The vascular manifestations of Behçet's disease: angiographic and CT findings

Long-term outcomes of endovascular treatment for aortic pseudoaneurysm in patients with Behçet's disease

OBJECTIVES

Behçet's disease (BD) is a multisystem inflammatory disorder with unknown etiology, and its aneurysmal lesions are associated with high mortality due to the high risk of rupture. This study intended to further explore the long-term safety and efficacy of endovascular therapy for BD-related aortic pseudoaneurysm (BAP).

METHODS

From January 2009 to May 2021, 17 BAP patients who underwent endovascular repair were retrospectively identified and enrolled. Adequate immunosuppressive treatment was instituted before and after endovascular treatment unless emergency surgery was required. The patients were followed up at 3, 6, and 12 months and yearly after the primary endovascular intervention by computed tomography angiography (CTA) examination.

RESULTS

Nineteen BAPs were identified among 17 patients. BAPs located at the aortic arch were found in three patients (17.6%), descending thoracic aorta in 5 (29.4%), and abdominal aorta in 10 (58.8%; suprarenal abdominal aorta in 2 [11.8%], and infrarenal abdominal aorta in 8 [47.1%]). The mean ESR during admission was 56.5 ± 24.9 mm/h (range = 30.0-120.0 mm/h), which fell to 22.7 ± 18.4 mm/h (range = 2.0-74.0 mm/h) before the endovascular intervention (p < 0.001). The rate of favorable immunosuppressive control before intervention is 76.5% (13/17). Technical success was achieved in all patients. Median follow-up time was 57.0 months (interquartile range [IQR] = 21.3-67.3 months). Pseudoaneurysm recurrence was observed in four patients, type I endoleak in one, pseudoaneurysms sac dilation in one, and external iliac artery occlusion in 1. Two patients died of pseudoaneurysm rupture. Five-year accumulated overall rate, recurrence-free rate, and reintervention-free survival rate of BAP patients were 92.8%, 75.4%, and 71.8%, respectively.

CONCLUSION

Endovascular treatment in BAP patients seemed to be associated with long-term safety and efficacy with a 5-year overall survival rate of 92.8%. Adequate immunosuppressive treatment was essential for BAP patients to prevent aortic pseudoaneurysm recurrence and improve the prognosis.

Risk factors of cardiovascular involvement in patients with Behcet's disease

Objectives

Behcet's disease (BD) is a multi-systemic inflammatory vasculitis which may be life-threatening if combined with cardiovascular problems. The aim of the study was to identify potential risk factors associated with cardiovascular involvement in BD.

Methods

We reviewed the medical databases of a single center. All BD patients identified as fulfilling the 1990 International Study Group criteria or the International Criteria for Behcet's Disease criteria. Cardiovascular involvement, clinical manifestations, laboratory features, and treatments were recorded. The relationship between parameters and cardiovascular involvement was analyzed.

Results

111 BD patients were included: 21 (18.9%) had documented cardiovascular involvement (CV BD group) and 99 (81.1%) had no cardiovascular involvement (non-CV BD group). Compared with non-CV BD, the proportion of males and smokers were significantly increased in CV BD (p = 0.024 and p < 0.001, respectively). Levels of activated partial thromboplastin time (APTT), cardiac troponin I and C-reactive protein were significantly higher (p = 0.001, p = 0.031, and p = 0.034, respectively) in the CV BD group. Cardiovascular involvement was associated with smoking state, the presence of papulopustular lesions, and higher APTT in multivariate analyzed (p = 0.029, p = 0.021, and p = 0.006, respectively). The ROC curve showed that APTT predicts the risk of cardiovascular involvement (p < 0.01) at a cut-off value of 33.15 s with a sensitivity of 57.1% and specificity of 82.2%.

Conclusion

Cardiovascular involvement in BD patients was associated with gender, smoking state, the presence of papulopustular lesions, and higher APTT. All patients newly diagnosed with BD should be systematically screened for cardiovascular involvement.

Adjunctive proximal aortic and aortodistal prosthetic wrapping of vascular anastomoses for Adamantiadis-Behçet's aortic/aortoiliac aneurysms: A revisit

BACKGROUND

We described our local experiences with a single-layer wrapping technique for the vascular anastomoses in patients with Adamantiadis-Behçet's aortic/aortoiliac aneurysms using InterGard Silver-impregnated Dacron® patch prosthesis.

METHODS

Between January 2013 to December 2019, we retrospectively reviewed 20 patients presented with Adamantiadis-Behçet's aortic/aortoiliac aneurysms. All patients presented with Adamantiadis-Behçet's aortic/aortoiliac aneurysms. Two groups were analyzed, Group I, considered as a control group (n = 20). While group II (n = 20), of which prosthetic wrapping was performed. Follow up took place for a maximum of 24 months.

RESULTS

during a six-year retrospective study period, 20 patients were recruited. They included 15 males and five females (ratio 3:1). The median age was 30.5 ± 4.2 years. Anastomotic pseudoaneurysms were reported in group I (control, [non-wrapping group]). While group II doesn't (wrapping group). Paired samples t test revealed a significant difference between those underwent wrapping and those with non-wrapping (p = .019 and .038). False aneurysms were reported in 80% of the non-wrapping group as estimated by the Kaplan-Meier curves. While Log-rank test results revealed a significant difference between both the studied groups (p < .008). Primary graft patency was 90% at 24 months as reported by the Kaplan-Meier survival method.

