Stenosis or Occlusion of the Right Subclavian and Common Carotid Arteries Is More Common than That of the Innominate Artery in Takayasu Arteritis

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1 Vsculr Specilist Interntionl Vol. 31, No. 4, December 2015 pissn eissn Stenosis or Occlusion of the Right Subclvin nd Common Crotid Arteries Is More Common thn Tht of the Innominte Artery in Tkysu Arteritis Originl Article Bong Won Prk 1, Sng Jun Prk 1, Hojong Prk 1, Je Chol Hwng 2, Young Woo Seo 2, nd Hong Re Cho 1 Deprtments of 1 Surgery nd 2 Rdiology, Ulsn University Hospitl, University of Ulsn College of Medicine, Ulsn, Kore Purpose: The im of this study ws to introduce the phenomenon tht stenosis or occlusion occurs less frequently in the innominte rtery thn in the right subclvin nd common crotid rteries, which re not first-order brnches of the ort, in Tkysu rteritis (TA). Mterils nd Methods: We retrospectively reviewed the medicl records nd imge findings of ll ptients who were dignosed with TA from 2006 to Two vsculr surgeons nd two rdiologists interpreted the imges by disese chrcter, loction, nd extent of occlusion bsed on computed tomogrphy ngiogrphy, mgnetic resonnce ngiogrphy, or digitl subtrction rteriogrphy. We hve lso reviewed the literture on rteril involvement in TA. Results: A totl of 42 ptients were dignosed with TA. The men ge ws 43.9 yers, nd 83.3% (35/42) of the ptients were women. The left subclvin rtery ws the most common stenosis or occlusion site (17, 40.5%) mong the ortic brnches. The innominte rtery ws less common site (3, 7.1%) thn the right subclvin rtery (4, 9.5%) nd the right common crotid rtery (9, 21.4%). All innominte rtery cses were found fter endovsculr procedures of the right subclvin or common crotid rteries. Conclusion: The innominte rtery might develop stenosis or occlusion less frequently thn the right subclvin nd common crotid rteries in Koren TA ptients. Received August 14, 2015 Revised September 12, 2015 Accepted September 14, 2015 Corresponding uthor: Sng Jun Prk Deprtment of Surgery, Ulsn University Hospitl, University of Ulsn College of Medicine, 877 Bngeojinsunwhn-doro, Dong-gu, Ulsn 44033, Kore Tel: Fx: E-mil: ud3012md@medimil.co.kr Conflict of interest: None. Key Words: Tkysu rteritis, Brchiocephlic trunk, Aort, Pthologic constriction, Cerebrovsculr disorders Copyright 2015, The Koren Society for Vsculr Surgery This is n Open Access rticle distributed under the terms of the Cretive Commons Attribution Non-Commercil License ( which permits unrestricted non-commercil use, distribution, nd reproduction in ny medium, provided the originl work is properly cited. Vsc Spec Int 2015;31(4): INTRODUCTION Tkysu rteritis (TA) is rre chronic inflmmtory disese chrcterized by pn-rteritis of the ort nd its min brnches. Although rre, it is n importnt disese in Kore owing to its reltively high prevlence in Asi nd the young ge of ptients t its onset [1]. The etiology nd pthogenesis of this disese is not yet fully known [2]. The clinicl fetures, which re slightly different in ech country, re not well-known becuse of the rrity of this disese [3]. The following ws n incidentl finding in our hospitl; innominte rtery stenosis or occlusion occurred less frequently thn stenosis or occlusion of the right subclvin rtery or right common crotid rtery in 120

