Visceral Artery Interventions in Takayasu's Arteritis

Abstract

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.

A young woman with Takayasu arteritis: surgical and anesthetic management of Bentall procedure in a patient with abdominal aortic aneurysm and renal artery stenosis

“…The incidence of abdominal aneurysm rupture has been reported to be low; however, as the disease occurs in young patients, a yearly routine follow-up is required to decide whether an abdominal aortic reconstruction is needed [4,12].…”

“…The use of steroid treatment is considered in the active state of TA and immunosuppressive drug treatment is added to the therapeutic regimen if steroid treatment is not successful to control the active disease state, which involves the presence of two or more of the following features: 1) fever or arthralgia, 2) raised erythrocyte sedimentation rate (ESR) (> 20 mm/h), 3) new claudication, bruit, or vascular pain, 4) new typical angiographic features. Arteriography is the best modality for the diagnosis of Takayasu's disease along with the use of magnetic resonance angiography (MRA) and computed tomography (CT) scans that are commonly used during the process of diagnosis [7,11,12]. Surgery consists always of a bypass operation to vessels normal on angiography and distal to the occlusive or stenotic lesion.…”

Imaging Features of Takayasu Disease

“…Most published reports related to endovascular management of Takayasu disease have described the results and outcome of balloon angioplasty of stenoses involving the renal arteries. Renal angioplasty is considered technically successful if (1) the arterial lumen after angioplasty has less than 30% residual stenosis, (2) the arterial lumen is at least 50% larger than its pretreatment diameter, and (3) the pressure gradient is less than 20 mmHg and has decreased at least 15 mm Hg from the pretreatment gradient (Sharma and Gupta 2009). PTA is repeated if restenosis is detected.…”

“…Angioplasty was technically successful in 89.3% of 75 treated lesions. More recently, Sharma and Gupta (2009) reported 276 patients with renovascular hypertension secondary to Takayasu disease treated by interventional radiologic techniques over a 14-year period. These included 264 renal arteries in 193 patients, and 88 aortas in 83 patients.…”

The results of treatment in renal artery stenosis due to Takayasu disease: comparison between surgery, angioplasty, and stenting. A monocentrique retrospective study

“…Although surgical revascularization of the renal artery shows good longterm patency (3)(4)(5), the endovascular treatment is preferred as the initial treatment. Percutaneous transluminal renal angioplasty is established as the most widely used treatment (6)(7)(8) but the establishment of a stent has specific indications as a bailout procedure especially for residual stenosis hemodynamically significant or when there is dissection limiting the flow (9). Although there had been numerous studies showing the results of endovascular treatment of renal artery stenosis in Takayasu arteritis, there are a few comparing data on the long-term results of open surgery, angioplasty, and the introduction of a stent.…”