CONCLUSIONS

adjunctive wrapping for vascular anastomoses using Intergard Silver-impregnated Dacron® patch in patients with Adamantiadis-Behçet's aortic/aortoiliac aneurysms is an applicable, simple, and reliable technique. It was associated with low morbidity and mortality rates. Moreover, we discussed a relatively old technique aiming to explore its success and safety in treating arterial aneurysms in Adamantiadis-Behçet's disease patients.

Behçet's Disease: A Radiological Review of Vascular and Parenchymal Pulmonary Involvement

Behcet's disease (BD) is a chronic systemic inflammatory disorder characterized by underlying chronic vasculitis of both large- and small-caliber vessels. Thoracic involvement in BD can occur with various types of manifestations, which can be detected with contrast-enhanced MSCT scanning. In addition, MR can be useful in diagnosis. Characteristic features are aneurysms of the pulmonary arteries that can cause severe hemoptysis and SVC thrombosis that manifests as SVC syndrome. Other manifestations are aortic and bronchial artery aneurysms, alveolar hemorrhage, pulmonary infarction, and rarely pleural effusion. Achieving the right diagnosis of these manifestations is important for setting the correct therapy and improving the patient's outcome.

Hepatic Artery Pseudoaneurysm Following Gunshot Injury With Early Rupture

Pseudoaneurysms are a rare and potentially life-threatening complication that can be caused by trauma, infections, tumors, autoimmune diseases, organ transplants, or idiopathic causes. The management of liver trauma is based on the anatomy of the injury and the patient’s physiology. Posttraumatic hepatic artery pseudoaneurysm (HAP) is a life-threatening complication that requires prompt recognition and a multidisciplinary approach in its management. We present a case of HAP rupture two weeks following a gunshot wound to the liver.

Serious Right Coronary Artery Thrombosis Revealing Behçet's Disease in a Female Patient: A Case Report

Although atherosclerosis remains the major cause of acute coronary syndrome, there are many other etiologies that should be taken into account, especially in young patients with no atherosclerotic risk factors. Coronary involvement is extremely rare in patients with Behçet's disease, notably in young patients. In addition, acute inferior myocardial infarction revealing Behçet's disease has rarely been reported. Through this article, we report a case of Behçet's disease with arterial involvement diagnosed after myocardial infarction resulting from thrombosis of the right coronary artery in a 50-year-old woman with no specific medical history.

Endovascular treatment for Behçet's disease: a case report

Behçet's disease (BD) is a multisystemic vasculitis of unknown etiology. Cardiovascular involvement has been thoroughly described in the literature and the major cause of death in BD is secondary to aneurysm complications. In this case report, a patient with BD presented with a recurrent abdominal aortic aneurysm, which was corrected using a custom-made endoprosthesis. The optimal treatment for patients with BD remains highly controversial and challenging because of technical difficulties and frequent recurrence. Endovascular intervention seems to be a feasible alternative with considerably less morbidity than conventional surgery.

Recurrent symptomatic ischemic stroke in a 46-year-old African male revealing Angio-Behçet with severe cardiovascular involvement

Behçet’sdisease (BD) is a chronic, multisystem vasculitis. It is categorized under variable vessel vasculitis in the new Chapel Hill nomenclature as it involves blood vessels of any type and size. It is characterized by relapsing aphthous ulcers commonly occurring in the oral mucosa and genitalia with ocular involvement. Other organ systems may be involved any time throughout the course of the disease. The exact cause is unknown. However, combination of genetic and environmental factors is likely to play a role.

Cardiac involvement may occur in the form of intracardiac thrombus, endocarditis, myocarditis, pericarditis, endomyocardial fibrosis, coronary arteritis, myocardial infarction, and valvular disease.

We present a case of Angio-Behçet in a 46-year-old African male with severe cardiovascular involvement including pulmonary artery hypertension (PAH), right ventricular failure and left ventricular diastolic dysfunction diagnosed after 2 episodes of symptomatic ischemic stroke resulting from complete occlusion of the right internal carotid artery (ICA) up to its intracranial portion.

Immunosuppressive and anticoagulant therapies have induced improvement in cardiac manifestations. Nevertheless, prompt recognition of the primarily vascular manifestation of BD without mucocutaneous manifestations was responsible for considerable delay that did not afford surgical therapy for the carotid occlusion.

Investigation of the arterial intima-media thickness in Behcet’s disease patients without vascular complaints

Objectives

Behcet’s disease is a multisystemic, inflammatory disease. Various factors have been implicated in the disease, including genetics, infections, immunoglobulins, immune complexes, antibodies, and oxidative stress. However, the underlying etiopathogenesis remains unclear. Behcet’s disease can occur with or without vascular involvement. This prospective study investigated the relationship between the intima-media thickness of the major arteries, in addition to other factors affecting the disease process, in Behcet’s disease without vascular involvement.

Methods

Twenty-four patients (average age: 38.50 ± 10.931) without vascular involvement or any vascular complaints who were diagnosed with Behcet’s disease were included in the study. Sixteen healthy subjects (average age: 39.75 ± 7.793) were included as a control group. Demographic information and medical histories were recorded, and routine blood tests were performed in both groups. The intima-media thickness of the subclavian, axillary, femoral, and carotid arteries of all the participants were recorded using Doppler ultrasonography. The data were then subjected to intergroup statistical and correlation analyses.

