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Dzhus M, Mostbauer H. Coronary artery lesions in Takayasu arteritis. Reumatologia 2024; 61:460-472. [PMID: 38322104 PMCID: PMC10839913 DOI: 10.5114/reum/176483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 12/06/2023] [Indexed: 02/08/2024] Open
Abstract
Introduction Takayasu arteritis (TAK) is a granulomatous inflammation of vessels of large diameter, mainly affecting the aorta and its proximal branches, which is more common in young women. The incidence of coronary artery disease in TAK is unknown and not sufficiently studied. Material and methods A literature review was performed for the period 2003 to 2023 using a search of the PubMed and Scopus scientific databases. We used the following key words to search the academic journal databases: "Takayasu arteritis", "coronary angiography", "myocardial revascularization", "coronary artery disease", "angina pectoris", and "myocardial infarction". Results The analysis of studies showed that coronary artery lesions (CAL) in TAK are not uncommon, being identified particularly in children and young individuals. Pathology of the coronary arteries increases the morbidity and mortality of TAK patients. In TAK, the ostia and proximal segments of the coronary arteries are more frequently affected, presenting as stenosis or occlusion with the development of stable coronary artery disease, unstable coronary artery disease, acute myocardial infarction, and sudden death. The diagnosis of TAK and coronary artery pathology is often complicated due to nonspecific manifestations and frequently the absence of symptoms. The treatment of patients with TAK with CAL is challenging and requires both pharmacological therapy and interventional or surgical methods of myocardial revascularization. Conclusions Takayasu arteritis is a more prevalent cause of CAL development, especially in young patients, than previously believed, and cardiovascular death due to CAL is not rare. Early diagnosis of TAK with CAL, particularly occlusion or hemodynamically significant stenosis, and the prompt initiation of appropriate treatment prevent dangerous complications, reduce mortality, and improve prognosis.
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Affiliation(s)
- Marta Dzhus
- Department of Internal Medicine No. 2, O. Bohomolets National Medical University, Kyiv, Ukraine
| | - Halyna Mostbauer
- Department of Internal Medicine No. 2, O. Bohomolets National Medical University, Kyiv, Ukraine
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2
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Zhang X, Miao Q, Yu C, Zhang Y, Wu D, Tian Y, Li H, Wang C. Postoperative acute kidney injury after on-pump cardiac surgery in patients with connective tissue disease. Front Cardiovasc Med 2023; 10:1266549. [PMID: 38028488 PMCID: PMC10646509 DOI: 10.3389/fcvm.2023.1266549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 10/18/2023] [Indexed: 12/01/2023] Open
Abstract
Objective Patients with connective tissue disease have a poor prognosis after receiving cardiac surgery. This study described the clinical scenarios and investigated factors correlated with acute kidney injury (AKI) after on-pump cardiac surgery in patients with systemic lupus erythematosus (SLE) or vasculitis. Methods Patients with SLE or vasculitis who underwent on-pump cardiac surgery from March 2002 to March 2022 were enrolled, while patients with preoperative renal dysfunction were excluded. AKI was defined according to the Kidney Disease: Improving Global Outcomes (KDIGO) criteria. Uni- and multivariable analyses were performed to identify potential factors associated with postoperative AKI. Results Among 123 patients enrolled, 39 (31.7%) developed AKI within seven days after receiving on-pump cardiac surgery. Four patients died in the hospital, resulting in an overall in-hospital mortality of 3.3%, and all deaths occurred in the AKI group. Patients in the AKI group also had longer ICU stays (median difference 3.0 day, 95% CI: 1.0-4.0, P < 0.001) and extubation time (median difference 1.0 days, 95% CI: 0-2.0, P < 0.001) than those in the non-AKI group. Multivariable logistic regression revealed that BMI over 24 kg/m2 (OR: 3.00, 95% CI: 1.24-7.28) and comorbid SLE (OR: 4.73, 95% CI: 1.73-12.93) were independently correlated with postoperative AKI. Conclusion Factors potentially correlated with AKI following on-pump cardiac surgery in patients with connective tissue disease were explored. Clinicians should pay more attention to preoperative evaluation and intraoperative management in patients with risk factors.
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Affiliation(s)
- Xue Zhang
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Qi Miao
- Department of Cardiac Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Chunhua Yu
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Yuelun Zhang
- Medical Research Center, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Di Wu
- Department of Rheumatology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Yajie Tian
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Hanchen Li
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Chunrong Wang
- Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China
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Nan N, Pan L, Dong R, Song X. Mismatch of systematic and local inflammatory activity in Takayasu arteritis with coronary involvement: a case report. Eur Heart J Case Rep 2023; 7:ytad346. [PMID: 37554963 PMCID: PMC10406451 DOI: 10.1093/ehjcr/ytad346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Revised: 01/17/2023] [Accepted: 07/19/2023] [Indexed: 08/10/2023]
Abstract
BACKGROUND Accurate evaluation of the activity stage in Takayasu arteritis (TA) is important for the revascularization of TA with coronary artery involvement (TA-CAD). Here, we report the case of a patient with a mismatch of systemic and local inflammatory activity, leading to 13 times the need for recurrent coronary revascularization. CASE SUMMARY A 31-year-old woman with a family history of coronary artery disease underwent percutaneous coronary intervention (PCI) for critical ostial lesions. This patient was identified with Numano Type V TA and she underwent optimal medical therapy and PCIs. Her clinical inflammatory markers were quickly normalized. However, in-stent restenosis events recurred every 3 months. Virtual-histology intravascular ultrasound (VH-IVUS) and 18F-fluorodeoxyglucose (FDG)-positron emission tomography (PET)/computed tomography (CT) confirmed local vascular inflammation. A coronary artery bypass graft (CABG) was also conducted. Before this procedure, both the CABG grafts and the anastomotic areas were accurately assessed with 18FDG-PET/CT. Eventually, this patient remained both angina- and event-free for 2 years post-CABG. DISCUSSION The persistence of TA activity despite normal clinical inflammatory markers is uncommon as is the need for recurrent revascularization after appropriate PCI management. Intracoronary imaging and 18FDG-PET/CT play a critical role in assessing TA activity as well as precisely guiding CABG grafts and anastomosis sites to prevent graft failure.
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Affiliation(s)
- Nan Nan
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
- Beijing Engineering Research Center of Cardiovascular Wisdom Diagnosis and Treatment, No. 2, Anzhen Road, Chaoyang District, Beijing 100029, China
| | - Lili Pan
- Department of Rheumatology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Ran Dong
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Xiantao Song
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
- Beijing Engineering Research Center of Cardiovascular Wisdom Diagnosis and Treatment, No. 2, Anzhen Road, Chaoyang District, Beijing 100029, China
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Cobilinschi CO, Grădinaru E, Săulescu I, Cârstea N, Caraiola S, Bălănescu AR, Opriș-Belinski D. Refractory Takayasu's Arteritis with Severe Coronary Involvement-Case Report and Literature Review. J Clin Med 2023; 12:4394. [PMID: 37445428 DOI: 10.3390/jcm12134394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 06/21/2023] [Accepted: 06/22/2023] [Indexed: 07/15/2023] Open
Abstract
This report presents the case of a female patient diagnosed with Takayasu arteritis from childhood, with severe, refractory coronary involvement, leading to two acute coronary syndromes and multiple anginous episodes. Consequently, the patient suffered aorto-bicarotid bypass two times, multiple interventional procedures with stent implantation, balloon angioplasty, and up to ten repeated in-stent restenosis that required reinterventions, despite being on maximal immunosuppressive treatment. In recent years, various studies have been reported that aim to best characterize this particular type of vascular damage and to indicate optimal therapeutic options for treatment. The latter should be based on the activity of the underlying disease; however, no reliable markers are available in TA. The management of TA patients with coronary involvement continues to be a challenge and requires both drug and interventional techniques to avoid life-threatening events.
