Asian Cardiovasc Thorac Ann 1999;7:339-344
© 1999 Asia Publishing EXchange Pte Ltd
Takayasu's Arteritis: Current Status of Angioplasty and Stenting
Harinder K Bali, DM,
Anshul K Jain, DM
|
Department of Cardiology Postgraduate Institute of Medical Education and Research Chandigarh, India
|
|
For reprint information contact: Harinder K Bali, DM Tel: 91 172 74 4401 Fax: 91 172 74 5078 email: medinst{at}pgi.chd.nic.in Department of Cardiology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India.
|
 |
Abstract
|
|---|
Takayasu's arteritis is a chronic inflammatory disease characterized by stenotic occlusive lesions of the aorta and its major branches. The medical management of such lesions is far from satisfactory and surgical treatment is associated with high morbidity and mortality. Angioplasty with or without stenting has emerged as the treatment of choice for such lesions. Angioplasty and stenting of various vessels in Takayasu's arteritis are reviewed, highlighting the advantage of stents in reducing the rate of restenosis in chronically occluded or diffusely diseased vessels.
|
Introduction
|
|---|
Takayasu's arteritis (TA) is a chronic inflammatory disease that involves the aorta and its major branches, leading to arterial stenosis or occlusion with subsequent cerebral, renal, limb, mesenteric, or cardiopulmonary ischemia.1,2 The exact etiology of the disease is unknown but factors such as connective tissue disorders (systemic lupus erythematosus, rheumatoid arthritis, sarcoidosis), infections (tuberculosis), and an immune phenomenon have been implicated in this disease.3 However, the evidence favors an immune aberration as the prime etiologic factor. Abnormalities of humoral and cellular immunity have been demonstrated in such patients.4 Increased CD4+ to CD8+ ratio, high levels of intracellular calcium in the T-lymphocytes of circulating immune complexes, high gammaglobulin levels, anti-aortic antibodies, and dense NK-cell infiltrates in the wall of the aorta are some of the described abnormalities. What triggers such an immune response remains speculative.
The disease is most commonly diagnosed on the basis of clinical and angiographic criteria proposed by Ishikawa5 in 1988 (Table 1
). The vessels most frequently involved are the subclavian artery, carotid artery, descending thoracic or abdominal aorta, and the renal arteries. The lesions are mainly stenotic but localized or large aneurysms have also been described.6 Stenotic lesions in TA are firm, fibrotic, non-ulcerated, and usually involve the ostium of the vessel. There is often involvement of more than one vessel in the same individual and there may be multifocal lesions in the artery. The disease may involve a long segment of one vessel, causing diffuse narrowing. The chronic course generally results in the development of extensive collaterals across the stenosis. In addition, the disease has a strong tendency to recur at either the same site or a different one.7
In the past, surgical revascularization was the only mode of management for these lesions. Surgery involves bypassing the stenosed segments, graft anastomosis, or endarterectomy. In cases of renal artery stenosis, autotransplantation of the kidney may also be carried out. Surgical reconstruction is made difficult by extensive perivascular fibrosis and thickened and fibrosed arterial walls. In addition, graft reocclusion, aneurysm of the anastomotic site, and recurrence of the disease at a new site mandate reoperation.8 Brachiocephalic reconstructive surgery in particular has a high complication rate (5% to 23%) including chylothorax, endarterectomy thrombosis, pneumothorax, phrenic nerve palsy, and Horner's syndrome.9 Overall, surgery carries a high morbidity and mortality.
Recently, percutaneous transluminal balloon angioplasty (PTBA) has emerged as the treatment of choice for stenotic lesions. The major advantages of this technique include its safety, efficacy, ease of performance, the feasibility of tackling multiple lesions at the same sitting, and the ability to repeat the procedure without any significant morbidity in cases of recurrence. The results of angioplasty can be improved by stent placement. Stents not only help to achieve larger luminal diameters but may also abolish or markedly reduce gradients across the stenotic segment. It is postulated that such immediate hemodynamic benefit would translate into improved effort tolerance, better quality of life, and lower restenosis rates. The following is a brief review of major series of angioplasty and stenting in patients with TA.