Results

There were no significant differences between the arterial intima-media thickness values of the Behcet’s disease patients and those of the control group ( p > 0.05). However, there was a significant difference between the neutrophil–lymphocyte ratio ( p = 0.004), low-density lipoprotein ( p = 0.007), and triglyceride ( p = 0042) levels of the two groups. Significant correlations were found between intima-media thickness and neutrophil–lymphocyte ratio levels ( p = 0.012) and the disease duration ( p = 0.030). There was also a significant correlation between the intima-media thickness of the femoral artery and disease duration ( p = 0.014).

Conclusions

The results showed that the duration of illness had a significant effect on arterial intima-media thickness in Behcet’s disease. Blood neutrophil–lymphocyte ratio levels were also associated with increased intima-media thickness.

Peripheral Non-atherosclerotic Arterial Disorders: What Radiologists Need to Know

Peripheral non-atherosclerotic arterial disorders (NAADs) are a heterogeneous group of rather uncommon conditions that tend to manifest in subjects without atherosclerosis. Each of these conditions has distinctive pathophysiology; however, there are some common clinical and radiological characteristics and in some cases a common treatment approach that unifies these conditions to a specific group, hence the NAADs. Clinicians and radiologists often fail to recognize NAADs, and there might be a delay in the management of such patients; this may result in seriously adverse outcomes that could otherwise have been avoided or minimized. Knowledge of these conditions and of their radiological appearances is therefore important to help establish a correct diagnosis to allow the prompt initiation of treatment. The purpose of this pictorial review is to present a selection of NAADs cases and to discuss the radiological characteristics and the most common lines of therapeutic approaches.

Spontaneous aortic pseudoaneurysm rupture into the sigmoid colon in Behçet’s disease patient

Behçet’s disease (BD) is a multisystem autoimmune disorder characterized by recurrent orogenital ulcers, uveitis, and skin lesions. The vascular manifestations include thrombophlebitis, stenosis, occlusion, and pseudoaneurysm. BD infrequently precipitates aortic pseudoaneurysm rupture into the sigmoid mesocolon and lumen of the adjacent colon. Here we report an extremely rare case of spontaneous abdominal aortic pseudoaneurysm rupture via the sigmoid mesocolon into the lumen of the sigmoid colon in a 37-year-old patient with BD.

Endovascular Repair and Adjunctive Immunosuppressive Therapy of Aortic Involvement in Behçet's Disease

OBJECTIVES

Aortic aneurysm is a serious problem in Behçet's disease, but open surgical therapy carries the risk of recurrent pseudoaneurysm. Here the outcomes of endovascular repair and adjunctive immunosuppressive therapy for aortic disease in Behçet's disease are presented.

MATERIALS

This was a retrospective study. Between 2002 and 2012, nine patients with Behçet's disease (8 male, median age 41 years, range 33-60 years) were treated by endovascular stent grafting for abdominal or thoraco-abdominal aortic pseudoaneurysm.

METHODS

Computed tomography angiography revealed infrarenal pseudoaneurysm in six (66.6%) patients and suprarenal pseudoaneurysm in three (33.3%). Patients received immunosuppressive therapy with oral prednisolone (60 mg/day) and cyclophosphamide (200 mg/day) for 2 weeks or more before the procedure, and intravenous hydrocortisone (200 mg/day) combined with cyclophosphamide (200 mg/day) for 3 days after the procedure. Thereafter, oral immunosuppressive therapy was continued for 2 years.

RESULTS

A straight tube graft was implanted in seven patients and a bifurcated graft in two patients. Two stage procedures (debranching before endovascular therapy) were performed in three patients for thoraco-abdominal aortic pseudoaneurysms. Stent grafting was successful in all patients, without any peri-operative complications. However, two patients needed abdominal exploration later: one for seroma around the graft and the other for a fistula between the duodenum and the graft. No recurrence of aneurysm was observed during a mean follow up of 40 ± 16 months. One patient died in the 15th month from a non-vascular cause.

CONCLUSIONS

Endovascular stent graft implantation and adjunctive immunosuppressive therapy seems to be safe and effective in the treatment of aortic involvement in Behçet's disease, but this approach needs further evaluation.

"To-and-fro" waveform in the diagnosis of arterial pseudoaneurysms

Medical ultrasound imaging with Doppler plays an essential role in the diagnosis of vascular disease. This study intended to review the clinical use of “to-and-fro” waveform at duplex Doppler ultrasonography (DDU) in the diagnosis of pseudoaneurysms in the arterial vessels of upper and lower extremities, abdominal aorta, carotid and vertebral arteries as well as to review our personal experiences of “to-and-fro” waveform at DDU also. After receiving institutional review board approval, an inclusive literature review was carried out in order to review the scientific foundation of “to-and-fro” waveform at DDU and its clinical use in the diagnosis of pseudoaneurysms in various arterial vessels. Articles published in the English language between 2000 and 2013 were evaluated in this review study. Pseudoaneurysms in arterial vessels of the upper and lower extremities, abdominal aorta, carotid and vertebral arteries characterized by an extraluminal pattern of blood flow, which shows variable echogenicity, interval complexity, and “to-and-fro” flow pattern on color Doppler ultrasonography. In these arterial vessels, Duplex ultrasonography can demonstrate the degree of clotting, pseudoaneurysm communication, the blood flow patterns and velocities. Spectral Doppler applied to pseudoaneurysms lumen revealed systolic and diastolic turbulent blood flow with traditional “to-and-fro” waveform in the communicating channel. Accurate diagnosis of pseudoaneurysm by spectral Doppler is based on the documentation of the “to-and-fro” waveform. The size of pseudoaneurysm determines the appropriate treatment approach as surgical or conservative.