2 Clinicl Fetures of Tkysu Arteritis TA ptients. This finding ws very interesting becuse the right subclvin rtery nd right common crotid rtery re not first-order brnches of the ort. We investigted ptients with TA t our institution nd evluted their rteril stenosis or occlusion ptterns. We lso reviewed the literture on TA. MATERIALS AND METHODS We retrospectively reviewed the medicl records from the dtbse of ll ptients dignosed with or mnged for TA from Mrch 2006 to December 2014 in Ulsn University Hopitl (Ulsn, Kore). Dignosis ws confirmed fter reviewing medicl records nd imging studies of ptients who were dignosed with TA with n Interntionl Clssifiction of Diseses code M34. We lso pplied the criteri of the Americn College of Rheumtology 1990 to further confirm the dignosis [4]. This study ws pproved by institute review bord of Ulsn University Hospitl (IRB No ). Imging studies of the rteries were reviewed by two vsculr surgeons nd two rdiologists. An rteril lesion ws defined s luminl nrrowing or occlusion of the ort nd its mjor brnches, or neurysml chnges on computed tomogrphy (CT) ngiogrphy, mgnetic resonnce ngiogrphy, or conventionl rteriogrphy. For the coronry rteries, coronry CT rteriogrphy scns or conventionl coronry rteriogrphy findings were used. Left nd right rteries were considered seprtely. We lso conducted comprehensive review of the literture for English rticles published between 1966 nd The keyword for serching the PubMed dtbse ws Tkysu rteritis. We lso mnully serched the references of the selected rticles for ny relevnt rticles tht we could find on rteril stenosis or occlusion ptterns nd the rce or country of origin of TA ptients. Tble 1. Demogrphic dt nd clinicl chrcteristics (n=42) Chrcteristic Dt Age (y) 43.9 (5-75) Gender, femle 35 (83.3) Aneurysml chnge 4 (9.5) Arteril stenosis 42 (100) Arteril occlusion 31 (73.8) Use of immunosuppressnts 36 (85.7) Invsive tretment 8 (19.1) Vlues re presented s men (rnge) or number (%). The tretments were undergone only in our institute, nd they involved neurysm resection, rteril bypss, endovsculr tretment or combintion of them. RESULTS During the study period, 44 ptients with TA were identified, nd 42 ptients were investigted fter excluding two ptients with n uncler dignosis. The demogrphic nd clinicl fetures of the ptients re summrized in Tble 1. The men ge of the ptients ws 43.9 yers (rnge 5-75 yers), nd 35 of the ptients (83.3%) were women. All of the ptients hd t lest one rteril stenosis or occlusion in the ort or its min brnches. Four ptients (9.5%) hd neurysml chnges. Thirty-six ptients (85.7%) hd tken immunosuppressnts such s steroids, methotrexte, or zthioprine. The others hd never tken immunosuppressnts becuse they were dignosed with TA when they were older nd were not showing ny disese ctivity. Eight ptients (19.1%) underwent invsive tretments such s neurysm resection, rteril bypss, or endovsculr surgery in our hospitl. Six ptients who underwent invsive tretment hd t lest two trget lesions to correct. The rteril stenoses or occlusions in the TA ptients re shown in Tble 2. The ffected rteries included 5 coronry rteries, 3 innominte rteries, 4 right subclvin rteries, 9 right common crotid rteries, 11 left common crotid rteries, 17 left subclvin rteries, 2 celic rteries, 2 superior mesenteric rteries, 1 inferior mesenteric rtery, 6 renl rteries (ll with bilterl involvement), nd 0 ilic Tble 2. Arteril stenosis or occlusion nd involvement of ortic segment in Tkysu rteritis (n=42) Involved rtery Number (%) Coronry rtery 5 (11.9) Innominte rtery 3 (7.1) Right subclvin rtery 4 (9.5) Right common crotid rtery 9 (21.4) Left common crotid rtery 11 (26.2) Left subclvin rtery 17 (40.5) Celic rtery 2 (4.8) Superior mesenteric rtery 2 (4.8) Renl rtery b 6 (14.3) Inferior mesenteric rtery 1 (2.4) Ilic rtery 0 (0) Ascending ort 0 (0) Aortic rch 0 (0) Descending ort 17 (40.5) Abdominl ort 9 (21.4) Totl 86 All innominte rteries were simultneously involved with the right subclvin or crotid rteries; b ll renl rteries were involved on both sides