|
Subclavian Angioplasty
|
|---|
Since the first report of successful angioplasty in atherosclerotic subclavian arterial disease by Bachman and Kim,10 PTBA has been increasingly applied in symptomatic subclavian arterial disease of varied etiology. Joseph and colleagues11 described PTBA of the subclavian artery in 24 patients with TA. The lesions were focal (less than 3 cm) in 14 arteries and diffuse in 12. The initial success rate was 81% (17 of 19 stenoses and 4 of 7 occlusions). On follow-up, restenosis occurred in 6 arteries, all of which had extensive lesions. The cumulative patencies for short-segment and long-segment lesions were 100% and 50%, respectively. Tyagi and colleagues12 reported their 10-year follow-up of 35 cases of TA. High inflation pressures were required for dilatation of the lesions (9.9 ± 4.6 atm). The procedure was successful in 88.8% of cases of subclavian arterial stenosis and in 50% of cases of short-segment chronic total occlusion. Restenosis occurred in 20.8% of all cases during a follow-up of 43.4 ± 24.1 months.
Results of PTBA have been uniformly less than satisfactory in diffuse long-segment disease and chronic total occlusion, due to frequent suboptimal results, high rates of reocclusion, and a prohibitive incidence of restenosis. To overcome these problems, we performed de novo stenting of 4 subclavian arteries (Figures 1A and 1B). Three patients had chronic total ostial occlusion and 1 had long-segment diffuse disease with extensive collaterals. Three patients were given Palmaz-Schatz stents (Johnson & Johnson, Miami, FL, USA); P 204 in 2 cases and P 304 in one. The other patient was given an AVE iliac bridge stent (AVE, Inc., Santa Rosa, CA, USA). There was 100% primary and secondary patency.13 Thus, stenting can be useful for patients with suboptimal results after PTBA or with flow-limiting dissection. In patients with diffuse long-segment disease and in those with chronic total occlusion, de novo stenting should be performed.
View larger version (299K):
[in this window]
[in a new window]
|
Figure 1. Left subclavian angiograms (A) showing 95% stenosis with extensive collateral formation and (B) after angioplasty and stenting.
|
|
|
Aortoplasty and Stenting
|
|---|
Since the first report of aortoplasty by Yagura and colleagues,14 stenotic lesions of the aorta, both congenital and due to TA, have been managed successfully with PTBA. Among the large series, Rao and colleagues15 reported a cumulative patency rate of 67% in a 52-month follow-up (mean, 86 weeks) of 16 patients undergoing aortoplasty. Complications related to the procedure occurred in 5 patients (31%). Tyagi and colleagues16 described their experience with PTBA in 38 cases of TA involving the aorta. Balloon dilatation was successful in 34 cases and resulted in a reduction of the mean peak systolic pressure gradient from 75.2 ± 29.1 mm Hg to 24.8 ± 19 mm Hg (p < 0.001). Hemodynamic and angiographic follow-up studies in 20 patients showed the gradient had decreased further in 7 patients to less than 15 mm Hg, it had not changed in 12, and had increased in one. A reappraisal of this study indicates that the gradient continued to be higher than 20 mm Hg after PTBA in 11 patients, and above 40 mm Hg in 4. The resting gradient is likely to increase on exercise. In the present era, the persistence of a gradient is less acceptable and probably a residual gradient of less than 20 mm Hg should be the criterion for successful aortoplasty.
We performed stenting of the aorta in 4 patients, of whom 3 had long-segment stenosis and 1 had short-segment stenosis; 5 Wallstents (Schneider, Minneapolis, MN, USA) were used and the procedure was successful with complete disappearance of the systolic pressure gradient in all cases.13 Angiographic follow-up at 6 months was obtained in 3 of these patients (Figures 2A and 2B), which showed persistent benefit with no restenosis, although a small asymptomatic aneurysm had formed at the lower end of the stent in one case (unpublished data). Other reports have described occasional use of aortic stenting for dissection following PTBA.17–19 Thus, patients who have long-segment disease and those who have dissection or persistence of a gradient of more than 20 mm Hg after PTBA (suboptimal result) should undergo aortic stenting.