Left main coronary artery thrombosis revealing angio-Behçet syndrome

Although acute myocardial infarction commonly results from coronary atherothrombosis, there are several other etiologies that should be taken initially into account, especially in young adults without significant atherosclerotic risk factors. Thrombophilia and coronary arteritis are, in this context, examples of etiologies that should be looked after. Through this article, we present a case of Behçet's disease with arterial involvement diagnosed after myocardial infarction resulting from thrombosis of the left main coronary artery in a 38-year-old young man without any particular past medical history.

Successful Stent Implantation for Aortoiliac Bifurcation Stenosis in a Young Patient with Behçet's Disease

Behçet's disease (BD) is a multisystem vascular inflammatory disease. BD can affect blood vessels of nearly all sizes and types. Arterial involvement is a rare but serious condition in the course of BD. Here, we report a case of stenosis at the iliac artery bifurcation which was treated with percutaneous balloon angioplasty and stent implantation in a 37-year-old patient with BD.

[A saccular aneurysm of the abdominal aorta revealing Behçet disease: when to operate?]

L'atteinte vasculaire est fréquente au cours de la maladie de Behçet. Elle est essentiellement représentée par les thromboses veineuses alors que l'atteinte artérielle est plus rare. Elle peut être isolée ou multifocale et peut toucher tous les territoires avec prédilection pour l'aorte abdominale, les artères pulmonaires et les artères des membres inférieurs. L'atteinte anévrysmale de l'aorte abdominale est trompeuse se manifestant par une symptomatologie atypique responsable d'un retard diagnostique favorisant la rupture. Dans notre cas, des douleurs abdominales paroxystiques ont incité le patient à consulter rapidement. L'enquête étiologique a conclue à un angio Behcet. Rarement, l'anévrysme de l'aorte abdominale est révélé par une complication telle que la rupture dans le rétro péritoine ou le tube digestif. Les indications chirurgicales des anévrysmes de l'aorte sont discutées ici. Un traitement immunosuppresseur au long cours s'impose en post opératoire pour limiter le risque de récidive.

Intense pulsed light in the treatment of telangiectasias: case report of Behçet's disease with superficial vascular involvement

Behçet's disease (BD) is a chronic systemic inflammatory disorder of unknown etiology with variable clinical manifestations. HLA-B51 allele is the most strongly associated known genetic factor. The mucocutaneous lesions (oral aphthae, genital aphthae, skin lesions such as pseudofolliculitis) constitute the hallmark of the disease, but also gastrointestinal, vascular, central nervous systems, and others may be involved. We report a case of a young man affected with Behçet's disease who presented facial telangiectasias and striae rubra in the inner region of his arms and at the level of his hips, as uncommon minor superficial vascular manifestations of BD. To manage them we have subjected the patient to a cycle of Intense Pulsed Light (IPL) therapy. Our findings showed that the use of IPL is a safe and effective treatment for telangiectasias and striae rubra, also in the complex clinical condition of Behçet's disease. In fact, the treatments were well tolerated, no sign of scarring or hyper/hypopigmentation was reported and we obtained a significant improvement of the lesions in terms of color and size of them.

Anterior mediastinal fat in Behçet's disease: qualitative and quantitative CT analysis

The fat-rich anterior mediastinum could be a sensitive window for monitoring minute changes in vascularity induced by systemic vasculitis. To evaluate this hypothesis, an analysis of anterior mediastinal fat in patients with Behçet's disease and a control group was conducted. This study included 43 patients diagnosed with Behçet's disease within the last 11 years who underwent CT scan; 55 patients were selected as a control population. Mediastinal fat was classified according to CT morphology. Comparison of serum inflammatory markers was performed for evaluation of disease activity according to morphologic types, and average Hounsfield unit of the anterior mediastinum was measured. Significantly higher mean CT attenuation was observed in the Behçet's disease group, compared with the control group (-48.5 ± 33.5 vs. -67.7 ± 18.7, respectively, P < 0.05). Mediastinal fat types were classified as follows: pure fatty tissue (2 vs. 31 % [Behçet's disease vs. control group]), diffuse soft tissue infiltration (16 vs. 29 %), tubular structures (21 vs. 4 %), mixed infiltration with tubular structures (42 vs. 15 %), and evident thymic tissue (19 vs. 22 %). The value for mean mediastinal attenuation was significantly higher in the group with a high level of C-reactive protein than in the normal level group. The mean CT attenuation of anterior mediastinal fat is significantly higher in the Behçet's disease group, compared with the normal group. Although pathologic confirmation is needed, the cause is postulated to be either inflammatory neovascularization or minimal thymic hyperplasia induced by Behçet's disease.

