Changes in the plasma levels of thromboxane B2 and cyclic nucleotides in patients with Takayasu disease

Surgical strategy for refractory aortitis

In some instances, we encounter cases suffered from inflammatory aortic diseases (aortitis) in Japan, some of which are at the active stages with systemic inflammation. Most of them are refractory with some technical difficulties of surgical treatment. The aortic wall, particularly, at the active stage, is too fragile to hold the surgical sutures. Consequently, the suture reinforcement with Teflon felt is required. In the late stage after surgery, false aneurysms on the suture line, that is, suture detachment potentially occur. To prevent such sequelae in the early and late phases, continuous (life-long) as well as perioperative inflammation control using corticosteroid as an initial drug and/or other immunosuppression agents. This decade, instead of the conventional open surgical repairs, endovascular treatments have widely spread, predominantly for stenotic aortic/arterial lesions. In particular, for more difficult patients suffered from more troublesome Behçet disease, endovascular treatments would have greater advantages to avoid more occasionally occurred pseudo-aneurysm on the other parts as well as the surgical suture lines. The key issues on surgical treatment for refractory aortitis are perioperative inflammation control including the long term with corticosteroid and/or immunosuppressive agents, appropriate open surgical or endovascular treatment approaches, and sufficient reinforcement of surgical suture lines.

Antithrombotic therapy in aortic diseases: A narrative review

Aortic diseases are a heterogeneous group of disorders, including atherothrombotic conditions like aortic atheroma, cholesterol embolization syndrome, aortic mural thrombus, thrombus within an aneurysm, and large vessel vasculitis. In this review, we provide a summary of the current evidence regarding atherothrombotic diseases of the aorta, focusing on therapeutic avenues. In patients with previous stroke, aortic arch atheroma is recognized as a strong predictor of recurrent atheroembolism, and antiplatelet therapy alone is still associated with a high (11.1%) residual risk of recurrent stroke. In secondary prevention, the use of dual antiplatelet therapy or moderate intensity anticoagulation with warfarin may lower the risk of recurrent stroke at a cost of increased life-threatening bleeding. Thrombi adherent to the aortic wall are generally associated with underlying atherosclerosis or aneurysmal disease. Primary aortic mural thrombus is a rare condition, sometimes related with systemic prothrombotic or inflammatory diseases. Retrospective studies suggest that anticoagulation is beneficial in patients with mobile mural thrombus. The pathogenesis and consequences of thrombus in an aortic aneurysm, or in an endograft following endovascular aneurysm repair, have been studied, but the role of antiplatelet therapy in those two conditions is still unclear and should be driven by general cardiovascular risk prevention. The benefit of anticoagulation to reduce thrombus load is uncertain. Patients with large vessel vasculitis experience increased cardiovascular events secondary to inflammation-driven atherothrombotic processes. Antiplatelet therapy is recommended as part of the therapy for prevention of cardiovascular disease. Anticoagulation with warfarin has shown limited benefit in few retrospective studies.

Thrombosis in vasculitic disorders-clinical manifestations, pathogenesis and management

Inflammation and coagulation are known to affect each other in many ways. Vasculitis represents a group of disorders where blood vessels (small, medium, large or variable) are infiltrated with inflammatory cells. Accumulating evidence in the literature suggests both clinical and physiological association between vasculitis and thrombosis. Vasculitis-associated thrombosis involves arteries and veins, and a tight connection has been reported between the activity of vasculitis and the appearance of thrombosis. Pathophysiology of these relations is complex and not completely understood. While thrombophilic factors are associated with vasculitis, it remains unclear whether a true association with clinical thrombosis is present. Furthermore, several factors leading to hemostasis, endothelial injury and induction of microparticles were described as possibly accounting for thrombosis. Management of thrombosis in vasculitis patients is challenging and should be further assessed in randomized controlled studies. The current review describes clinical manifestations, pathogenesis and management of thrombosis associated with different vasculitides.

Takayasu's arteritis and its role in causing renal artery stenosis

Takayasu's arteritis is a systemic vasculitis that involves medium- and large-sized arteries. Renal artery involvement is a potential manifestation of TA that occurs in 60% of the patients in India and the Far East. This manifestation can lead to renal failure and/or renovascular hypertension. Renovascular hypertension is generally resistant to medical therapy and often requires additional invasive management strategies, such as angioplasty or surgical bypass. In this review, we present the epidemiology, clinical manifestations, diagnosis and treatment of Takayasu's arteritis with particular emphasis on renal artery stenosis. The aim is to increase the awareness of this condition among clinicians because early diagnosis and the timely introduction of treatment can lead to improved outcomes in this poorly understood clinical enigma.

[How to manage Takayasu arteritis?]

Thorough clinical and imaging assessment of the arterial tree when a diagnosis of Takayasu arteritis is established. Glucocorticoïd as intiation therapy. Immunosuppresive agent should be considered as adjunctive therapy if resistance or dependance to glucocorticoïd therapy. Supportive care, antihypertensive drugs, glucocorticoïd induced osteoporosis preventive therapy, tuberculosis screening should not be forgiven. Monitoring of therapy should be clinical and supported by biological markers and imaging. Reconstructive surgery should be performed in the quiescent phase of disease.

Antiplatelet therapy for the prevention of arterial ischemic events in takayasu arteritis

BACKGROUND

Vessel wall inflammation, atherosclerosis and hypercoagulability may be responsible for ischemic events in Takayasu arteritis (TA). No study has evaluated the effect of antiplatelet therapy for the prevention of ischemic events in TA.

METHODS AND RESULTS

Forty-eight patients who met the ACR Classification Criteria for TA under follow-up at the Vasculitis Unit of Universidade Federal de São Paulo were evaluated retrospectively for clinical manifestations, therapy and arterial ischemic events. The mean age at study was 38.0 years and the mean age at TA diagnosis was 29.1 years. Women comprised for 89.6% of patients and 60.4% were Caucasian. Risk factors for cardiovascular disease were found in 44 patients (91.7%) The most common comorbidities for TA patients were hypertension (77.1%), high low-density lipoprotein (45.8%) and obesity (16.7%). Antiplatelet therapy was used by 62.5% of patients whereas anticoagulants were used by 12.5%. Acute ischemic events occurred in 29.2% of patients. TA patients with ischemic events used significantly less antiplatelet agents (14.3%) than those without ischemic events (82.4%), P<0.0001. No difference concerning ischemic events was observed in patients on anticoagulant therapy (P=0.339). The 3 deaths of TA patients were observed only in those who had presented ischemic events (P=0.021). Antiplatelet agents had a protective effect against ischemic events (hazard ratio =0.055, 95% confidence interval: 0.06-0.514; P=0.011).

CONCLUSIONS

Antiplatelet therapy is associated with a lower frequency of ischemic events in patients with TA.

Medical treatment of Takayasu arteritis

The guidelines for medical treatment of Takayasu arteritis established in 1987 by the Systemic Vascular Disorders Research Committee, Ministry of Health and Welfare of Japan are presented. The first part of the guidelines concerns treatment with adrenocorticosteroids and the second part concerns other medical treatment. A review of the literature referring to steroid therapy and other medical treatment of Takayasu arteritis is also included.