Takayasu arteritis associated with heart valve diseases (pulmonary and aortic) and arteritis (coronary and renal)]

The most severe arteritis due to Takayasu's disease are those related to renal and coronary arteries. The first one because it produces severe arterial hypertension and the second one because it puts the patient in high risk of suffering either myocardial ischemia or infarction. These situations worsen when this entity is associated to valvular heart lesions. The authors present the clinical cases of two female patients with Takayasu's disease. One of them in acute phase of the illness, where coronary arteritis, mild coarctation of the aorta, right pulmonary artery stenosis, and pulmonary valve stenosis were present. The second patient was seen during the remission phase of the disease with obstruction of the left subclavicular artery, renal arteritis, severe arterial hypertension and aortic valve insufficiency. The authors discuss the prognosis of patients with Takayasu's disease associated to valvular heart disease and its role in the etiology of pulmonary valvular stenosis. Finally, the authors point out the importance of recognizing the active and non active phases of the Takayasu's disease in relation of the adequate stage for surgical treatment of the lesions caused by this disease.     

Two-stage repair for aortic regurgitation complicated by severe coarctation of the thoracoabdominal aorta due to Takayasu's arteritis

Takayasu's arteritis is a rare inflammatory aortoarteritis of unknown etiology and causes stenoocclusive disease of the aorta and its branches as well as aortic regurgitation. A surgical case of Takayasu's arteritis is presented. A 56-year-old female exhibited aortic regurgitation complicated by severe coarctation of the thoracoabdominal aorta due to Takayasu's arteritis. In this case, a 2-staged repair, consisting of an axillofemoral bypass and an aortic valve replacement, was successfully performed.     

Aortitis

Inflammatory or noninfectious aortitis may be idiopathic or it may be part of a systemic autoimmune disease, such as Takayasu's arteritis, Beh?et's disease, or giant cell arteritis. At the acute stage, there is thickening of the aortic wall with dilatation of the aorta, more commonly in the thoracic aorta. If it involves the aortic root, there may be annuloaortic ectasia or aortic regurgitation. At a later stage, there may be aneurysmal dilatation of the aorta and rarely dissection or rupture of the aorta. In Takayasu's arteritis, stenosing lesions can occur as well as aneurysmal dilatation of the aorta or arteries. Stenosing lesions may be treated with angioplasty with or without stenting, whereas aneurysmal dilatation of the aorta is treated by aneurys-mectomy with arterial reconstruction or conduit. Severe aortic regurgitation may require aortic valve surgery with or without replacement of the ascending aorta. Irrespective of the interventional procedure undertaken as appropriate for the lesion, control of inflammation with steroid therapy with or without other immunosuppressive agents is of paramount importance. Otherwise, prosthetic valve or graft dehiscence may occur after aortic surgery, and restenosis rate is also higher after percutaneous transluminal angioplasty or stenting.     

Takayasu's arteritis revealed by aortic regurgitation with ascending aortic aneurysm (About 2 cases)

Aortic regurgitation caused by non-specific aortitis is relatively rare, and is now considered as an important risk factor related to mortality. Aortic valve replacement surgery is the only curative treatment. Aneurismal dilatation of the ascending thoracic aorta associated with aortic regurgitation is a rare involvement in Takayasu, there are many difficult problems in surgical treatment of this lesion, because of its inflammatory nature, so steroid therapy before and after surgery is therefore vital. We report the cases of tow young Moroccans women (32-35 years-old) with an ascending aortic aneurism associated to aortic insufficiency. The subsequent evaluation of the entire aorta, demonstrated the presence of multiple steno-occlusive lesions. Aortic valve replacement was performed associated with graft replacement of the ascending aorta without coronary artery reimplantation. Histopathological examination of the ascending aorta and aortic valve, showed findings in favour Takayasu's arteritis.     

Severe chronic aortic insufficiency requiring valve replacement: an infrequent complication of Takayasu's disease

Takayasu's arteritis (TA) is a granulomatous vasculitis of medium and large arteries, which most often presents as pulseless disease due to widespread arterial stenoses. Only the minority of TA patients have aortic valve insufficiency, which is due to aortic root dilatation following aortitis and aneurysm formation. No other cardiac valve is involved. We report a case of Takayasu's disease-related severe aortic insufficiency (AI) in a Filipino woman, which necessitated aortic valve replacement. It is important to consider TA in the differential diagnosis of AI in young women, particularly those with early-onset systemic hypertension and pulse deficits. Early diagnosis and therapy of TA can improve outcomes.     