Major vascular involvement in Behçet's disease: a retrospective study of 796 patients

Behçet's disease (BD) is a multi-systemic inflammatory disorder which can affect all types and sizes of blood vessels. This study aims to evaluate the prevalence and characteristics of vascular involvement in BD. Among 796 patients diagnosed with BD, 102 patients (81 male, 21 female) with vascular involvement were included, whose detailed clinical characteristics were recorded. The diagnosis of vascular lesions was made on clinical signs, by Doppler ultrasonography, and/or angiography using computed tomographic or magnetic resonance techniques. Vascular involvement occurred in 12.8 % of BD patients. Male to female ratio was 3.86:1. Mean age at onset of vascular involvement was 29.5 ± 11.3 years. Vascular lesion was the initial sign of BD in 28 patients, accounting for 27.5 %. Of 102 BD patients with vascular involvement, 72 had venous lesions (70.6 %) and 56 had arterial lesions (54.9 %), among which 26 (25.5 %) patients had both venous and arterial involvements. Female BD patients were more often involved with arterial lesions, whereas male BD patients developed venous lesions more often than females, P = 0.000. The most common type of vascular involvement was deep venous thrombosis in lower extremities (n = 49), other affected venous sites including inferior vena cava, superior vena cava, and cerebral venous. The prominent type of arterial lesions was dilatation (n = 25, including 24 cases of aneurysms); other types included eight cases of occlusion and 23 cases of stenosis. The main locations of arterial lesions were the aorta (n = 19), lower extremity arteries (n = 15), pulmonary arteries (n = 13), coronary arteries (n = 5), and subclavian arteries (n = 5). Compared with those without vascular lesions, ocular involvement, genital ulcers, and arthritis were significantly less frequent among patients with vasculo-BD (23.5 vs 35.2 %, P = 0.024; 54.9 vs 76.5 %, P = 0.000; 19.6 vs 30.5 %, P = 0.026), whereas a higher frequency of cardiac involvement was found in vasculo-BD patients (20.6 vs 3.6 %, P = 0.000). Vascular involvement is a complication in BD patients. This study illustrated that venous lesions are more frequently involved than arterial lesions. Vascular lesions correlated with a high frequency of cardiac involvement and a low incidence of ocular lesions, genital ulcers, and arthritis.

Atypical Vascular Involvement in a Case of Behçet's Disease

Introduction. Behçet's disease (BD) is a form of vasculitis of unknown etiology which is rare in our environment. It is characterized by a variety of clinical manifestations and usually affects young adults. Recurrent oral and genital ulcers are a characteristic and extremely frequent symptom, but mortality is linked with more significant symptoms such as aortic pseudoaneurysm, pulmonary pseudoaneurysm, and cerebral venous thrombosis. Patient and Method. We present a case of a young male with atypical BD and severe polyvascular involvement (previous cerebral venous thrombosis and current peripheral venous thrombosis, acute ischemia, and peripheral arterial pseudoaneurysm) who required urgent surgical intervention due to a symptomatic external iliac pseudoaneurysm. Result. The pseudoaneurysm was successfully treated, we performed an iliofemoral bypass, and we treated it with steroids and immunosuppressive therapy. Conclusions. These rare clinical manifestations highlight the importance of considering BD in young patients, even in usual cases of vascular intervention, whether arterial or venous in nature.

Insights into imaging of aortitis

BACKGROUND

Aortitis is a subtype of the more general term "vasculitis", an inflammatory condition of infectious or noninfectious origin involving the vessel wall. The term "vasculitis" refers to a broad spectrum of diseases with different aetiologies, pathophysiologies, clinical presentations and prognoses. The clinical manifestations are nonspecific, as are the laboratory findings such as pain, fever, weight loss, vascular insufficiency and elevated levels of acute phase reactants, as well as other systemic manifestations, and sometimes may mimic other entities. Thus, if not suspected as part of the initial differential diagnosis, aortitis can be overlooked during the workup of patients with constitutional symptoms and systemic disorders.

METHODS

Imaging is rarely used for the primary diagnosis, but imaging findings, although nonspecific, can help in the assessment of these patients and is often required for making the final diagnosis. Imaging can be critical in the initiation of appropriate management and therapy.

RESULTS

Noninvasive cross-sectional imaging modalities such as contrast-enhanced CT, magnetic resonance (MR) imaging, nuclear medicine and in particular positron emission tomography (PET) are the leading modalities in modern diagnostic imaging of aortitis for both the initial diagnosis and follow-up.

CONCLUSION

This review focusses on the most common manifestations of aortitis with which radiologists should be familiar. TEACHING POINTS : • Aortitis is an inflammatory condition of infectious/noninfectious origin involving the vessel wall. • Imaging findings can help in the assessment of aortitis and are often crucial for the final diagnosis. • Contrast-enhanced CT, MRI and PET-CT are used for both the initial diagnosis and follow-up of aortitis.

Left pleural effusion and fever of unknown origin--a clue to thoracic arterial pathology

The subset of patients who have both fever of unknown origin (FUO) and a nondiagnostic pleural effusion on presentation has not been previously investigated. A retrospective search of all patients classified as 'classic' FUO one week after admission to a department of general internal medicine identified 71 patients over 15 years. Seven were found to have associated pleural effusion(s) on admission (9.8%). In three patients thoracic large vessel pathology was diagnosed (chronic aortic dissection, giant cell arteritis and Takayasu arteritis). In these patients, the pleural effusion was predominantly left-sided, small to moderate in amount and nondiagnostic on thoracentesis. The effusions resolved spontaneously or with appropriate treatment. Thus, in patients with prolonged fever and systemic symptoms, a 'bland' left-sided pleural effusion may be a diagnostic clue to underlying inflammation of large thoracic arteries. Pleural irritation due to its anatomical proximity to the large arteries on the left side of the thorax may underlie the pathogenesis. Recognition of this sign may lead to a more timely diagnosis of occult thoracic large vessel pathology.