3 Prk et l. Tble 3. Arteril involvement ptterns of Tkysu rteritis Yer Country Cse (n) Most common ortic brnch Most common ortic segment Lest common ortic segment Innominte rtery involvement Reference 2013 United Sttes 126 LCA Infrrenl ort Aortic rch 25% Schmidt et l. [15] 2012 United Sttes 62 LSA Thorcic ort Abdominl ort Unknown Gryson et l. [5] 2011 Frnce 82 CCA Abdominl ort Aortic rch 28% Arnud et l. [16] 2007 Kore 85 CCA DTA Ascending ort 70% Chung et l. [13] 2007 United Sttes 75 Abdominl ort Unknown Unknown Unknown Mksimowicz- McKinnon et l. [22] 2005 Kore 108 SA DTA Ascending ort 3% Prk et l. [6] 2005 Itly 104 LSA DTA Aortic rch 8% Vnoli et l. [7] 2004 Turkey 45 Unknown Unknown Unknown Unknown Ureten et l. [17] 1998 Indi 10 Renl rtery Abdominl ort Ascending ort 20% Shrm et l. [9] 1997 Indi/Jpn 182 CCA DTA Aortic rch Unknown Moriwki et l. [12] 1996 Jpn 182 CCA DTA Aortic rch 20% Ht et l. [11] 1996 Indi 106 Renl rtery DTA Ascending ort Unknown Jin et l. [8] 1995 Kuwit 13 Unknown Unknown Unknown Unknown el-reshid et l. [23] 1992 Isrel 50 Unknown Unknown Unknown Unknown Rosenthl et l. [24] 1992 Jpn 2,738 Unknown Unknown Unknown Unknown Koide [25] 1985 United Sttes 32 Renl rtery Unknown Unknown 43% Hll et l. [10] 1983 Sweden 15 Unknown Unknown Unknown Unknown Wern et l. [26] 1977 Mexico 107 Abdominl ort Abdominl ort Ascending ort Unknown Lupi-Herrer et l. [14] LCA, left crotid rtery; LSA, left subclvin rtery; CCA, common crotid rtery; DTA, descending thorcic ort; SA, subclvin rtery. They counted rteril wll thickness s well s rteril stenosis or occlusion. rteries. All innominte rtery cses were dignosed s rteril stenosis fter endovsculr procedure for right subclvin rtery or right common crotid rtery, brnches of the innominte rtery. We reviewed 18 ppers to investigte the rteril involvement of TA nd the results re summrized in Tble 3. There were 13 ppers from which we could identify the most common ffected ortic brnch rteries nd 11 ppers which reported the ffected ortic segment. Three ppers (from the United Sttes, Kore, nd Itly) reported tht the left subclvin rtery ws the most commonly ffected rtery mong totl of 274 ptients [5-7]. Three other ppers (from the United Sttes nd two from Indi) reported tht the renl rtery ws most commonly ffected mong totl of 146 ptients [8-10]. Two ppers (from Jpn nd Indi) reported tht the common crotid rtery ws the most commonly ffected site mong totl of 364 ptients [11,12]. There were 10 ppers from which we could identify the most commonly ffected ortic segment. Six of the 10 ppers reported the descending ort ws the most commonly ffected ortic segment [6-8,11-13]. Five out of the 10 ppers reported tht the scending ort ws the lest commonly ffected ortic segment [6,8,9,13,14]. We could identify the frequency of innominte rtery involvement in eight ppers. The innominte rtery ws involved in 3% (Kore) [6], 8% (Kore, only occlusion cses) [13], 8% (Itly) [7], 20% (Indi) [9], 20% (Jpn) [11], 25% (United Sttes) [15], 28% (Frnce) [16], nd 43% (United Sttes) [10]. Two Koren ppers nd one Itlin pper showed tht the right subclvin rtery nd right crotid rtery were more commonly ffected by stenosis or occlusion thn the innominte rtery [6,7,13]. We could not find ny other ppers reporting the comprison between the frequencies of stenosis or occlusion of the innominte, right subclvin nd common crotid rteries. DISCUSSION TA is very rre disese, nd its incidence nd rteril involvement pttern vry depending on ethnicity nd ntionlity [5,9,12,13,16-18]. We hd n interest in the rteril stenosis or occlusion ptterns of this disese becuse TA is known to ffect the ort nd its min brnches, but in our study, stenosis or occlusion of the innominte rtery ws less common (3 ptients, 7.1%) thn the right subclvin rtery (4, 9.5%) nd the right common crotid rtery (9, 21.4%); the innominte rtery ws spred s first-order ortic brnch (Fig. 1). The three innominte rtery cses of our study occurred fter stent insertion t other hospitls. Previously published 122