Ostial left main stenosis due to takayasu arteritis: multimodality imaging and surgical ostioplasty

Takayasu's arteritis is an inflammatory process, involving larger blood vessels-namely the aorta and its branches. The majority of these patients present with symptoms of vascular obstruction. We report a case of a 38-year-old Chinese female who presented with one month history of angina pectoris as the initial manifestation. Coronary angiography showed 99% ostial left main coronary stenosis. The diagnosis was first suspected in the operating room by TEE and subsequently supported by laboratory studies and aortic biopsy. The technique of myocardial revascularization was altered and she underwent patch ostioplasty of the left main coronary artery and aortic valve repair to correct aortic regurgitation.     

Takayasu's disease: diagnosis

Takayasu's disease is a syndrome of inflammatory arteritis involving the aorta and its branches due to varying etiologies. The diagnosis is usually made after clinical, radiological and biological investigations, but the pathognomonic sign of the disease is inflammatory sclerosis of the adventitial media. There appear to be five prognostic factors: hypertension, arterial aneurysm, aortic regurgitation, coronary insufficiency, and retinopathy.     

Cardiac manifestations of Takayasu's arteritis: apropos of 5 cases]

PURPOSE: Cardiac manifestations of Takayasu's arteritis are rarely reported in the literature. However, these symptoms are not rare and when they do occur, they determine the disease prognosis. Due to its frequency, its severe nature, and even sometimes diagnosis failure, high blood pressure is the major cause of cardiac manifestations. More specific cardiac manifestations of either coronary, valvular, or more rarely, myocardial origin may also occur. METHODS: Analysis of five cases of Takayasu's arteritis and a literature review allowed evaluation of both the frequency and characteristics of this disease. RESULTS: Four female and one male patients presenting with symptoms of Takayasu's arteritis, according to Fiessinger's score, were evaluated. Diagnosis of cardiac disease was based on clinical, echocardiographic and angiographic criteria. Four patients had related high blood pressure. Valvular manifestations were present in all the patients. They included mitral insufficiency (1 case); aortic insufficiency (2 cases), and both mitral and aortic insufficiency (2 cases). Two patients showed clinical manifestations of a myocardiac disease, and another showed coronary signs. Treatment did not involve surgery, including only antihypertensive drugs, nitrites, and diuretics associated with digitalin in case of cardiac failure. The disease outcome, including a 5-18 year follow-up, involved symptom decrease in all the patients. CONCLUSION: Despite the rarity of cardiac manifestations in patients suffering from Takayasu's arteritis, symptoms of this disease should always be investigated, as these manifestations alter the prognosis. Aortic insufficiency is the most frequently encountered cardiac manifestation.     

大动脉炎累及冠状动脉的特点和外科治疗

目的:探讨大动脉炎累及冠状动脉的特点和外科治疗.方法:共手术治疗6例冠状动脉开口狭窄或闭塞的患者,其中5例行冠状动脉旁路移植术,1例直接扩大冠状动脉开口;同期行升主动脉-腹主动脉人工血管转流术1例,Bentall主动脉根部替换术2例,Cabrol主动脉根部替换术和二尖瓣替换术1例.结果:无手术死亡.发生围术期心肌梗死和低心排综合征1例.结论:大动脉炎累及冠状动脉的同时,常合并主动脉及其分支的狭窄,也常同时合并升主动脉壁增厚、扩张和(或)主动脉瓣关闭不全等,明显增加了同期手术的难度.由于锁骨下动脉常受累,乳内动脉不适于作为旁路移植材料.     

Coronary involvement in Takayasu's disease. Apropos of 3 cases, of which 2 were surgically treated, and review of the literature