[Behcet syndrome: thirty comments with lung and vascular injury of peripheral vessels]

INTRODUCTION

Behcet's disease is a systematic vasculitis of unknown cause, characterized essentially by eye, cutaneous, articular, neurological and vascular manifestations.

METHODS

We retrospectively analysed the Behcet's disease cases that were followed up in our ward from January 2000 to January 2009. The inclusion criteria were those of International Study Group on Behçet's disease (aphthosis mouth was required). Data were retrieved and analysed with two softwares (Access(®) and Epi Info(®)).

RESULTS

We observed 30 cases with vascular lesions on a series of 92 patients with Behcet's disease. Most patients were male, with an average age around 40. The venous manifestations, concerning essentially the lower limbs (deep and superficial thrombosis) were found at 27 patients (90 %), and the average of age during the appearance of the venous lesions was 40 years. Arterial lesions appear more late in 13 patients (43 %) (average of age 43 years). We noted, on the other hand, 11 cases of aneurysms and five cases of arterial thrombosis. The use of corticosteroids was necessary in all cases in association with the others drugs (anticoagulants, colchicine, immunosuppressors). Among the patients having had aneurysms, six were treated surgically. The outcome was favorable for most patients. Two patients had pulmonary embolism and two post-surgery complications. One patient died in the consequences of an intragastric break of an aneurysm of the abdominal aorta.

CONCLUSION

The vascular involvement in Behcet's disease is manifested primarily by thrombophlebitis. Achieving blood pressure, less common, is problematic therapeutic because of the recurrent and life threatening.

Vascular manifestations of Behcet's disease: report of a case and review of the literature

Adamantiades-Behçet's disease (ABD) is a relapsing vasculitis of unknown aetiology and variable clinical manifestations. The syndrome can be presented in a myriad of ways and can involve nearly every organ. Although vascular involvement is not included among the ABD diagnostic criteria, it is a unique clinical manifestation in adults with a potentially devastating outcome. We report an ABD case, presenting with a thrombotic occlusion of the inferior vena cava. The authors review the recent literature, emphasizing the spectrum of vascular manifestations accompanying Behçet's disease.

A study on thrombophilic factors in Italian Behcet's patients

BACKGROUND

Behcet's disease (BD) may complicate with arterial and venous thrombosis. The purpose of this work is to evaluate in an Italian group of BD patients with thrombotic events a large panel of inherited and acquired thrombophilic factors.

METHODS

Thirty BD patients, of which nine with previously arterial or venous thrombosis and 21 without, underwent the following investigations: plasma antithrombin activity, protein C activity, free protein S level, sensitivity to APC, total plasma homocysteine concentration, serum folate level, determination of anti-phospholipid antibodies, serum Lp(a) levels, tests for gene polymorphisms of factor V Leiden, prothrombin and methylenetetrahydrofolate reductase genes. Tests for the gene polymorphisms were also performed in a group of healthy control subjects.

RESULTS

All the six patients with arterial or deep venous thrombosis showed thrombophilic conditions such as protein C or protein S deficiency (one case each), hyperhomocysteinemia (two cases), positivity of anti-phospholipid antibodies associated with APC resistance or hyperhomocysteinemia (one case each). Among three subjects with superficial thrombophlebitis only one showed a mild hyperhomocysteinemia. No differences were found between BD patients and control subjects concerning polymorphisms of the genes considered. Among BD patients the Factor V H1299R mutation showed a weak association with venous thrombosis (P=0.048).

CONCLUSION

In BD patients different concomitant significant thrombophilic risk factors may contribute to the development of thrombotic events. Patients affected by vasculo-Behcet should be evaluated for the presence of coexisting major thrombophilic conditions.

[Multiple arterial thrombosis in Behçet's disease]

Behcet's disease (BD) is a multisystemic vasculitis. Its etiopathogeny remains unknown. Vascular involvement in BD is frequent and venous thrombosis is the most common manifestation (30% of cases). Arterial involvement is rare (2.7 to 7%). The latter is often severe and considered as a life threatening complication. Pathogenesis of thrombosis occurring in BD remains unclear. We report a 45-year-old man, from south of Tunisia, who presented a BD with a bifocal arterial involvement: right internal carotid thrombosis and bilateral proximal thrombosis of the two pulmonary arteries. Therapeutic strategies to address this multiple arterial involvement and the pathogenesis of thrombosis raise many questions.

Interventional radiology in the diagnosis, management, and follow-up of pseudoaneurysms

Arterial wall disruption, as a consequence of inflammation/infection, trauma (penetrating or blunt), or iatrogenic causes, may result in pseudoaneurysm formation. Currently, iatrogenic causes are increasing as a result of the growth of endovascular intervention. The frequency of other causes also seems to be increasing, but this may simply be the result of increased diagnosis by better imaging techniques, such as multidetector contrast-enhanced computed tomography. Clinically, pseudoaneurysms may be silent, may present with local or systemic signs, or can rupture with catastrophic consequences. Open surgical repair, previously the mainstay of treatment, has largely been replaced by image-guided occlusion methods. On the basis of an experience of over 100 pseudoaneurysms, treatments at various anatomical sites, imaging modalities used for accurate diagnosis, current changing therapeutic options for pseudoaneurysm management, approved embolization agents, and clinical follow-up requirements to ensure adequate treatment will be discussed. Image-guided direct percutaneous and endovascular embolization of pseudoaneurysms are established treatment options with favorable success rates and minimal morbidity. The pendulum has now swung from invasive surgical repair of pseudoaneurysms to that of image-guided interventional radiology.