View larger version (232K):
[in this window]
[in a new window]
|
Figure 2. Angiograms showing (A) long-segment diffuse stenotic involvement of the descending thoracic aorta and (B) after deployment of 2 Wallstents.
|
|
|
Renal Angioplasty and Stenting
|
|---|
TA is the most common cause of renovascular hypertension in Asian countries.3 Renal lesions in TA are often bilateral and involve the ostia. The management of renovascular hypertension usually requires polydrug therapy, leading to side-effects and poor patient compliance. PTBA of the renal arteries has been shown to have excellent immediate and long-term results. Dong and colleagues20 reported their experience of 22 patients followed up for at least 6 months; normalization of blood pressure was achieved in 13 patients and an improvement in 6, giving an overall success rate of 86%. Tyagi and colleagues21 performed renal angioplasty in 54 patients, with a success rate of 89% and a restenosis rate of 13.5%. In another study by the same authors on PTBA of renal arteries in 35 children aged 5 to 14 years, the procedure was successful in 88.6% but restenosis occurred in 25.8%.22 The higher restenosis rate in children was probably because of the small diameter of their renal vessels and disease in an active phase. One patient with bilateral renal artery stenosis underwent PTBA of both arteries with good initial results and developed restenosis in only one renal artery despite the presence of active disease. The authors observed that although active disease increases the chances of restenosis, not all vessels undergo restenosis but some may become completely occluded precluding any further procedure. Therefore, in cases of severe uncontrolled renovascular hypertension, the procedure should be carried out in spite of evidence of disease activity so as to prevent progressive renal damage as a consequence of hypertension.
We performed renal stenting in 2 patients with TA. In an 11-year-old child, an AVE Micro I stent was used for flow-limiting dissection after PTBA (Figures 3A and 3B). The other patient had severe ostial stenosis with suboptimal results after PTBA. Both patients are doing well on follow-up; one is awaiting angioplasty and stenting of the contralateral renal artery. Patients with suboptimal results or flow-limiting dissection after PTBA and those with diffuse or ostial disease of a renal artery should undergo de novo stenting. Self-expanding stents such as Wallstent or Symphony (Boston Scientific, Galway, Ireland) and balloon-mounted stents such as Palmaz-Schatz or AVE can be used safely.
View larger version (352K):
[in this window]
[in a new window]
|
Figure 3. Angiogram showing (A) ostial stenosis of the right renal artery. Percutaneous transluminal balloon angioplasty caused a flow-limiting dissection with complete occlusion of the renal artery. (B) Angiogram after deployment of a stent, showing a normally patent vessel.
|
|
|
Carotid, Coronary, and Mesenteric Angioplasty and Stenting
|
|---|
The experience in carotid angioplasty is limited to occasional case reports in the literature.23 Joseph and colleagues24 described a successful case of carotid stent angioplasty via the transseptal route because of absent pulses in all four limbs. We attempted carotid angioplasty and stenting in 6 patients, 4 of whom had chronic total occlusion of the common carotid and 1 had spontaneous dissection of the left common carotid artery.13 In 1 patient with chronic total occlusion of the carotid artery, the guidewire could not be negotiated across the lesion and the procedure was abandoned. In the other 5 patients, stents were deployed after pre-dilatation (Figures 4A and 4B). Three patients received Wallstents and 2 received Palmaz-Schatz stents (P 204 and P 304); no residual stenosis was seen. Two patients with active disease developed stent restenosis; repeated high-pressure dila-tation gave acceptable results in one case. This experience indicates that angioplasty and stenting is safe and effective in the management of stenotic lesions of the carotid arteries. Stenting should preferably be avoided in the acute phase. However, restenosis does not occur in all lesions due to disease activity and if the symptoms persist or are likely to cause irreversible damage, PTBA and stenting should be performed in spite of disease activity. The exact cause of stent restenosis is unclear. Our limited experience indicates that restenosis after stent deployment occurs due to progression of the disease within the stent rather than stent compression. Whether this problem can be overcome by covered stent-grafts remains to be seen.