Coronary arteries like other branches of the aorta may be involved in Takayasu's disease. This complication is not rare (7% of cases) but appears to be relatively unappreciated. Three new cases are reported of main coronary artery disease, two of which were treated by coronary bypass surgery. A review of the literature of 1 130 cases of Takayasu's disease revealed 86 cases with coronary involvement, 33 of which were confirmed anatomically and 15 by coronary arteriography. The clinical manifestations, angina and/or myocardial infarction, were present in 5% and 3% respectively, of patients with Takayasu's disease. They may be the first sign of the disease and, in some cases, the only symptomatic arterial localisation. The coronary lesions are either ostial, a direct complication of the aortic disease, or on a main vessel, usually proximal. Histological studies show typical changes of stenosing inflammatory panarteritis involving mainly the media and adventitia. Thrombosis and secondary atheromatous plaques may be observed. Aneurysms are rare. Apart from cases with typical ostial lesions, the coronary angiographic appearances are not specific, but some features are suggestive of the diagnosis; the occurrence in young women; the presence of associated peripheral arterial lesions, their localisation and grouping; their radiological and/or histological characteristics. The spontaneous prognosis of these proximal lesions is usually poor and justifies surgical revascularisation by coronary bypass. Six patients, including two in this series, have been treated surgically. The associated aortic lesions may pose special technical problems which we discussed. The relatively high incidence of coronary involvement in Takayasu's disease and its often unexpected revelation by myocardial infarction or sudden death, suggest that coronary arteriography should be undertaken more often during investigation of the arterial lesions of these patients. Takayasu's disease should figure prominently amongst the causes of coronary artery disease in young women.     

Heart valvular and coronary manifestations of Takayasu disease. Apropos of a surgically-treated case]

Cardiac involvement in Takayasu's disease is well documented. This is often the result of severe hypertension. However, severe clinical manifestations of aortic regurgitation and coronary insufficiency are much less common. The authors report a case in which post-infarction angina and severe left ventricular failure led to a double valve replacement and an aorto-right coronary bypass graft procedure. The diagnosis of Takayasu's disease was suspected before surgery and was confirmed by histological examination.     

Percutaneous coronary intervention and aortic valve implantation in a patient with breast cancer

We present a case of a 70 year-old female with severe aortic stenosis, multivessel coronary artery disease and breast cancer who successfully underwent complex percutaneous coronary revascularisation, transapical aortic valve implantation and mastectomy.     

Takayasu's arteritis: reversal of pulse deficit after early treatment with corticosteroids

Takayasu's arteritis is a rare disease characterized by inflammation and stenosis of large arteries. The aortic arch and its branches are most often affected. Initial symptoms are nonspecific and the diagnosis may be delayed until signs of vascular insufficiency appear. Results of medical treatment have been conflicting. We report a case of a young woman with a short history of pulse deficits, high erythrocyte sedimentation rate, narrowing of the subclavian arteries on arteriography, and a complete return of pulses after high dose corticosteroids. Takayasu's arteritis is a treatable disease in its early phase, but treatment response may be disappointing after irreversible vascular lesions develop.     

Coronary arterial narrowing in Takayasu's aortitis.

A patient with Takayasu's aortitis and angina pectoris due to severe narrowing of the right and left coronary arterial ostia is described. Takayasu's arteritis produces a panaortitis, with thickening of the adventitia predominating, and an inflammatory cell infiltrate involving the adventitia, outer media and vasa vasorum. Narrowing of the coronary arteries in this disease is due to extension into these arteries of the processes of proliferation of the intima and contraction of the fibrotic media and adventitia that occur in the aorta. The distal coronary arteries usually do not manifest arteritis and are normal in caliber. Angina pectoris may be the first symptom of the disease if the coronary arteries are the initial site of severe arterial narrowing. The coronary arterial bypass graft operation is effective therapy for treating coronary arterial narrowing due to Takayasu's arteritis.     

Severe aortic regurgitation: a rare presentation of giant cell arteritis

A 53-year-old patient with no past history of rheumatic fever or lues presented with severe aortic regurgitation, underwent hemodynamic evaluation, and subsequently, an uneventful aortic valve replacement. The initial pathological interpretation was nonspecific aortitis. Six months following surgery arthralgia, muscular pain, difficulty in mastication, and fatigue occurred. There was no fever, however, sedimentation rate was 100/130. Cardiac examination was normal. Review of the pathological specimens revealed granulomatous arteritis with giant cells, typical of giant cell arteritis. Though the association of aortic regurgitation and giant cell arteritis is well recognized, only two such cases of severe aortic regurgitation requiring valve replacements have yet been described, of them, one probably had Takayasu's arteritis. An accurate diagnosis is of importance since steroid treatment is effective, and if introduced early, the inflammatory process may be arrested.     

Aortic valve replacement with combined myocardial revascularisation.