Radiologic and clinical findings of Behçet disease: comprehensive review of multisystemic involvement

Behçet disease is a chronic, relapsing, systemic disorder of unknown etiology, characterized by recurrent oral and genital ulcers, uveitis, and other clinical manifestations in multiple organ systems. Although the diagnosis is made on the basis of the combination of typical clinical symptoms, radiologic findings of Behçet disease show characteristic features of its involvement in the gastrointestinal, neurologic, cardiovascular, and thoracic organ systems. In the gastrointestinal tract, Behçet disease may produce various types of ulcers in the esophagus, stomach, and small and large intestines, as well as deeply penetrating ulcerations in the ileocecal region, with frequently accompanying enteric fistulas. Neurologic involvement includes typical and atypical parenchymal neurobehcet disease, dural sinus thrombosis, cerebral arterial aneurysm, occlusion, dissection, and meningitis. Vascular involvement is divided into three subsets including venous occlusion, arterial occlusion, and arterial aneurysm. Cardiac manifestations include intracardiac thrombus, endomyocardial fibrosis, periaortic pseudoaneurysm, and rupture of the sinus of Valsalva. Manifestations of Behçet disease in the thorax include pulmonary arterial aneurysm, pulmonary arterial thromboembolism, thrombosis in the superior vena cava, pulmonary infarction, hemorrhage, and vasculitis of the pleura and pericardium. These various manifestations of Behçet disease respond to steroid treatment; however, one of the characteristics of Behçet disease is the high rate of complications and recurrence after surgery. Familiarity with its various radiologic and clinical characteristics is essential in making an accurate early diagnosis and for prompt treatment of patients with Behçet disease.

Dermatological features in Behçet disease-associated vena cava obstruction

BACKGROUND

Behçet disease (BD) is a multisystemic disorder that is classified as vasculitis and can affect all types and sizes of blood vessels. Although vascular diseases are not regarded as essential for a diagnosis of BD, vascular complications can be fatal.

OBJECTIVES

The purpose of this study was to examine the clinical characteristics of 14 patients with BD accompanied by an obstruction of the superior vena cava (VC), the inferior VC, or both, and then determine the dermatological features that indirectly suggest VC obstructions in patients with BD.

METHODS

Among the 3500 patients registered at the BD Specialty Clinic of Severance Hospital from 1997 to 2006, 14 patients were diagnosed with BD-associated VC obstructions. Their medical records were reviewed.

RESULTS

Nine of the 14 patients with BD were male, and the age range for disease onset was 11-46 years. Computed tomography revealed superior VC thrombosis in seven patients, inferior VC thrombosis in four patients, and the involvement of both in three patients. The most prominent features in superior VC obstruction were facial oedema (n = 7, 50%) and neck vein distension (n = 6, 43%). Other features included dilated veins in the chest wall, upper body oedema, proptosis, and upper extremity swelling. Patients with an inferior VC obstruction commonly had dilated veins on the abdominal walls. These patients also had abdominal distension and lower extremity swelling. Corticosteroids, colchicine, immunosuppressants, and anticoagulants with or without heparinization were the most common treatment regimens giving good response. Attempts to treat patients with a high dose of steroid pulse therapy were ineffective. Ballooning venoplasty was a useful therapeutic modality for VC thrombosis during the early stage, although this procedure could not be performed in patients with BD with severe thrombosis.

CONCLUSIONS

Several cutaneous features of VC obstruction should be recognized in patients with BD. Early detection might permit an early diagnosis and treatment of occlusion of the VC.

Intracardiac thrombus, superior vena cava syndrome, and pulmonary embolism in a patient with Behçet's disease: a case report and literature review

A 26-year-old woman with intermittent fever was admitted to our hospital, and gradually developed facial edema. Examinations including computed tomography, transesophageal echocardiography, digital subtraction angiography, and pulmonary perfusion scintigraphy revealed intracardiac thrombus, superior vena cava syndrome, and pulmonary embolism. Clinical findings and laboratory data led us to make a diagnosis of Behçet's disease. Combination of intracardiac thrombus, superior vena cava syndrome, and pulmonary embolism are rare complications in Behçet's disease. Behçet's disease should be considered in the differential diagnosis of intracardiac mass of the right heart, and early diagnosis and treatment are essential for the management of Behçet's disease especially with large-vessel manifestations. In addition to a case report, we review the literature and report the characteristics of intracardiac thrombus in Behçet's disease.

[Retinal venous occlusion in Behçet disease]

PURPOSE

The aim of our study is to report three cases of retinal venous occlusion in patients with Behçet disease and to discuss the physiopathology of this vascular accident.

METHODS

In this retrospective study, out of a series of 32 patients suffering from Behçet disease, we report three cases of retinal venous occlusion. General and ophthalmologic features are described. Treatment strategy is detailed for each case.

RESULTS

There were 2 cases of branch retinal venous occlusion and one case of central retinal venous occlusion. Relapses and retinal neovascularization were the most common complications.

CONCLUSION

The retinal venous occlusion in Behçet's disease is a non-common but severe complication. Early and appropriate treatment is required to improve the functional prognosis.

Superior epigastric artery pseudoaneurysm--a rare complication of chest drain insertion in coronary artery bypass grafting

BACKGROUND

Although chest drain insertion during coronary artery bypass grafting is a fairly standard procedure, however it may result in extremely rare complications.

