A follow-up study of balloon angioplasty and de-novo stenting in Takayasu arteritis

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Abstract

Percutaneous balloon angioplasty (PTBA) is a universally accepted mode of therapy for stenotic coronary and peripheral arterial lesions. To establish the role of PTBA and stent placement in patients with Takayasu’s arteritis (TA), these procedures were performed in 20 patients with TA. All patients received steroids, aspirin and ticlodipine (for stent placement) prior to procedure. Angioplasty was carried in patients with symptomatic stenotic vessel of more than 70% of normal diameter or a peak systolic gradient of more than 50 mm across stenotic aortic lesion. Stenting was performed for ostial lesion, long segment lesion or incomplete relief of stenosis and dissection following angioplasty. Carotid angioplasty and stenting was performed in five patients, aortic angioplasty in nine patients, aortic angioplasty and stenting in four patients, renal angioplasty in three patients, renal angioplasty and stenting in two patients and subclavian angioplasty in two patients, subclavian, angioplasty and stenting in three patients and coronary angioplasty and stent placement in one patient. The procedure was successful in all but one patient. On following up, two patients with carotid stent placement had restenosis. A saccular aneurysm developed at the lower end of stent in one patient with aortic stent placement. The PTBA with or without stent placement is a safe and effective method for relief of stenotic lesion in patients with TA.

Introduction

Takayasu Arteritis is a sizeable problem in Japan and South Asian countries including India [1]. The management of Takayasu Arteritis (TA) is challenging. Steroids and immuno-suppressive agents have been used with variable success [2], [3], [4], [5]. Revascularisation procedures are usually performed for significant stenotic lesions in TA [6]. Although percutaneous transluminal balloon angioplasty (PTBA) is an established treatment for the management of atherosclerotic coronary and non-coronary vascular stenotic lesions and non-atherosclerotic stenotic peripheral arterial lesions, however, restenosis remains a major concern with PTBA [7], [8]. Stent supported angioplasty achieves better luminal diameter and lowers the rate of restenosis [8], [9]. We are reporting our experience with 20 patients of TA who underwent angioplasty and de-novo stenting and were followed for a minimum period of 6 months.

Section snippets

Material and methods

Twenty patients of angiographically proven TA were included in the study. All patients underwent a detailed clinical evaluation and laboratory investigations. The patients with disease activity as judged by systemic features – fever, musculoskeletal pains, vascular ischaemia or raised erythrocyte sedimentation rate of more than 20 mm in the first hour were given steroids (Prednisolone 2 mg/kg). The doses of steroid were adjusted according to the erythrocyte sedimentation rate and clinical

Technique

An informed and a written consent was obtained from all patients prior to the procedure. All procedures were performed under local anaesthesia through the right femoral or brachial punctures using the Schneider technique. Direct surgical exposure of artery was done for percutaneous access to the vessel where required. Heparin was given as bolus during the procedure to maintain an activated coagulation time between 250 and 300 s.

Angioplasty was performed using the standard coaxial

Results

Of the 20 patients, there were 11 males and 9 females with a mean age of 28±13.1 years. Hypertension was present in 18 (90%), fatigue in 13 (65%)and headache in 11 (55%) of the patients. Vascular bruits were heard in 12 (60%) patients. Two patients presented with congestive heart failure. Laboratory investigations revealed an elevated erythrocyte sedimentation rate (more than 20 mm/h) in 6 patients and left ventricular hypertrophy on electrocardiographic in 5 patients. Angiographic findings

Discussion

The management strategies of TA include medical therapy with steroids or immunosuppressive agents and revascularization procedure [2], [3], [4], [5]. During the active phase of the disease, steroids have been shown to improve the systemic inflammatory symptoms within a few days to weeks. Absent pulses may appear in up to 50% of cases. Cytotoxic drugs – methotrexate or cyclophosphamide, have been used when steroids could not induce remission [3], [5].

In the chronic stage, the principle of

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