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Affiliation(s)
- Claudia Oana Cobilinschi
- Department of Rheumatology and Internal Medicine, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Department of Rheumatology and Internal Medicine, Sf Maria Clinical Hospital Bucharest, 011172 Bucharest, Romania
| | - Elena Grădinaru
- Department of Rheumatology and Internal Medicine, Sf Maria Clinical Hospital Bucharest, 011172 Bucharest, Romania
| | - Ioana Săulescu
- Department of Rheumatology and Internal Medicine, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Department of Rheumatology and Internal Medicine, Sf Maria Clinical Hospital Bucharest, 011172 Bucharest, Romania
| | - Nicolae Cârstea
- Department of Interventional Cardiology, Ares Excellency Centers, 021967 Bucharest, Romania
| | - Simona Caraiola
- Department of Rheumatology and Internal Medicine, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Department of Internal Medicine, Colentina Clinical Hospital, 020125 Bucharest, Romania
| | - Andra Rodica Bălănescu
- Department of Rheumatology and Internal Medicine, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Department of Rheumatology and Internal Medicine, Sf Maria Clinical Hospital Bucharest, 011172 Bucharest, Romania
| | - Daniela Opriș-Belinski
- Department of Rheumatology and Internal Medicine, Carol Davila University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Department of Rheumatology and Internal Medicine, Sf Maria Clinical Hospital Bucharest, 011172 Bucharest, Romania
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Iwakura T, Takanashi S, Masuda A, Hayashida M, Haraguchi G, Nanasato M, Isobe M, Shimokawa T. Coronary ostial angioplasty for juvenile Takayasu arteritis involving the coronary artery using external iliac artery grafts. Gen Thorac Cardiovasc Surg 2022; 70:1005-1008. [PMID: 35690990 PMCID: PMC9663377 DOI: 10.1007/s11748-022-01838-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 05/25/2022] [Indexed: 11/26/2022]
Abstract
Takayasu arteritis can affect the coronary ostia, leading to myocardial ischemia. Coronary ostial angioplasty effectively treats coronary artery ostial lesions associated with Takayasu arteritis. We present a case of juvenile Takayasu arteritis with bilateral subclavian artery occlusions treated with a novel coronary artery ostial angioplasty using the external iliac artery.
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Affiliation(s)
- Tomohiro Iwakura
- Department of Cardiovascular Surgery, Sakakibara Heart Institute, 3-16-1, Asahi-cho, Fuchu-shi, Tokyo, 183-0003, Japan.
| | - Shuichiro Takanashi
- Department of Cardiovascular Surgery, Sakakibara Heart Institute, 3-16-1, Asahi-cho, Fuchu-shi, Tokyo, 183-0003, Japan
| | - Akio Masuda
- Department of Cardiovascular Surgery, Sakakibara Heart Institute, 3-16-1, Asahi-cho, Fuchu-shi, Tokyo, 183-0003, Japan
| | - Miyu Hayashida
- Department of Cardiology, Sakakibara Heart Institute, 3-16-1 Asahi-cho, Fuchu-shi, Tokyo, 183-0003, Japan
| | - Go Haraguchi
- Department of Cardiology, Sakakibara Heart Institute, 3-16-1 Asahi-cho, Fuchu-shi, Tokyo, 183-0003, Japan
| | - Mamoru Nanasato
- Department of Cardiology, Sakakibara Heart Institute, 3-16-1 Asahi-cho, Fuchu-shi, Tokyo, 183-0003, Japan
| | - Mitsuaki Isobe
- Department of Cardiology, Sakakibara Heart Institute, 3-16-1 Asahi-cho, Fuchu-shi, Tokyo, 183-0003, Japan
| | - Tomoki Shimokawa
- Department of Cardiovascular Surgery, Sakakibara Heart Institute, 3-16-1, Asahi-cho, Fuchu-shi, Tokyo, 183-0003, Japan
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Hosono K, Nakanishi R, Koike H, Matsumoto S, Oka Y, Fujii T, Ikeda T. Impact of computed tomography on the diagnosis of Takayasu arteritis with acute coronary syndrome: A case series. J Cardiol Cases 2022; 26:76-80. [DOI: 10.1016/j.jccase.2022.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Revised: 02/24/2022] [Accepted: 03/01/2022] [Indexed: 11/29/2022] Open
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Chen S, Luan H, He J, Wang Y, Liu S, Li Y, Zeng X, Yuan H. Serum concentrations of small dense low-density lipoprotein cholesterol and lipoprotein(a) are related to coronary arteriostenosis in Takayasu arteritis. J Clin Lab Anal 2021; 35:e23966. [PMID: 34709671 PMCID: PMC8649385 DOI: 10.1002/jcla.23966] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 07/30/2021] [Accepted: 08/07/2021] [Indexed: 12/29/2022] Open
Abstract
Background Serum small dense low‐density lipoprotein cholesterol (sdLDL‐C) and lipoprotein(a) [Lp(a)] levels are related to coronary disease, but their specific associations with coronary arteriostenosis in Takayasu arteritis (TA) have not been ascertained. This study explored the correlations between serum sdLDL‐C and Lp(a) levels and coronary arteriostenosis in TA patients as well as the degree of artery stenosis. Methods This retrospective study included 190 TA patients and 154 healthy subjects. TA patients were divided into three categories based on the degree of coronary stenosis: Group I, stenosis >50%; Group II, stenosis 1%–50%; and Group III, stenosis 0%. Independent risk factors for coronary arteriostenosis in TA were identified by logistic regression, followed by receiver operating characteristic curve analysis to determine the specificity and sensitivity of risk factors and Youden's Index score calculation to determine the cutoff points. Results Takayasu arteritis patients had significantly higher serum levels of sdLDL‐C and Lp(a) than healthy controls (p < 0.0001). The total cholesterol, triglyceride, LDL‐C, sdLDL‐C, and Lp(a) levels and the sdLDL‐C/LDL‐C ratio in Group I were significantly higher than those in Groups II and III (p < 0.05). An elevated serum sdLDL‐C level elevated the risk of coronary arteriostenosis by 5‐fold (cutoff value, 0.605 mmol/l). An increased serum Lp(a) level increased the risk of coronary arteriostenosis by 3.9‐fold (cutoff value, 0.045 g/l). An elevated sdLDL‐C/LDL‐C ratio increased the risk of coronary arteriostenosis by 2.1‐fold (cutoff value, 0.258). Conclusions Serum sdLDL‐C and Lp(a) levels and sdLDL‐C/LDL‐C ratio may be used as diagnostic factors for coronary arteriostenosis in TA patients.