4 Clinicl Fetures of Tkysu Arteritis Fig. 1. Mgnetic resonnce ngiogrm shows stenosis of the right common crotid rtery (white rrow), ptent innominte rtery (white rrowhed), nd complete occlusion of the left common crotid rtery (blck rrow). studies hve reported high restenosis or occlusion rtes fter endovsculr procedures performed on ptients with TA [1,19,20]. We suspect tht the innominte rtery occlusions might hve occurred becuse of previous endovsculr procedures for the right subclvin rtery or the right common crotid rtery. According to reports from Jpnese popultions nd Cucsin popultions in Frnce, innominte rtery involvement ccounted for pproximtely 30% of cses; they did not show innominte-rtery spring compred to involvement of the right subclvin or common crotid rteries [11,16]. Prk et l. [6] reported tht the innominte rtery ws less frequently (3%) ffected in Koren ptients with TA thn the right subclvin rtery (48%) nd the right common crotid rtery (31%). Vnoli et l. (Itly) [7] lso reported tht the innominte rtery (8%) ws involved less frequently thn the right subclvin rtery (30%) nd the right crotid rtery (23%). Some ppers hve reported tht involvement of the innominte rtery ws common [13,21]. However, Chung et l. [13] included even pthologic chnges of the rteril wll on CT scn s involvement, while Prk et l. [6] nd our group only counted lesions with stenosis or occlusion. In the study of Chung et l. [13], if only occlusive lesions were to be counted, the rteril involvement rte would hve been s follows: innominte rtery 7.4%; right subclvin rtery 25.3%; nd right common crotid rtery 32.9%. Chung et l. [13] lso studied for Koren ptients. These results suggest tht the rteril stenosis or occlusion ptterns of Koren ptients with TA might be different from tht of ptients in Jpn or other countries [4,5,7,8,10,11,14,15,22-26]. Among ptients in Asin countries, rteril involvement ptterns hve been shown to be different between ptients in Jpn nd Indi [11,12,25]. In our literture review, we found tht the rteril occlusion or stenosis ptterns of Itly were different from those in Frnce nd the United Sttes [7,15,16]. Therefore, we believe tht the rteril stenosis or occlusion ptterns of TA ptients might vry depending on rce or ntionlity. In ddition, when we restore the blood flow of the right subclvin rtery or the right common crotid rtery by endovsculr procedures for Koren ptients, we should be creful to preserve the innominte rtery for the future. Spring of the scending ort is nother notble feture. This is one of the well-known fetures of TA, with similr results reported from both Estern nd Western countries [6,8,9,13,14]. Considering tht TA is progressive disese, the scending ort should be used s the inflow rtery when n rteril lesion occurs, which mkes it possible to mintin stble flow even if the disese progresses in the future [21]. A mjor limittion of this study ws tht the number of cses ws smll nd ll the cses were collected retrospectively. While dding review of other Koren or foreign ppers, we believe tht prospective nd lrge number of observtions will be necessry to confirm the pttern of innominte rtery spring in Koren TA ptients. CONCLUSION Despite being first-order brnch of the ort, the innominte rtery might be developing stenosis or occlusion less commonly thn the right subclvin rtery nd right common crotid rtery, second-order brnches of the ort. We should focus more ttention on voiding dmge to the innominte rtery when we perform interventions for the right subclvin rtery or the right common crotid rtery in ptients with Tkysu rteritis

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