CASE PRESENTATION

This is the first case being reported that demonstrates a pseudoaneurysm of superior epigastric artery resulting from chest drain insertion following coronary artery bypass grafting.

CONCLUSION

Adequate caution should be used along with good understanding of the anatomical landmarks during apparently simple and standard operative procedures.

What Does It Take to Diagnose Behçet Disease?

Behçet disease is a systemic inflammatory disease of unknown etiology initially described as a triad of recurrent oral ulcers, genital ulcers, and hypopyon uveitis affecting young male adults. Internationally agreed diagnostic criteria have been proposed to assist in the diagnosis. We present the case of a 26-year-old African-American male who presented with right brachial plexopathy due to axillary aneurysm. Further evaluation revealed the presence of a common carotid artery aneurysm, superior vena cava, and left subclavian vein thrombosis. A few months later, he developed severe bilateral panuveitis with hypopyon, retinal vasculitis, and optic nerve inflammation. Although our patient had no recollection of oral or genital ulcers, the constellation of deep vein thrombosis, multiple arterial aneurysms, bilateral panuveitis, positive pathergy skin test, and elevated inflammatory markers led to the working diagnosis of Behçet disease. Arterial involvement occurs in 3%-5% of patients with Behçet disease and may manifest as either true or false aneurysms. Deep vein thrombosis is the most common venous manifestation and involvement of venae cavae and their tributaries is not uncommon. Anterior and posterior uveitis and retinal vasculitis not only have a prognostic value in Behçet disease but in this particular case supported the diagnosis. In conclusion, incomplete forms of Behçet vasculitis exist and clinicians should be alert to atypical presentations of the disease.

Vascular involvement in Behçet's disease: a retrospective analysis of 2319 cases

BACKGROUND

Vascular lesions can be the presenting sign of Behçet's disease (BD) preceding classical symptoms. The aim of this study was to evaluate the prevalence and types of vascular involvement in BD.

METHODS

Among 2319 patients diagnosed with BD according to the criteria of the International Study Group for BD, 332 patients (279 male, 53 female) with vascular involvement were included in this study.

RESULTS

Prevalence of vascular involvement was 14.3%. Vascular involvement was found to be more common in males (P<0.001, male:female ratio 5.26:1). Mean age at onset of vascular involvement was 30.58+/-7.88. Vascular lesion was the presenting sign of BD in 50 patients (2.1%), whereas in 109 patients (4.7%) it started together with other clinical symptoms at the age of diagnosis. Superficial vein thrombophlebitis (SVT) was the most common vascular symptom (53.3%) followed by deep vein thrombosis (DVT) (29.8%). Arterial lesions were rare (3.6%). Of the patients 13.3% had more than one type of vascular involvement. Lower extremities were the most frequent localization in patients with SVT, whereas the femoral vein was mainly involved in patients with DVT and the pulmonary artery was mainly involved in the patients with arterial lesions.

CONCLUSION

In countries like Turkey where BD is more frequent, young male patients presenting with vascular involvement should be evaluated for BD.

[Aortic abdominal aneurysm rupture leading to a massive gastrointestinal bleeding in a patient with Behçet's disease]

INTRODUCTION

Arterial involvement in Behçet's disease is rare, present in 2-8% of cases. Aortic aneurysms represent the most frequent arterial lesions encountered in this disease and are associated with high mortality.

CASE REPORT

We report the exceptional observation of an abdominal aortic aneurysm ruptured to the duodenum, responsible of a massive gastro intestinal bleeding in a patient with Behçet's disease requiring an emergent surgical intervention. The outcome was favorable.

DISCUSSION

The clinical presentation of abdominal aortic aneurysms in Behçet's disease is often atypical leading to an important diagnosis delay and favours the rupture of the aneurysm.

Characteristics of vascular involvement in Behçet's disease

OBJECTIVE

Behçet's disease (BD) is a multisystemic inflammatory disorder classified among the vasculitides, which can affect all types and sizes of blood vessels. Vascular involvement may be seen in 25-50% of BD patients. In this study, we examined the characteristics of vascular involvement in patients with BD.

METHODS

One hundred and eighty patients with BD were included in the study. The diagnosis of vascular involvement was made on clinical signs, by Doppler ultrasonography and/or angiography using computed tomographic or magnetic resonance techniques where appropriate. Detailed clinical characteristics were recorded for each patient.

RESULTS

Seventy-one patients (39.4%) had vascular involvement. In patients with vascular lesions, the frequency of male sex was significantly higher than in patients without vascular lesions (89.8% vs. 63.3%, respectively; p < 0.001). Of 71 BD patients with vascular involvement, 68 had venous lesions (95.8%). Three patients had arterial lesions without venous thrombosis. Eleven patients had arterial involvement with venous thrombosis. The most frequent type of vascular involvement was deep venous thrombosis in the lower extremities (n = 56, 78.9%). There was a significant association between deep venous thrombosis and superficial thrombophlebitis (r = 0.325, p < 0.01). Twenty-four patients (33.8%) had vena cava thrombosis and two had vena hepatica thrombosis. In patients with vascular involvement, the frequency of erythema nodosum was significantly higher (p = 0.001) and the frequency of ocular involvement was significantly lower (p < 0.05) than in patients without vascular involvement.

CONCLUSION

Our study illustrates the frequency and significance of vascular involvement in BD.