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Affiliation(s)
- Si Chen
- Department of Clinical Laboratory, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Haixia Luan
- Department of Clinical Laboratory, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Jianxun He
- Department of Clinical Laboratory, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yan Wang
- Department of Clinical Laboratory, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Shuang Liu
- Department of Clinical Laboratory, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yongzhe Li
- Department of Clinical Laboratory, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing, China
| | - Xiaoli Zeng
- Department of Clinical Laboratory, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Hui Yuan
- Department of Clinical Laboratory, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
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Ci W, Zhao Y, Bi T. Male Patients with Takayasu Arteritis and Coronary Artery Involvement are Prone to have Serious Coronary Stenosis and High Mortality. Curr Vasc Pharmacol 2021; 20:62-68. [PMID: 34303330 DOI: 10.2174/1570161119666210720114939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 04/25/2021] [Accepted: 06/07/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Takayasu arteritis (TAK) is a rare autoimmune vasculitis that predominantly affects the aorta and its major branches, including the coronary arteries. Limited information is available regarding sex-specific differences in coronary artery involvement among TAK patients. OBJECTIVE To assess the differences in coronary angiographic findings and the long-term outcomes between male and female TAK patients having coronary artery involvement. METHODS This retrospective cohort study included 87 TAK patients, grouped by sex, who underwent coronary angiography. General characteristics, clinical features, coronary angiographic findings, and therapeutic strategies were obtained from medical records. Major Adverse Cardiac Events (MACE), including death from any cause; myocardial infarction; repeated coronary artery revascularization; and rehospitalization due to unstable or progressive angina, or heart failure occurring during follow-up, were also recorded. RESULTS A total of 207 coronary lesions with stenosis were found in 87 TAK patients. The prevalence of ostial coronary lesions was lower in men than in women (9.1 vs. 23.9%, p=0.031). We observed less moderate stenosis (6.8 vs 22.7%, p=0.018) and more severe stenosis or occlusion (70.5 vs 46.0%, p=0.004) in the coronary lesions of male TAK patients. During the up to 7-year follow-up, death from any cause was greater in men than in women (21.4 vs. 1.5%, p=0.003); no other significant differences in MACE occurrence were observed between sexes. CONCLUSIONS Among TAK patients with coronary artery involvement, males tend to have more severe coronary stenosis and a higher risk for long-term mortality than females.
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Affiliation(s)
- Weiping Ci
- Department of Rheumatology and Immunology, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
| | - Yinan Zhao
- Department of Endocrinology and Metabolism, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
| | - Tao Bi
- Department of Radiology, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
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Maz M, Chung SA, Abril A, Langford CA, Gorelik M, Guyatt G, Archer AM, Conn DL, Full KA, Grayson PC, Ibarra MF, Imundo LF, Kim S, Merkel PA, Rhee RL, Seo P, Stone JH, Sule S, Sundel RP, Vitobaldi OI, Warner A, Byram K, Dua AB, Husainat N, James KE, Kalot MA, Lin YC, Springer JM, Turgunbaev M, Villa-Forte A, Turner AS, Mustafa RA. 2021 American College of Rheumatology/Vasculitis Foundation Guideline for the Management of Giant Cell Arteritis and Takayasu Arteritis. Arthritis Rheumatol 2021; 73:1349-1365. [PMID: 34235884 DOI: 10.1002/art.41774] [Citation(s) in RCA: 183] [Impact Index Per Article: 61.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 01/24/2021] [Accepted: 04/13/2021] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To provide evidence-based recommendations and expert guidance for the management of giant cell arteritis (GCA) and Takayasu arteritis (TAK) as exemplars of large vessel vasculitis. METHODS Clinical questions regarding diagnostic testing, treatment, and management were developed in the population, intervention, comparator, and outcome (PICO) format for GCA and TAK (27 for GCA, 27 for TAK). Systematic literature reviews were conducted for each PICO question. The Grading of Recommendations Assessment, Development and Evaluation methodology was used to rate the quality of the evidence. Recommendations were developed by the Voting Panel, comprising adult and pediatric rheumatologists and patients. Each recommendation required ≥70% consensus among the Voting Panel. RESULTS We present 22 recommendations and 2 ungraded position statements for GCA, and 20 recommendations and 1 ungraded position statement for TAK. These recommendations and statements address clinical questions relating to the use of diagnostic testing, including imaging, treatments, and surgical interventions in GCA and TAK. Recommendations for GCA include support for the use of glucocorticoid-sparing immunosuppressive agents and the use of imaging to identify large vessel involvement. Recommendations for TAK include the use of nonglucocorticoid immunosuppressive agents with glucocorticoids as initial therapy. There were only 2 strong recommendations; the remaining recommendations were conditional due to the low quality of evidence available for most PICO questions. CONCLUSION These recommendations provide guidance regarding the evaluation and management of patients with GCA and TAK, including diagnostic strategies, use of pharmacologic agents, and surgical interventions.
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Affiliation(s)
- Mehrdad Maz
- University of Kansas Medical Center, Kansas City
| | | | | | | | | | | | | | | | | | - Peter C Grayson
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, NIH, Bethesda, Maryland
| | | | | | - Susan Kim
- University of California, San Francisco
| | | | | | - Philip Seo
- Johns Hopkins University, Baltimore, Maryland
| | | | | | | | | | - Ann Warner
- Saint Luke's Health System, Kansas City, Missouri
| | | | | | | | | | | | | | | | | | | | - Amy S Turner
- American College of Rheumatology, Atlanta, Georgia
| | - Reem A Mustafa
- University of Kansas Medical Center, Kansas City, and McMaster University, Hamilton, Ontario, Canada
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10
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Maz M, Chung SA, Abril A, Langford CA, Gorelik M, Guyatt G, Archer AM, Conn DL, Full KA, Grayson PC, Ibarra MF, Imundo LF, Kim S, Merkel PA, Rhee RL, Seo P, Stone JH, Sule S, Sundel RP, Vitobaldi OI, Warner A, Byram K, Dua AB, Husainat N, James KE, Kalot MA, Lin YC, Springer JM, Turgunbaev M, Villa-Forte A, Turner AS, Mustafa RA. 2021 American College of Rheumatology/Vasculitis Foundation Guideline for the Management of Giant Cell Arteritis and Takayasu Arteritis. Arthritis Care Res (Hoboken) 2021; 73:1071-1087. [PMID: 34235871 DOI: 10.1002/acr.24632] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 01/24/2021] [Accepted: 04/13/2021] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To provide evidence-based recommendations and expert guidance for the management of giant cell arteritis (GCA) and Takayasu arteritis (TAK) as exemplars of large vessel vasculitis. METHODS Clinical questions regarding diagnostic testing, treatment, and management were developed in the population, intervention, comparator, and outcome (PICO) format for GCA and TAK (27 for GCA, 27 for TAK). Systematic literature reviews were conducted for each PICO question. The Grading of Recommendations Assessment, Development and Evaluation methodology was used to rate the quality of the evidence. Recommendations were developed by the Voting Panel, comprising adult and pediatric rheumatologists and patients. Each recommendation required ≥70% consensus among the Voting Panel. RESULTS We present 22 recommendations and 2 ungraded position statements for GCA, and 20 recommendations and 1 ungraded position statement for TAK. These recommendations and statements address clinical questions relating to the use of diagnostic testing, including imaging, treatments, and surgical interventions in GCA and TAK. Recommendations for GCA include support for the use of glucocorticoid-sparing immunosuppressive agents and the use of imaging to identify large vessel involvement. Recommendations for TAK include the use of nonglucocorticoid immunosuppressive agents with glucocorticoids as initial therapy. There were only 2 strong recommendations; the remaining recommendations were conditional due to the low quality of evidence available for most PICO questions. CONCLUSION These recommendations provide guidance regarding the evaluation and management of patients with GCA and TAK, including diagnostic strategies, use of pharmacologic agents, and surgical interventions.