View larger version (231K):
[in this window]
[in a new window]
|
Figure 4. Selective right brachiocephalic angiograms (A) showing chronic total occlusion of the common carotid artery and extensive collateral formation. Tandem stenotic lesions in the subclavian artery are also seen. (B) After angioplasty and stenting of the common carotid and plain balloon angioplasty of the subclavian artery.
|
|
There are several case reports describing excellent immediate and long-term results of angioplasty with or without stenting of the coronary arteries.25 Patients with mesenteric arterial stenosis are usually asymptomatic but occasionally present with ischemic bowel syndrome. Ozdil and colleagues26 described a case of successful angioplasty and stenting of the superior mesenteric and coeliac trunks with Palmaz-Schatz P 204 and P 154 stents, respectively. Tyagi and colleagues27 also reported a marked improve-ment after stent angioplasty in the symptomatic status of a patient presenting with chronic mesenteric ischemia.
|
Percutaneous Management of Aneurysmal Lesions
|
|---|
Aneurysmal dilatation of the aorta and its major branches, although uncommon, may occur in isolation or together with stenotic lesions; these aneurysms may be fusiform or saccular.6 Management of such lesions has been mainly surgical. Recently, excellent results of percutaneous management of localized atherosclerotic aneurysms of various vessels have been reported.28,29 However, there are no reports of percutaneous management of such lesions in patients with TA. Covered stent-grafts may be parti-cularly useful in treating aneurysmal lesions in such cases.
Although PTBA with or without stenting has emerged as the treatment of choice for management of the stenotic lesions of Takayasu's arteritis, occasional intra-stent restenosis and recurrence of disease at new sites remains a potential problem to be tackled by further research into the pathogenesis of this disease.
|
References
|
|---|
-
Sen PK, Kinare SG, Engineer SD. The middle aortic syndrome. Br Heart J 1963;25:610–8.
-
Lupi-Herrera E, Sanchez-Torres G, Marcoshamer J, Mispireta J, Horwitz S, Vela JE. Takayasu's arteritis: clinical study of 107 cases. Am Heart J 1977;93:94–103.[Medline]
-
Chugh KS, Sakhuja V. Takayasu's arteritis as a cause of renovascular hypertension in Asian countries. Am J Nephrol 1992;12:1–8.[Medline]
-
Dhar J, Ganguly NK, Kumari S, Sharma BK. Role of calcium and protein kinase C in activation of T cells in Takayasu's arteritis. Jpn Heart J 1995;36:341–8.[Medline]
-
Ishikawa K. Diagnostic approach and proposed criteria for the clinical diagnosis of Takayasu's arteriopathy. J Am Coll Cardiol 1988;12:964–72.[Abstract]
-
Matsumura K, Hirano T, Takeda K, Matsude A, Nagawa T, Yamagudi N, et al. Incidence of aneurysms in Takayasu's arteritis. Angiology 1985;42:308–15.
-
Virmani R, Lande A, McAllister HA. Pathological aspects of Takayasu arteritis. In: Lande A, Berkman YM, McAllister HA, editors. Aortitis: clinical, pathologic and radiographic aspects. New York: Raven, 1986:56.
-
Takagi A, Tada Y, Sato O, Miyata T. Surgical treatment of Takayasu's arteritis: a long-term follow-up study. J Cardiovasc Surg 1989;30:553–8.[Medline]
-
Beebe HG, Stark R, Johnson M, Jolly PC, Hill LD. Choices of operation for subclavian vertebral arterial disease. Am J Surg 1980;139:616–23.[Medline]
-
Bachman D, Kim RM. Transluminal dilatation for subclavian syndrome. AJR 1980;13:995–6.
-
Joseph S, Mandalam KR, Rao VR, Gupta AK, Unni MN, Rao SA, et al. Percutaneous transluminal angioplasty of subclavian artery in nonspecific aortoarteritis: results of long-term follow-up. J Vasc Intern Radiol 1994;5:573–80.[Medline]
-
Tyagi S, Gambhir DS, Kaul UA, Verma P, Arora R. A decade of subclavian angioplasty: aortoarteritis versus atherosclerosis. Indian Heart J 1996;48:667–71.[Medline]
-
Bali HK, Jain S, Jain A, Sharma BK. Percutaneous angioplasty and stent placement in Takayasu arteritis. Int J Cardiol 1998;66(Suppl 1):S213–7.
