The Management of Takayasu's Arteritis: Personal Experience

Franciscis, Stefano de; Serra, Raffaele; Luongo, Alessandro; Sabino, Giuseppe; Puzziello, Alessandro

doi:10.1016/j.avsg.2007.03.021

Cited by 24 publications

(14 citation statements)

References 19 publications

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“…Similar findings were reported for childhood-onset TAK 27. Given the complications of maintaining patients on long-term systemic corticosteroids, including infection, weight gain, hyperglycemia, hypertension, ocular complications, osteoporosis and aseptic necrosis, steroid-sparing agents have been shown to be frequently required for maintaining remission or for steroid-resistant disease in TAK 2,5–7,27–31. In our survey, 53% of physicians (and 100% of pediatric rheumatologists) would start immunosuppressants in all patients with TAK and an additional 36% would start immunosuppressants in patients with severe organ involvement at presentation.…”

Section: Discussionsupporting

confidence: 66%

Variations in the clinical practice of physicians managing Takayasu arteritis: a nationwide survey

Barra

Liang

Benseler

et al. 2017

OARRR

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ObjectiveTakayasu arteritis (TAK) is a large vessel vasculitis that predominately affects young women and can cause severe ischemic complications. Given the rarity of TAK, the management of this condition is challenging. We aim to describe current rheumatologist practices for the management of TAK and identify discrepancies and gaps in knowledge.MethodsAn online survey (developed by the Canadian Vasculitis Network and approved by the Canadian Rheumatology Association) containing 48 questions with regard to the diagnosis, monitoring and treatment of TAK was distributed to 495 Canadian adult and pediatric rheu-matologists by email.ResultsSixty-six rheumatologists completed the survey (13% response rate): the majority (73%) were from academic centers and ≤25% reported managing more than ten patients in their career. For establishing the diagnosis of TAK, they relied on a combination of signs and symptoms of ischemia, elevations of inflammatory markers and vascular imaging (typically computed tomography and magnetic resonance angiography). The frequency of monitoring for disease activity and the methods employed (clinical, laboratory or imaging) were variable. All physicians used corticosteroids for the treatment of TAK, but 42% would treat for at least 6–12 months, 26% for 12–24 months and 23% would never stop corticosteroids. Fifty-three percent would always use an immunosuppressant (most commonly methotrexate or azathioprine) in addition to corticosteroids and the remainder would only start an immunosuppressant in patients with refractory or relapsing disease.ConclusionPhysician practices for the management of TAK are variable, suggesting that there are knowledge gaps, which may impact outcomes in patients with TAK.

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Section: Discussionsupporting

confidence: 66%

Variations in the clinical practice of physicians managing Takayasu arteritis: a nationwide survey

Barra

Liang

Benseler

et al. 2017

OARRR

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“…8,17 Irrespective of the type of involvement, almost all patients have ischemic disorders in the territory of involved vessels. 18 The disease is characterized by a slowly progressive cardiovascular (48%), neuroophthalmic (36%), and skin morbidity (13%). Systemic hypertension and heart disease have been reported as significant mortality predictors.…”

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confidence: 99%

Visceral Artery Interventions in Takayasu's Arteritis

Sharma

Gupta²

2009

Semin intervent Radiol

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Takayasu's arteritis is an idiopathic chronic inflammatory disease affecting the aorta, its major branches and the pulmonary arteries. It leads to stenosis, occlusion, dilatation, and aneurysm formation in the involved vessels. Visceral arterial involvement occurs in 11 to 68% cases. Steno-obstructive lesions are most commonly seen and are usually symptomatic. Dilative and aneurismal lesions are uncommon and, when present, are usually clinically silent. Renal arteries are most commonly involved (24 to 68%), resulting in renovascular hypertension, whereas mesenteric arterial involvement is seen in 11 to 28% cases and is usually clinically silent. The assessment of disease activity is of utmost importance in its management as revascularization is best performed in the inactive phase. The disease activity can be assessed by clinical, biochemical, or radiological markers. The primary objectives of treatment include the control of disease activity by drug therapy, pharmacologic control of blood pressure (BP), supportive management and revascularization (surgical or endovascular) of the symptomatic ischemic territory. Surgical treatment is challenging due to the diffuse nature of the disease and involvement of adjacent aortic walls. It has a high incidence of anastomotic aneurysm formation (12 to 14%) and graft failure (20 to 40%) over time. Endovascular therapy (usually in the form of balloon angioplasty) has specific technical and procedural issues, but is safe and effective in the control of hypertension with success rates ranging between 80 to 96%. The overall complication rates are low. The cumulative 5-year patency rate for the management of renal artery stenosis is 67%. The use of stents is usually restricted as a bailout to treat obstructive dissection after angioplasty, due to a variety of reasons as their use may adversely affect the long-term outcome of treatment. Angioplasty is less effective in relieving obstruction in the mesenteric arteries and the outcomes are also infrequently reported.

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“…In a longer‐term follow up of these patients (mean 43 months), those who continued to be on leflunomide ( n = 5) had similar clinical response and angiographic progression at the end of the observation period when compared to those who had to change to another immunosuppressive therapy for persistent disease activity ( n = 7) . Oral or monthly intravenous cyclophosphamide use in adult patients with TA has been described in retrospective case series from Europe for 14 patients with TA with follow‐up period ranging 10–45 months, with favorable clinical responses in all and resolution of vascular wall inflammation by PET‐CT (in three out of four patients) . Less favorable outcomes have been reported with the use of cyclophosphamide in pediatric TA …”

Section: Conventional Dmardsmentioning

confidence: 99%

Recent advances in the management of Takayasu arteritis

et al. 2019

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Takayasu arteritis (TA) is a challenging large vessel vasculitis to treat. Distinguishing disease activity from vascular damage is difficult, often relying on clinician judgement aided by composite clinical disease activity indices with angiographic evidence of vessel wall thickening or vessel wall hypermetabolism demonstrable on positron emission tomography computerized tomography (PET CT). Glucocorticoids form the mainstay of remission induction. While other conventional disease modifying anti-rheumatic drugs (cDMARDs) or biologic DMARDs (bDMARDs) are commonly used, evidence supporting their usefulness is sparse and generally of low quality. The only two randomized controlled trials (RCT) of a DMARD in TA failed to show efficacy of abatacept in reducing relapses of TA, however, tocilizumab showed a trend towards reduction in time to relapses. Of the cDMARDs, methotrexate, azathioprine, mycophenolate mofetil (MMF), leflunomide and cyclophosphamide have shown clinical efficacy in case series, with some evidence that methotrexate, azathioprine and MMF might retard angiographic progression. Among bDMARDs, anti-tumor necrosis factor alpha agents and tocilizumab may be useful in patients refractory to cDMARDs with retardation of angiographic progression, based on evidence derived from mostly retrospective case series, whereas the role of rituximab and ustekinumab needs further elucidation. Revascularization, either surgical or endovascular, is the treatment of choice to relieve critical, symptomatic stenoses and are best undertaken during inactive disease. Emerging evidence suggests that patients with TA also have increased cardiovascular risk and this requires appropriate management. Large studies involving multiple centers are the need of the hour to appropriately evaluate utility of currently available immunosuppressive therapy in TA.

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The Management of Takayasu's Arteritis: Personal Experience

Cited by 24 publications

References 19 publications

Variations in the clinical practice of physicians managing Takayasu arteritis: a nationwide survey

Variations in the clinical practice of physicians managing Takayasu arteritis: a nationwide survey

Visceral Artery Interventions in Takayasu's Arteritis

Recent advances in the management of Takayasu arteritis

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