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Affiliation(s)
- Mehrdad Maz
- University of Kansas Medical Center, Kansas City
| | | | | | | | | | | | | | | | | | - Peter C Grayson
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, NIH, Bethesda, Maryland
| | | | | | - Susan Kim
- University of California, San Francisco
| | | | | | - Philip Seo
- Johns Hopkins University, Baltimore, Maryland
| | | | | | | | | | - Ann Warner
- Saint Luke's Health System, Kansas City, Missouri
| | | | | | | | | | | | | | | | | | | | - Amy S Turner
- American College of Rheumatology, Atlanta, Georgia
| | - Reem A Mustafa
- University of Kansas Medical Center, Kansas City, and McMaster University, Hamilton, Ontario, Canada
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Zhou Y, Feng Y, Zhang W, Li H, Zhang K, Wu Z. Physical Exercise in Managing Takayasu Arteritis Patients Complicated With Cardiovascular Diseases. Front Cardiovasc Med 2021; 8:603354. [PMID: 34055922 PMCID: PMC8149735 DOI: 10.3389/fcvm.2021.603354] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 03/29/2021] [Indexed: 12/12/2022] Open
Abstract
Takayasu arteritis (TA) is a kind of large-vessel vasculitis that mainly affects the aorta and its branches, and the patients are usually women at a relatively young age. The chronic inflammation of arteries in TA patients leads to stenosis, occlusion, dilatation, or aneurysm formation. Patients with TA thereby have a high risk of cardiovascular disease (CVD) complications, which are the most common cause of mortality. This review summarizes the main cardiovascular complications and the risk factors of cardiovascular complications in patients with TA. Here, we discuss the benefits and potential risks of physical exercise in patients with TA and give recommendations about exercise prescription for TA patients to decrease the risks of CVD and facilitate rehabilitation of cardiovascular complications, which might maximally improve the outcomes.
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Affiliation(s)
- Yaxin Zhou
- Department of Clinical Immunology, Xijing Hospital, Air Force Medical University (Fourth Military Medical University), Xi'an, China
| | - Yuan Feng
- Department of Rheumatology and Immunology, Tangdu Hospital, Air Force Medical University (Fourth Military Medical University), Xi'an, China
| | - Wei Zhang
- Department of Rheumatology and Immunology, Xi'an No.5 Hospital, Xi'an, China
| | - Hongxia Li
- Department of Clinical Immunology, Xijing Hospital, Air Force Medical University (Fourth Military Medical University), Xi'an, China.,Department of Rheumatology and Immunology, Air Force Medical Center, Air Force Medical University (Fourth Military Medical University), Beijing, China
| | - Kui Zhang
- Department of Clinical Immunology, Xijing Hospital, Air Force Medical University (Fourth Military Medical University), Xi'an, China
| | - Zhenbiao Wu
- Department of Clinical Immunology, Xijing Hospital, Air Force Medical University (Fourth Military Medical University), Xi'an, China
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Arita Y, Nakaoka Y, Eda Y, Kitabayashi K, Hasegawa S. Perioperative Management of Takayasu Arteritis for Cardiac Surgery in a Patient Treated With Tocilizumab. JACC Case Rep 2020; 2:2363-2367. [PMID: 34317172 PMCID: PMC8304533 DOI: 10.1016/j.jaccas.2020.07.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 07/22/2020] [Indexed: 06/13/2023]
Abstract
We describe the case of a young woman with Takayasu arteritis with severe stenosis in the main trunk of the left coronary artery. After administration of prednisolone and tocilizumab to control disease activity, coronary artery bypass grafting was performed. Here, we report the successful perioperative management of this cardiac surgery. (Level of Difficulty: Advanced.).
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Key Words
- CABG, coronary artery bypass graft
- CRP, C-reactive protein
- CT, computed tomography
- ESR, erythrocyte sedimentation rate
- GC, glucocorticoid
- IL, interleukin
- LMCA, left main coronary artery
- PSL, prednisolone
- SAA, serum amyloid A
- TAK, Takayasu arteritis
- TCZ, tocilizumab
- Takayasu arteritis
- disease activity
- interleukin-6
- perioperative management
- tocilizumab
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Affiliation(s)
- Yoh Arita
- Department of Cardiology, Japan Community Healthcare Organization Osaka Hospital, Osaka, Japan
| | - Yoshikazu Nakaoka
- Department of Vascular Physiology, National Cerebral and Cardiovascular Center Research Institute, Suita, Japan
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yuko Eda
- Department of Cardiology, Japan Community Healthcare Organization Osaka Hospital, Osaka, Japan
| | - Katsukiyo Kitabayashi
- Cardiovascular Surgery, Japan Community Healthcare Organization Osaka Hospital, Osaka, Japan
| | - Shinji Hasegawa
- Department of Cardiology, Japan Community Healthcare Organization Osaka Hospital, Osaka, Japan
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14
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Huang Z, Zhang H, Wang M, Yang W, Qiao S, Hu F. Revascularization Versus Medical Therapy in Takayasu's Arteritis Patients with Coronary Artery Involvement. Rheumatol Ther 2020; 8:119-133. [PMID: 33230786 PMCID: PMC7991006 DOI: 10.1007/s40744-020-00251-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Accepted: 10/30/2020] [Indexed: 11/06/2022] Open
Abstract
Introduction Treatment strategies to improve clinical outcomes in Takayasu's arteritis (TA) with coronary lesions have ranged from pharmacological therapy to invasive procedures, such as coronary angioplasty, stenting, and surgery. However, the therapeutic strategy for this kind of patient is still unclear. This study aimed to investigate the clinical characteristics and influence of revascularization versus medical therapy in TA patients with coronary artery involvement. Methods We analyzed the medical records of 806 TA patients between January 2008 and December 2019. Clinical features and treatment were analyzed, and patients were categorized into medical treatment and revascularization. Additionally, patients were sorted as percutaneous coronary intervention (PCI) and coronary artery bypass surgery (CABG) based on the strategy of revascularization. Results Ninety cases with coronary lesions induced by TA were enrolled. Among 90 cases, 39 patients adopted conservative treatment, and 51 patients received revascularization (28 subjects with PCI, 23 participants with CABG). The median follow-up time was 63 (45–91) months. There is no significant difference in cardiovascular death between medical treatment and revascularization (2/39, 5.1% vs. 5/51, 9.8%, P = 0.971). The analysis of subgroup indicated that the mortality caused by cardiovascular disease was also similar in the CABG and PCI (2/28, 7.1% vs. 3/23, 13.0%, P = 0.772). However, the proportion of restenosis is much higher in the PCI compared with that of CABG (39.3%, 8.7%, P = 0.022, respectively). Heart failure is an independent predictor of death in these patients. Conclusions There is no significant difference in cardiovascular death between medical treatment and revascularization. The analysis of the subgroup indicated that the mortality caused by cardiovascular disease was also similar in the CABG and PCI, but the restenosis is much higher in the PCI compared with that of CABG. Heart failure is an independent predictor of death in these patients.
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Affiliation(s)
- Zhiwei Huang
- Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, China
| | - Hongliang Zhang
- Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, China
| | - Man Wang
- Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, China
| | - Weixian Yang
- Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, China
| | - Shubin Qiao
- Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, China.
| | - Fenghuan Hu
- Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, China.
