AR) in patients with Takayasu arteritis (TA) is believed to be caused by dilatation of the aortic ring or thickening of the aortic cusps, the pattern of left ventricular hypertrophy (LVH) in these patients has not been described. To clarify the geometry of the LV in patients with TA that had been documented both echocardiographically and hemodynamically, the authors evaluated 22 patients with TA and severe AR (group 1), 10 with TA and systemic hypertension (group 2), and 17 with isolated severe AR of other etiologies (group 3). M-mode echocardiography showed that LV dimensions were smaller in groups 1 and 2 than in group 3 and that wall thickness was greater in group 1 than in group 3. The concentric hypertrophic ratio (CHR = wall thickness/LV end-diastolic dimension+wall thickness) was larger than group 1 (p < 0.001) and group 2 (p < 0.01) than in group 3. CHR was similar in groups 1 and 2. Systolic blood pressure was significantly increased in group 2 and showed a tendency to increase in group 1 as compared with group 3. The results confirmed the presence of concentric LVH related to a pressure overload in patients with TA, even when TA was complicated by severe AR.

Isolated coronary ostial stenosis in Takayasu's arteritis: case report and review of the literature

This report describes a rare clinical course of a young Japanese woman with Takayasu's arteritis and a review of the literature. Her first symptom was angina pectoris due to isolated left coronary ostial stenosis, which was relieved by aortocoronary bypass grafting surgery using a saphenous vein graft. At that time, the C-reactive protein was negative and the histopathologic findings of the specimens of the aorta could not confirm aortitis. Although she was free from any cardiovascular symptoms for about fifteen years, syncopal attacks occurred owing to severe stenosis of the major branches of the aortic arch revealed by intravenous digital subtraction arteriograms. Thus, Takayasu's arteritis could be a cause of coronary ostial stenosis in young women even if the inflammatory findings are negative and the major branches of the aortic arch are not involved at operation. In addition, revascularization using internal thoracic arteries might possess a potential risk of coronary insufficiency due to a later involvement of these proximal arteries.

Vasculitis in childhood

Systemic vasculitic syndromes are rare in childhood. Vasculitis is the predominant feature of a large number of different clinical entities that are linked by the presence of inflammatory changes in the blood vessels. The nature of these diseases and their relationship to each other remain unclear. The clinical presentation associated with the size of the affected vessels and epidemiological data are very helpful for the diagnosis of those diseases. Recent advances are beginning to shed some light on the etiology and pathogenetic mechanisms involved in the various vasculitides. There is good evidence to support roles for circulating immune complexes, cell-mediated immunity, anti-neutrophil cytoplasmic antibodies and anti-endothelial cell antibodies in the pathogenesis. Renal involvement in vasculitis in children is commonly seen in Henoch-Schönlein purpura, microscopic polyarteritis, Wegener's granulomatosis, Churg-Strauss syndrome and polyarteritis nodosa. However, kidney disease can also be part of the clinical picture of Kawasaki disease and Takayasu arteritis. Recently, with the institution of early and aggressive immunosuppressive treatment of severe cases, significant improvement in the long-term survival of patients has been achieved. This review article addresses the pathological and clinical features (particularly renal involvement), therapeutic intervention and prognosis of the above-mentioned diseases.

Ventricular arrhythmias in Takayasu arteritis

We studied the prevalence, severity and clinical significance of ventricular arrhythmias in 78 female patients with Takayasu arteritis by 24-h ambulatory electrocardiography monitoring. Fifty (64%) of 78 patients had no or less than 30 beats/h premature ventricular contractions (Group A). The remaining 28 (36%) patients exhibited frequent or complex premature ventricular contractions (Group B). The frequency of HLA Bw52 which is closely associated with this morbid condition, echocardiographic and thallium-201 stress myocardial scintigraphic findings were then compared between these two groups. The frequency of positive HLA Bw52 was not significantly different between these two groups. Echocardiographically determined left ventricular mass (309 +/- 94 vs. 166 +/- 64 g; P < 0.01), frequency of complicated aortic regurgitation (77% vs. 24%; P < 0.01) and abnormal thallium-201 scintigraphic findings (76% vs. 38%; P < 0.05) were found higher in Group B as compared with those in Group A. These data indicate that frequent or complex ventricular arrhythmias in patients with Takayasu arteritis were associated with the presence of left ventricular hypertrophy, aortic regurgitation and decreased coronary reserve.

Non-specific aortoarteritis: long-term follow-up on immunosuppressive therapy

Thirteen patients with non-specific aortoarteritis and endomyocardial biopsy evidence of myocarditis were followed-up on immunosuppressive therapy comprising of prednisolone and cyclophosphamide in addition to conventional treatment for hypertension and/or congestive heart failure. Serial determinations of erythrocyte sedimentation rate, chest roentgenogram, radionuclide ventriculogram and hemodynamic study including endomyocardial biopsy were carried out at 12, 24 and 52 weeks of therapy. Arterial lesions were also assessed by digital subtraction angiography at 0 and 52 weeks of immunosuppressive therapy. At the end of a year of treatment all patients with congestive heart failure (10/13) showed symptomatic improvement by at least one New York Heart Association (NYHA) class. There was a significant fall in erythrocyte sedimentation rate (48 +/- 12 mm/1st h to 31 +/- 12 mm/1st h, P < 0.05), pulmonary artery pressure (32 +/- 14 mmHg to 20 +/- 9 mmHg, P < 0.05), left ventricular filling pressure (20 +/- 11 mmHg to 11 +/- 7 mmHg, P < 0.05) and increase in left ventricle ejection fraction (39 +/- 16% to 51 +/- 14%, P < 0.05) associated with resolution of morphological changes on endomyocardial biopsy. Arterial lesions remained static with neither progression nor appearance of new lesions. No significant complications of therapy were noticed in any patient. Our uncontrolled observations suggest that immunosuppressive therapy is safe and results in clinical, hemodynamic and myocardial morphological improvement in a subset of patients with non-specific aortoarteritis and associated myocarditis.

Takayasu's aortitis with renovascular hypertension

We report a case of Takayasu's disease with severe renovascular hypertension in a girl from Eritrea. In the "burn-out" phase after the erythrocyte sedimentation rate had normalized, reconstructive vascular surgery was performed as further progression of the disease seemed unlikely. However, probably due to her growth, the graft rotated and a second operation was successfully performed.