-
Yagura M, Sano I, Akioka H, Hayashi M, Uchida H. Usefulness of percutaneous transluminal angioplasty for aortitis syndrome. Arch Intern Med 1984;144:1456–68.
-
Rao SA, Mandalam KR, Rao VR, Gupta AK, Joseph S, Unni MN, et al. Takayasu arteritis: initial and long-term follow-up in 16 patients after percutaneous transluminal angioplasty of the descending thoracic and abdominal aorta. Radiology 1993;189:173–9.[Abstract/Free Full Text]
-
Tyagi S, Kaul UA, Nair M, Sethi KK, Arora R, Khalilullah M. Balloon angioplasty of aorta in Takayasu's arteritis: initial and long-term results. Am Heart J 1992;124:876–82.[Medline]
-
Sharma S, Bahl VK, Rajani M. Stent treatment of obstructing dissection after percutaneous transluminal angioplasty of aortic stenosis caused by nonspecific aortoarteritis. Cardiovasc Intervent Radiol 1997;20:3077–9.
-
Bahl VK, Chandra S, Taneja K. Self-expanding Wall stent for management of severe abdominal coarctation due to nonspecific aortoarteritis. Indian Heart J 1997;49:189–91.[Medline]
-
Tyagi S, Sharma VP, Arora R. Stenting of aorta for recurrent long stenosis due to Takayasu arteritis in a child. Pediatr Cardiol 1997;20:215–7.
-
Dong Z, Li S, Lu X. Percutaneous transluminal angioplasty for renovascular hypertension in arteritis: experience in China. Radiology 1987;162:477–9.[Abstract/Free Full Text]
-
Tyagi S, Kaul UA, Satsangi DK, Arora R. Balloon angioplasty for renovascular hypertension in Takayasu arteritis. Am Heart J 1993;125:1386–93.[Medline]
-
Tyagi S, Kaul UA, Satsangi DK, Arora R. Percutaneous transluminal angioplasty for renovascular hypertension in children: initial and long-term results. Paediatrics 1997;98:44–9.
-
Murakami R, Korogi Y, Matsuno Y, Matsukawa T, Hirai T, Takahashi M. Percutaneous transluminal angioplasty for carotid artery stenosis in Takayasu arteritis: persistent benefit over 10 years. Cardiovasc Intervent Radiol 1997; 20:219–21.[Medline]
-
Joseph G, Krishnaswami G, Baruah DK, Kuruthekulam SV, Abraham OC. Transseptal approach to aortography and carotid artery stenting in pulseless disease. Cathet Cardiovasc Diagn 1997;40:416–20.[Medline]
-
Lee HY, Rao SP. Percutaneous transluminal coronary angioplasty in Takayasu's arteritis. Am Heart J 1996;132:1084–6.[Medline]
-
Ozdil E, Krajcer Z, Angelini P. Images in cardiovascular medicine. Percutaneous angioplasty with adjunctive stent placement in mesenteric vessels in a patient with Takayasu's arteritis. Circulation 1996;95:1940–1.
-
Tyagi S, Verma PK, Kumar N, Arora R. Stent angioplasty for relief of chronic mesenteric ischemia in Takayasu arteritis. Indian Heart J 1997;49:315–8.[Medline]
-
Blum U, Voshage G, Lammer J, Beyersdorf F, Tollner D, Kretschmer G, et al. Endoluminal stent graft for infrarenal abdominal aortic aneurysms. N Engl J Med 1997;336:13–20.[Abstract/Free Full Text]
-
Dake MD, Miller C, Semba CP, Mitchell S, Waler PJ, Liddel RP. Transluminal placement of endovascular stent-graft for the treatment of descending thoracic aortic aneurysms. N Engl J Med 1994;331:1729–34.[Abstract/Free Full Text]
TOP
Abstract
Introduction