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15
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Zhang Y, Fan P, Zhang H, Ma W, Song L, Wu H, Cai J, Luo F, Zhou X. Clinical characteristics and outcomes of chronic heart failure in adult Takayasu arteritis: A cohort study of 163 patients. Int J Cardiol 2020; 325:103-108. [PMID: 33086124 DOI: 10.1016/j.ijcard.2020.10.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 09/24/2020] [Accepted: 10/11/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND Chronic heart failure (CHF) is a serious complication and a major cause of mortality in patients with Takayasu arteritis (TA). We aimed to explore the clinical features and long-term outcomes in TA patients with CHF. METHODS AND RESULTS Adult TA patients admitted to our hospital between January 2009 to April 2018 were classified as HF and non-HF group. The adverse events were defined as a composite of all-cause mortality and hospitalization for HF. The outcome of the HF-group was further analyzed. A total of 61 HF patients and 102 non-HF patients were identified. In the HF group, the median age at assessment was 41.9 years, and female was predominant (82.0%). The multivariable logistic regression model revealed that pulmonary hypertension, aortic regurgitation, mitral regurgitation, level albumin, and uric acid were independently associated with CHF. After a median follow-up of 1347 days, 25 adverse events occurred in HF patients, and the 5-year event-free rate was 54.7%. The Cox model showed that coronary artery involvement, aortic regurgitation, without interventional treatment were related to adverse events. CONCLUSIONS The 5-year event-free rate was not satisfying. Aggressive intervention may decreased the likelihood of adverse events in patients with CHF.
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Affiliation(s)
- Ying Zhang
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Peng Fan
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Huimin Zhang
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Wenjun Ma
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Lei Song
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Haiying Wu
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Jun Cai
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Fang Luo
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China.
| | - Xianliang Zhou
- Department of Cardiology, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China.
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16
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The relationships of serum homocysteine levels and traditional lipid indicators with disease activity and coronary artery involvement in Takayasu arteritis. Immunol Res 2020; 68:405-413. [PMID: 33064263 DOI: 10.1007/s12026-020-09157-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 10/01/2020] [Indexed: 12/14/2022]
Abstract
Serum homocysteine (HCY) levels have been associated with the occurrence of coronary stenosis and disease activity in large-vessel vasculitis. However, whether increases in serum HCY levels and traditional lipid indicators are associated with coronary artery involvement and disease activity in Chinese Han Takayasu arteritis (TA) patients is unknown. This study aims to investigate the clinical and laboratory features of TA by assessing their association with disease activity in TA patients, and to explore the risk factors associated with coronary artery involvement in these patients. Serum HCY levels and traditional lipid indicators were tested in one hundred ninety TA patients and one hundred fifty-four healthy controls. We analyzed the relationships of serum HCY levels and traditional lipid indicators with disease activity and analyzed the risk factors for coronary artery involvement. Twenty-one TA patients were found to have coronary artery stenosis (≥ 50%). TA patients had significantly higher levels of HCY than did healthy controls (p < 0.0001). Serum levels of HCY and low-density lipoprotein cholesterol (LDL-C); the ratios of LDL-C to high-density lipoprotein cholesterol (HDL-C), total cholesterol (TC) to HDL-C, and triglycerides (TG) to HDL-C; and the values of atherogenic index of plasma (AIP) were significantly higher in patients with active TA than in patients with inactive TA and in TA patients with coronary artery involvement than in TA patients without coronary artery involvement. By contrast, the serum levels of HDL-C were significantly lower in patients with active TA than in patients with inactive TA and in TA patients with coronary artery involvement than in TA patients without coronary artery involvement (p < 0.05). In addition, the serum levels of TC and TG were significantly higher in TA patients with coronary artery involvement than those in TA patients without coronary artery involvement. Elevated serum HCY levels increased the risk of coronary artery involvement by 1.3-fold (p = 0.011, odds ratio [OR] = 1.275, 95% confidence interval [CI]: 1.056-1.539), and the cutoff value for serum HCY was 9.55 μmol/L. Elevated serum TG levels increased the risk of coronary artery involvement by 3.5-fold (p < 0.0001, OR = 3.534, 95% CI: 1.907-6.547), and the cutoff value for serum TG was 1.215 mmol/L. The risk of coronary artery involvement was 2.5-fold higher when an elevated TG/HDL-C ratio was present (p < 0.0001, OR = 2.513, 95% CI: 1.567-4.032). This study showed that serum HCY and TG levels and the TG/HDL-C ratio are independent risk factors for coronary artery involvement in TA patients.
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17
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18
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Yuan SM, Lin HZ. Coronary artery involvements in Takayasu arteritis: systematic review of reports. Gen Thorac Cardiovasc Surg 2020; 68:883-904. [PMID: 32430746 DOI: 10.1007/s11748-020-01378-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 04/28/2020] [Indexed: 12/12/2022]
Abstract
Coronary artery involvements in patients with Takayasu arteritis (TA) have not been sufficiently described. By comprehensive retrieval of the pertinent literature published in the past two decades, 59 reports including 141 patients were recruited into this study. In TA patients with coronary artery involvements, the right coronary artery was the most commonly affected. Stenosis was the most common coronary artery lesion, and the coronary ostium was the most commonly affected coronary segment. Acute myocardial infarction was diagnosed in 17 (12.1%) patients of this cohort. Patients receiving surgical treatment showed a higher recovery rate than interventionally treated patients. Interventional therapy was associated with a higher reintervention rate than surgical treatment. The inflammation condition in TA patients can lead to in-stent restenosis and warrant reinterventions. Surgical treatment is a preferable treatment of choice over interventional therapy for the coronary artery lesions of TA patients.
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Affiliation(s)
- Shi-Min Yuan
- Department of Cardiothoracic Surgery, The First Hospital of Putian, Teaching Hospital, Fujian Medical University, Putian, Fujian, People's Republic of China
| | - Hui-Zhen Lin
- Department of Clinical Laboratory, The First Hospital of Putian, Teaching Hospital, Fujian Medical University, 389 Longdejing Street, Chengxiang District, Putian, 351100, Fujian, People's Republic of China.
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19
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Wang H, Zhang Y, Shen Z, Fang L, Liu Z, Zhang S. Comparing the effects of different management strategies on long-term outcomes for significant coronary stenosis in patients with Takayasu arteritis. Int J Cardiol 2020; 306:1-7. [DOI: 10.1016/j.ijcard.2020.02.051] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 02/05/2020] [Accepted: 02/18/2020] [Indexed: 02/02/2023]
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20
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Pan L, Du J, Liu J, Liao H, Liu X, Guo X, Liang J, Han H, Yang L, Zhou Y. Tocilizumab treatment effectively improves coronary artery involvement in patients with Takayasu arteritis. Clin Rheumatol 2020; 39:2369-2378. [PMID: 32144625 DOI: 10.1007/s10067-020-05005-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 01/21/2020] [Accepted: 02/20/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Coronary artery involvement in Takayasu arteritis (TAK) leads to poor prognosis and high mortality. Tocilizumab (TCZ) has been used to effectively treat large vessel vasculitis. However, the efficacy of TCZ in resolving coronary artery involvement in TAK is unclear. The aim of this retrospective study was to evaluate the efficacy of TCZ in the treatment of coronary artery involvement in TAK. METHODS Clinical features and manifestations of coronary artery lesions in 11 TAK patients were evaluated before and after TCZ treatment, and the results were compared with those of 11 patients treated with traditional disease-modifying antirheumatic drugs (DMARDs). RESULTS C-reactive protein (p = 0.006), erythrocyte sedimentation rate (ESR) (p = 0.011), and Kerr score (p = 0.007) were significantly decreased post-TCZ treatment for 6 months. The Indian Takayasu Clinical Activity Score (ITAS) 2010 (p = 0.019) and ITAS-A (p = 0.019) were significantly lower in patients treated with TCZ compared with those treated with traditional DMARDs. The glucocorticoid (GC) dose was tapered to 2.50 (0.00, 7.50) mg day-1 after TCZ treatment for 6 months, which was significantly lower than the GC dose after traditional DMARDs treatment [10.0 (5.00, 11.25) mg.day-1, (p = 0.033)]. After 6-month TCZ treatment, the total number of coronary artery lesions was reduced from 23 to 15 in 6 patients. Vascular wall thickening was remarkably improved in 2 lesions (in the ostia of the left main and right coronary arteries). CONCLUSION TCZ may decrease the disease activity and improve coronary artery lesion in patients with TAK. Key Points • TCZ treatment significantly decreased the disease activity in TAK patients with coronary artery involvement. • TCZ treatment significantly reduces the dosage of GC. • TCZ treatment led to an improvement in imaging findings of TAK patients with coronary artery involvement.