Early and late outcome was studied in 630 patients who underwent aortic valve replacement between 1974 and 1982. Group 1 (506 patients) did not have important coronary artery disease, group 2 (69 patients) had coronary artery disease and underwent coronary artery bypass grafting, and group 3 (55 patients) had coronary artery disease but did not undergo myocardial revascularisation. Early mortality (within 30 days of operation) was significantly lower for group 1 (6%) than for group 2 (13%) and for group 3 (16%). Operative mortality in all three groups was lower in patients operated on more recently. The three year survival of patients in group 1 (83%) was significantly higher than that of patients in group 3 (62%) but not than that of patients in group 2 (76%). The findings of this study suggest that the presence of coronary artery disease increases the risk of aortic valve replacement whether or not coronary artery grafting is performed. Myocardial revascularisation, however, seems to return patients with aortic valve and coronary artery disease to a survival curve similar to that of patients with isolated aortic valve disease.     

Treatment of Takayasu's arteritis: an analysis of 29 operated patients

Over a 25-year period 29 patients underwent 49 vascular procedures due to arterial insufficiency or vascular complications caused by Takayasu's arteritis. In bypass operations 36 grafts were inserted. The 5-year patency rates were 53% when grafts were used for patients with the active disease stage and 88% during the inactive disease stage (p = 0.059). The material of the graft, or postoperative warfarin or platelet-inhibitor drug treatment administered for at least 3 postoperative months had less bearing on graft patency. Ten out of the 11 graft occlusions occurred within the first 2 postoperative years. In operations due to lesions of the brachiocephalic arteries (20 patients), bypass procedures appeared to be superior to thromboendarterectomies; 67% (20/30) of the grafts and 17% (1/6) of the thromboendarterectomies remained patent. Five hypertensive patients underwent surgery because of renal artery stenosis. Hypertension was cured in one patient and in another the antihypertensive regimens could be reduced. There were 2 operative deaths, one due to myocardial infarction after aortic valve replacement and the other due to cerebral hemorrhage, probably because of excessive blood flow resulting from the insertion of an aorto-bicarotid bifurcation bypass graft. Four of the 7 late deaths occurring nine months to 15.7 years postoperatively were considered to be related to Takayasu's arteritis.     

Pre-pulseless Takayasu's arteritis evaluated with 18F-FDG positron emission tomography and gadolinium-enhanced magnetic resonance angiography

Takayasu's arteritis is a primary vasculitis that affects large vessels and is characterized by chronic granulomatous inflammation. Diagnosis has been primarily clinical, with verification by angiography as the gold standard. More recently, however, it has become apparent that positron emission tomography enables better evaluation of vascular inflammation. This study presents 2 cases of Takayasu's arteritis. Magnetic resonance angiography was used to evaluate aortic anatomy by analyzing vascular wall thickness and also to quantify disease activity by measuring gadolinium enhancement. Positron emission tomography was used to evaluate active vascular inflammation by quantifying fluorodeoxyglucose F18 uptake. We conclude that both techniques support clinical diagnosis and aid in the evaluation of disease activity during and after treatment.     

Unprotected left main stent placement in a patient with Takayasu's arteritis: an unusual solution for an unusual disease

We describe the case of a young woman with Takayasu's arteritis that initially manifested as heart failure due to left main coronary artery stenosis. The patient's occluded subclavian artery and the active inflammatory process of Takayasu's arteritis precluded coronary artery bypass grafting with the use of arterial grafts. Therefore, a drug-eluting stent was placed in the unprotected left main artery. This procedure resulted in the resolution of symptoms, with a patent stent and no new coronary lesions observed on 3-month angiography, and normal left ventricular function on 9-month echocardiography. We conclude that the use of drug-eluting stents may be an important treatment option for Takayasu's arteritis patients with life-threatening coronary artery disease for whom coronary artery bypass grafting is not an option.     

Recurrence of resistant hypertension after renal artery stent implantation： A case report

Takayasu＇s Arteritis is a chronic non-specific inflammatory vascular disease involving the aorta and its major branches. Takayasu＇s arteritis is one of important reason for renal artery stenosis（RAS） which may result in severe hypertension. Angioplasty, preferably with stenting, is recommended in RAS secondary to atherosclerosis. However, the safety and efficacy of stent implantation is still unclear in RAS caused by Takayasu＇s arteritis. In order to raise the awareness for the importance of Takayasu＇s arteritis in renal artery disease and further to discuss the endovascular revascularization strategies, we are going to present a case report regarding RAS resulted by Takayasu＇s arteritis and provide a timely summary and update on current understanding.