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Affiliation(s)
- Lili Pan
- Department of Rheumatology and Immunology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Juan Du
- Department of Rheumatology and Immunology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Jiayi Liu
- Department of Radiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Hua Liao
- Department of Rheumatology and Immunology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Xiaoli Liu
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, 2 Anzhen Road, Chaoyang District, Beijing, China
| | - Xi Guo
- Department of Interventional Radiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Jing Liang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, 2 Anzhen Road, Chaoyang District, Beijing, China
| | - Hongya Han
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, 2 Anzhen Road, Chaoyang District, Beijing, China
| | - Lixia Yang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, 2 Anzhen Road, Chaoyang District, Beijing, China
| | - Yujie Zhou
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, 2 Anzhen Road, Chaoyang District, Beijing, China.
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21
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Kikuchi S, Okada K, Hibi K, Maejima N, Yabu N, Uchida K, Tamura K, Kimura K. Coronary arteritis: a case series. EUROPEAN HEART JOURNAL-CASE REPORTS 2020; 4:1-6. [PMID: 32352046 PMCID: PMC7180521 DOI: 10.1093/ehjcr/ytaa011] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 06/04/2019] [Accepted: 01/14/2020] [Indexed: 12/02/2022]
Abstract
Background The present article describes two cases of patients with coronary arteritis (CA) whose identification of CA diagnosis (late vs. early) resulted in different clinical courses and outcomes. Case summary Case 1 is a 53-year-old woman with multiple coronary risk factors who was admitted with acute coronary syndrome (ACS) and significant stenosis in the left main trunk (LMT). Although clues suggested arteritis (LMT lesion without any other stenosis, occlusion of left internal thoracic artery, etc.), the diagnosis of CA (coronary involvement of unclassified arteritis) was delayed and revascularization, including coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI), was performed under uncontrolled inflammatory status. As a result, Case 1 experienced repeated ACS episodes due to graft failure and in-stent restenosis, and repeatedly underwent PCI. Case 2 is a 76-year-old woman with no significant coronary risk factors who was admitted with ACS. This patient was successfully diagnosed with coronary involvement of Takayasu arteritis before revascularization. Coronary artery bypass grafting was performed after stabilizing inflammation with prednisolone, and the patient remains angina-free beyond 1-year post-CABG. In both cases, intravascular imaging clearly identified the localization and degree of inflammation related to CA by demonstrating specific findings (ambiguous typical three-layer structure of arterial wall and extended low-echoic areas within adventitia). Discussion Accurate and early diagnosis with meticulous diagnostic and therapeutic strategies appear to be important for favourable clinical outcomes in the medical treatment of patients with coronary involvement of arteritis. Intravascular imaging has the potential to contribute to optimizing clinical management of CA.
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Affiliation(s)
- Shinnosuke Kikuchi
- Division of Cardiology, Yokohama City University Medical Center, 4-57 Urafune-cho, Minami-ku, Yokohama 232-0024, Japan
| | - Kozo Okada
- Division of Cardiology, Yokohama City University Medical Center, 4-57 Urafune-cho, Minami-ku, Yokohama 232-0024, Japan
| | - Kiyoshi Hibi
- Division of Cardiology, Yokohama City University Medical Center, 4-57 Urafune-cho, Minami-ku, Yokohama 232-0024, Japan
| | - Nobuhiko Maejima
- Division of Cardiology, Yokohama City University Medical Center, 4-57 Urafune-cho, Minami-ku, Yokohama 232-0024, Japan
| | - Naoto Yabu
- Division of Cardiolovascular Center, Yokohama City University Medical Center, 4-57 Urafune-cho, Minami-ku, Yokohama 232-0024, Japan
| | - Keiji Uchida
- Division of Cardiolovascular Center, Yokohama City University Medical Center, 4-57 Urafune-cho, Minami-ku, Yokohama 232-0024, Japan
| | - Kouichi Tamura
- Department of Medical Science and Cardiorenal Medicine, Yokohama City University Graduate School of Medicine, 3-9 Fukuura, Kanazawa-ku, Yokohama 236-0004, Japan
| | - Kazuo Kimura
- Division of Cardiology, Yokohama City University Medical Center, 4-57 Urafune-cho, Minami-ku, Yokohama 232-0024, Japan
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22
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Águeda AF, Monti S, Luqmani RA, Buttgereit F, Cid M, Dasgupta B, Dejaco C, Mahr A, Ponte C, Salvarani C, Schmidt W, Hellmich B. Management of Takayasu arteritis: a systematic literature review informing the 2018 update of the EULAR recommendation for the management of large vessel vasculitis. RMD Open 2019; 5:e001020. [PMID: 31673416 PMCID: PMC6803017 DOI: 10.1136/rmdopen-2019-001020] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 08/02/2019] [Accepted: 08/20/2019] [Indexed: 01/23/2023] Open
Abstract
Objective To collect available evidence on management of large vessel vasculitis to inform the 2018 update of the EULAR management recommendations. Methods Two independent systematic literature reviews were performed, one on diagnosis and monitoring and the other on drugs and surgical treatments. Using a predefined PICO (population, intervention, comparator and outcome) strategy, Medline, Embase and Cochrane databases were accessed. Eligible papers were reviewed and results condensed into a summary of findings table. This paper reports the main results for Takayasu arteritis (TAK). Results A total of 287 articles were selected. Relevant heterogeneity precluded meta-analysis. Males appear to have more complications than females. The presence of major complications, older age, a progressive disease course and a weaker inflammatory response are associated with a more unfavourable prognosis. Evidence for details on the best disease monitoring scheme was not found. High-quality evidence to guide the treatment of TAK was not found. Glucocorticoids are widely accepted as first-line treatment. Conventional immunosuppressive drugs and tumour necrosis factor inhibitors were beneficial in case series and uncontrolled studies. Tocilizumab failed the primary endpoint (time to relapse) in a randomised controlled clinical trial; however, results still favoured tocilizumab over placebo. Vascular procedures may be required, and outcome is better when performed during inactive disease. Conclusions Evidence to guide monitoring and treatment of patients with TAK is predominantly derived from observational studies with low level of evidence. Therefore, higher-quality studies are needed in the future.
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Affiliation(s)
- Ana F Águeda
- Rheumatology, Centro Hospitalar do Baixo Vouga EPE, Aveiro, Portugal
| | - Sara Monti
- Rheumatology, IRCCS Policlinico S. Matteo Foundation, University of Pavia, Pavia, Italy.,University of Pavia, PhD in Experimental Medicine, Pavia, Italy
| | - Raashid Ahmed Luqmani
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science (NDORMS), University of Oxford, Oxford, UK
| | - Frank Buttgereit
- Rheumatology and Clinical Immunology, Charité University Medicine Berlin (CCM), Berlin, Germany
| | - Maria Cid
- Vasculitis Research Unit, Department of Autoimmune Diseases, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Bhaskar Dasgupta
- Rheumatology, Southend University Hospital, Westcliff-on-Sea, UK
| | - Christian Dejaco
- Rheumatology, Department of Rheumatology, South Tyrol Health Trust, Hospital of Bruneck, Bruneck, Italy.,Rheumatology, Medical University Graz, Graz, Austria
| | - Alfred Mahr
- Internal Medicine, Hospital Saint-Louis, University Paris Diderot, Paris, France
| | - Cristina Ponte
- Rheumatology Research Unit, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal.,Rheumatology, Centro Hospitalar de Lisboa Norte, EPE, Hospital de Santa Maria, Lisboa, Portugal
| | - Carlo Salvarani
- Rheumatology, Università di Modena e Reggio Emilia and Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Wolfgang Schmidt
- Medical Centre for Rheumatology, Klinik für Innere Medizin, Rheumatologie und Klinische Immunologie Berlin-Buch, Immanuel Krankenhaus, Berlin, Germany
| | - Bernhard Hellmich
- Klinik für Innere Medizin, Rheumatologie und Immunologie, Vaskulitis-Zentrum Süd, Medius Kliniken, - Akademisches Lehrkrankenhaus der Universität Tübingen, Kirchheim-unter-Teck, Germany
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23
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Macedo LM, Lima NDA, de Castro Junior RL, Bannon SF. Takayasu arteritis with multiple coronary involvement and early graft relapse. BMJ Case Rep 2019; 12:12/4/e229383. [PMID: 31040146 DOI: 10.1136/bcr-2019-229383] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Coronary artery disease (CAD) due to Takayasu arteritis (TA) is rare. This article reports a case of severe involvement of multiple coronary arteries in a young woman. She was treated with coronary artery bypass grafting and had an early venous graft stenosis despite immunosuppressants. She became asymptomatic one year after a drug-eluting stent placement. This report shows the complexity of the diagnostic and therapeutic approach to TA with complex CAD.
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Affiliation(s)
| | - Neiberg de Alcantara Lima
- Internal Medicine, Western Michigan University Homer Stryker MD School of Medicine, Kalamazoo, Michigan, USA
| | | | - Susan Faragher Bannon
- Internal Medicine, Western Michigan University Homer Stryker MD School of Medicine, Kalamazoo, Michigan, USA
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Regressed coronary ostial stenosis in a young female with Takayasu arteritis: a case report. BMC Cardiovasc Disord 2019; 19:79. [PMID: 30940076 PMCID: PMC6446325 DOI: 10.1186/s12872-019-1066-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Accepted: 03/24/2019] [Indexed: 11/10/2022] Open
Abstract
Background Takayasu arteritis is a rare systemic vasculitis, which affects the aorta and its major branches, especially in young females. Diagnosis and treatment for Takayasu arteritis with coronary stenosis are important to prevent fatal complications. Immunosuppressive treatment such as corticosteroid is a common treatment for this condition. However, the effects of immunosuppressive treatment on inflammatory coronary stenosis caused by Takayasu arteritis remains unknown. Case presentation An 18-year-old female had chest oppression on effort and was referred to our hospital due to ST-segment depression in I, aVL, and V2–4 on electrocardiogram. Coronary angiography showed severe stenosis in the ostium of both the left main trunk and the right coronary artery. 18F-fluorodeoxyglucose (FDG) positron emission tomography/computed tomography showed isolated inflammation of the aortic root. She was diagnosed with Takayasu arteritis and treated with combined immunosuppressive treatment with corticosteroid and tocilizumab, which decreased the FDG uptake in the aortic root. Four months after initiation of the immunosuppressive treatment, coronary angiography showed regression of the coronary ostial stenosis. Coronary artery bypass surgery was considered, but the patient rejected invasive revascularization for coronary artery disease. She did not have chest oppression or ST-segment depression after the immunosuppressive treatment. She had no cardiac events for 6 months after discharge. Conclusions We described regressed coronary ostial stenosis in a young female patient with Takayasu arteritis. Immunosuppressive treatment might have a favorable effect on coronary ostial stenosis in Takayasu arteritis.
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25
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Misra DP, Wakhlu A, Agarwal V, Danda D. Recent advances in the management of Takayasu arteritis. Int J Rheum Dis 2019; 22 Suppl 1:60-68. [PMID: 30698358 DOI: 10.1111/1756-185x.13285] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Durga Prasanna Misra
- Department of Clinical Immunology; Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS); Lucknow India
| | - Anupam Wakhlu
- Department of Rheumatology; King George's Medical University; Lucknow India
| | - Vikas Agarwal
- Department of Clinical Immunology; Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS); Lucknow India
| | - Debashish Danda
- Department of Clinical Immunology & Rheumatology; Christian Medical College Hospital; Vellore India
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26
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Fan L, Zhang H, Cai J, Yang L, Liu B, Wei D, Yu J, Fan J, Song L, Ma W, Zhou X, Wu H, Lou Y. Clinical course and prognostic factors of childhood Takayasu's arteritis: over 15-year comprehensive analysis of 101 patients. Arthritis Res Ther 2019; 21:31. [PMID: 30670069 PMCID: PMC6341556 DOI: 10.1186/s13075-018-1790-x] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Accepted: 12/07/2018] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Childhood Takayasu's arteritis (c-TA) is scarcely reported but is characterized by devastating morbidity and mortality. This study aims to investigate the clinical course of c-TA and prognostic factors associated with rehospitalization and events including vascular complications, flares, and death. METHODS An ambispective study of 101 c-TA patients satisfying the American College of Rheumatology (ACR) criteria and/or the European League against Rheumatism (EULAR)/Pediatric Rheumatology International Trials Organization (PRINTO)/Pediatric Rheumatology European Society (PReS) criteria was conducted from January 2002 to December 2017. Data on demographic, clinical, laboratory, imaging, and therapeutic features were collected. Event-free survival, complication-free survival, flare-free survival, rehospitalization-free survival, and associated prognostic factors were assessed by Kaplan-Meier survival curve and propensity score analysis. RESULTS The median age at c-TA onset was 14 (interquartile range (IQR) 12-16) years and 76.2% were female. Hypertension (70.3%), blood pressure discrepancy (55.4%), bruits (51.5%), and pulse deficits (37.6%) were core presentations. Major vascular involvement included the renal artery (62.4%), abdominal aorta (42.6%), subclavian artery (43.6%), and carotid artery (42.6%). Glucocorticoids (78.2%), antihypertensive drugs (72.3%), antiplatelet agents (72.3%), and revascularization (57.4%) were made up the majority administered. At a median 2.4 (IQR 0.7-6.1) years of follow-up, events, rehospitalization, vascular complications, flares and death were observed in 44.6%, 37.6%, 44.6%, 26.7%, and 3%, respectively. The 5-year event-free survival, rehospitalization-free survival, vascular complication-free survival, and flare-free survival were 42.8%, 55.8%, 45.9%, and 62.3%, respectively. Body mass index (BMI) (hazard ratio (HR) = 0.49, 95% confidence interval (CI) 0.30-0.81, p = 0.005), stroke (HR = 7.37, 95% CI 2.35-23.1, p = 0.001), and revascularization (HR = 0.51, 95% CI 0.27-0.94, p = 0.032) were independent prognostic predictors of events. Predictors for rehospitalization include age at admission (HR = 0.81, 95% CI 0.69-0.94, p = 0.006), renal artery involvement (HR = 0.49, 95% CI 0.25-0.96, p = 0.037), and elevated C-reactive protein (CRP; HR = 2.50, 95% CI 1.24-5.00, p = 0.01). BMI level (p = 0.024) and renal artery involvement (p = 0.015) were also associated with vascular complications, while revascularization (p = 0.002) independently correlated with re-flares. CONCLUSIONS This large ambispective study of c-TA revealed an early 3% mortality at the first year and around 50% morbidity within 5 years after diagnosis. Hypertension, renal artery involvement, and revascularization based on anti-inflammation, antihypertension, and antiplatelet medications dominated c-TA with indications for optimistic prognosis. Patients with initial lower BMI level, a younger age at admission, stroke, and elevated CRP have a high risk of poor outcomes, requiring close c-TA monitoring and more aggressive management. TRIAL REGISTRATION NCT03199183 , unique protocol ID: 2016-ZX43. June 26, 2017.
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Affiliation(s)
- Luyun Fan
- State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Huimin Zhang
- State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
| | - Jun Cai
- State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
| | - Lirui Yang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Bin Liu
- School of Basic Medicine, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Dongmei Wei
- State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jiachen Yu
- State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jiali Fan
- State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lei Song
- State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wenjun Ma
- State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xianliang Zhou
- State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Haiying Wu
- State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ying Lou
- State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Lim RW, Keh YS, Yeo KK, Khanna NN. Takayasu’s arteritis: a review of the literature and the role of endovascular treatment. ASIAINTERVENTION 2018; 4:117-125. [PMID: 36484003 PMCID: PMC9706770 DOI: 10.4244/aij-d-16-00013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Accepted: 04/23/2018] [Indexed: 06/17/2023]
Abstract
Takayasu's arteritis (TA) is a chronic non-specific vasculitis with variable presentation in different ethnicities and countries. Treatment options vary and are dependent on the stage and presentation of the disease. We aimed to review current literature related to TA, focusing on the role of endovascular treatment in revascularisation. The temporal course of the disease and stage at presentation influence the management of TA. Treatment options include medical therapy, endovascular intervention or surgical vascular reconstruction. The decision to intervene is individualised according to vascular anatomy and the presence of haemodynamically significant lesions. There are currently no clear guidelines regarding the choice between the endovascular and open surgical approaches, but studies have shown that endovascular procedures are associated with slightly higher rates of restenosis while surgical procedures have higher rates of thrombosis. Periprocedural immunosuppression is suggested if the disease is active at the point of intervention. This improves outcomes but at the cost of immunosuppression-related side effects. Careful long-term follow-up is essential due to the risk of disease activation or flare-up, requiring appropriate evaluation of the diseased vessels.
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Affiliation(s)
| | | | - Khung Keong Yeo
- National Heart Centre Singapore, Singapore
- Duke-NUS Medical School, Singapore
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28
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Surgical intervention and its role in Takayasu arteritis. Best Pract Res Clin Rheumatol 2018; 32:112-124. [PMID: 30526891 DOI: 10.1016/j.berh.2018.07.008] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Revised: 06/27/2018] [Accepted: 07/06/2018] [Indexed: 12/13/2022]
Abstract
Vascular surgery remains an important option in the management of Takayasu arteritis (TA). Its use is predominantly confined to the treatment of symptomatic organ ischaemia or life-threatening aneurysm formation. In most cases, this follows the failure of medical therapy to prevent arterial injury. Open surgery and endovascular approaches are used. The choice between them, at least in part, is determined by the site and nature of the lesion. Open surgery, although more invasive, offers enhanced duration of arterial patency, whereas for endovascular intervention, primary angioplasty without stenting is preferred, with stenting reserved for primary or secondary angioplasty failures. Although there is increasing interest in the role of stent grafts and tailor-made endovascular stents, long-term outcomes remain to be reported. Interventional outcomes are improved and complications reduced by therapeutic control of disease activity before and after surgery. The wider use of combined immunosuppression and the introduction of biologic therapy for refractory TA may reduce future requirements for surgical intervention.
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Jung JH, Lee YH, Song GG, Jeong HS, Kim JH, Choi SJ. Endovascular Versus Open Surgical Intervention in Patients with Takayasu's Arteritis: A Meta-analysis. Eur J Vasc Endovasc Surg 2018; 55:888-899. [PMID: 29622513 DOI: 10.1016/j.ejvs.2018.02.030] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Accepted: 02/25/2018] [Indexed: 01/11/2023]
Abstract
OBJECTIVE/BACKGROUND Although medical treatment has advanced, surgical treatment is needed to control symptoms of Takayasu's arteritis (TA), such as angina, stroke, hypertension, or claudication. Endovascular or open surgical intervention is performed; however, there are few comparative studies on these methods. This meta-analysis and systematic review aimed to examine the outcome of surgical treatment of TA. METHODS A meta-analysis comparing outcomes of endovascular and open surgical intervention was performed using MEDLINE and Embase. This meta-analysis included only observational studies, and the evidence level was low to moderate. Data were pooled and analysed using a fixed or random effects model with the I2 statistic. RESULTS The included studies involved a total of 770 patients and 1363 lesions, with 389 patients treated endovascularly and 420 treated by surgical revascularization. Restenosis was more common with endovascular than open surgical intervention (odds ratio [OR] 5.18, 95% confidence interval [CI] 2.78-9.62; p < .001). In subgroup analysis according to the involved lesions, endovascular intervention patients showed more restenosis than open surgical intervention patients in the coronary artery, supra-aortic branches, and renal artery. In both the active and inactive stages, restenosis was more common in those treated endovascularly than in those treated by open surgery. However, stroke occurred less often with endovascular intervention than with open surgical intervention (OR 0.33, 95% CI 0.12-0.90; p = .003). Mortality and complications other than stroke and mortality did not differ between endovascular and open surgical intervention. CONCLUSION This meta-analysis has shown a lower risk of restenosis with open surgical intervention than with endovascular intervention. Stroke was generally more common with open surgical intervention than with endovascular intervention. However, there were differences according to the location of the lesion, and the risk of stroke in open surgery is higher when the supra-aortic branches are involved rather than the renal arteries.
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Affiliation(s)
- Jae Hyun Jung
- Korea University College of Medicine, Seoul, South Korea; Division of Rheumatology, Department of Internal Medicine, Korea University Guro Hospital, Seoul, South Korea
| | - Young Ho Lee
- Korea University College of Medicine, Seoul, South Korea; Division of Rheumatology, Department of Internal Medicine, Cardiovascular Centre, Korea University Anam Hospital, Seoul, South Korea
| | - Gwan Gyu Song
- Korea University College of Medicine, Seoul, South Korea; Division of Rheumatology, Department of Internal Medicine, Cardiovascular Centre, Korea University Anam Hospital, Seoul, South Korea
| | - Han Saem Jeong
- Korea University College of Medicine, Seoul, South Korea; Division of Cardiology, Department of Internal Medicine, Cardiovascular Centre, Korea University Anam Hospital, Seoul, South Korea
| | - Jae-Hoon Kim
- Korea University College of Medicine, Seoul, South Korea; Division of Rheumatology, Department of Internal Medicine, Korea University Guro Hospital, Seoul, South Korea
| | - Sung Jae Choi
- Korea University College of Medicine, Seoul, South Korea; Division of Rheumatology, Department of Internal Medicine, Korea University Ansan Hospital, Ansan-si, Gyeonggi-do, South Korea.
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30
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Cardiovascular involvement in systemic rheumatic diseases: An integrated view for the treating physicians. Autoimmun Rev 2018; 17:201-214. [DOI: 10.1016/j.autrev.2017.12.001] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2017] [Accepted: 10/12/2017] [Indexed: 02/07/2023]
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31
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Salvo F. Takayasu arteritis in young women with acute ischemic heart disease: Time to shift from anecdote to clinical practice? Int J Cardiol 2018; 252:37-38. [DOI: 10.1016/j.ijcard.2017.11.064] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2017] [Accepted: 11/20/2017] [Indexed: 10/18/2022]
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