Takayasu arteritis nonspecific aortoarteritis signs diagnosis therapy

AH – arterial hypertension

Blood Pressure – Blood Pressure

CABG – coronary artery bypass grafting

BAP – balloon angioplasty

BCA – brachiocephalic arteries

BCS – brachiocephalic trunk

VBB – vertebrobasilar basin

VBN – vertebrobasilar insufficiency

GFCF – All-Russian Scientific Society of Cardiology

ICA – Internal Carotid Artery

IVUS – intravascular ultrasound

VYAV – internal jugular veins

DS – duplex scanning

MI – myocardial infarction

CAS – carotid angioplasty with stenting

CT – computed tomography

KTA – computed tomography angiography

CEA – Carotid Endarterectomy

HDL – high density lipoproteins

LPI – ankle-brachial index

LDL – low density lipoproteins

LSK – linear blood flow velocity

ICD-10 – international classification of diseases of the 10th revision

INR – international normalized attitude

MRA – magnetic resonance angiography

MRI – magnetic resonance imaging

MSCTAG – multispiral computed tomography angiography

NMK – cerebrovascular accident

NSA – external carotid artery

ONMK – acute cerebrovascular accident

OCA – common carotid artery

PA – vertebral artery

PVA – superficial temporal artery

PI ICA – pathological tortuosity of the internal carotid artery

PNMK – transient cerebrovascular accident

PST – subclavian-carotid transposition

PET – positron emission tomography

RCT – a randomized clinical trial

CA – carotid artery

SMA – middle cerebral artery

SMN – cerebrovascular insufficiency

CRP – C-reactive protein

SSEP – somatosensory evoked potential

TIA – transient ischemic attack

TCD – transcranial dopplerography

TLBAP – transluminal balloon angioplasty

US – ultrasonic scanning

FEK – fraction of oxygen extraction

DDS – color duplex scanning

CPD – cerebral perfusion pressure

CPR – cerebral perfusion reserve

EIKMA – extraintracranial microanastomosis

AHA – American Association of Cardiology

CI (con? Dence interval) – confidence interval

PI – pulsator index (Gosling index)

S / D – ratio of systolic linear blood flow velocity to diastolic linear blood flow velocity (Stuart index)

Symptoms of nonspecific aortoarteritis

It is extremely difficult to identify the symptoms of the disease at home (and in the clinic). Characteristic features include pulse disturbances (absence or asymmetry), difference in blood pressure on two hands, extraneous aortic murmurs, occlusion and narrowing of the aorta.

Patients complain of pain in the hands and weakness, they can hardly tolerate physical activity. Pain can occur in the left shoulder, neck or chest.

Sometimes Takayasu arteritis affects the optic nerve. In this case, double vision is fixed, one-sided blindness, retinal occlusion. Vascular damage can lead to myocarditis, myocardial infarction, coronary circulation dysfunction.

The narrowing of the vascular lumen provokes the development of arterial hypertension. This ailment is practically not corrected by well-known medications. The course of Takayasu syndrome is divided into chronic and acute stages. The chronic stage covers a period of 6-8 years and is characterized by a stable set of symptoms that accurately diagnose the problem.

And here are the signs of the acute phase:

  • weight loss;
  • temperature disturbances;
  • increased sweating (mainly at night);
  • high fatigue;
  • rheumatic pains (affect large joints);
  • pericarditis, pleurisy and skin nodules.

There is also a set of symptoms that should alert you at the very beginning of the development of pathology. Headaches and chronic muscle fatigue are alarming bells. It is also worth paying attention to impaired memory and joint pain. If you find one of these symptoms, consult a doctor immediately.

Appendix A2. Clinical Guidelines Development Methodology

Target audience of developed clinical recommendations:

  1. Cardiovascular surgery
  2. Surgery
  3. Neurology
  4. Ultrasound diagnostics
  5. X-ray

Diagnosis of pathology is complicated by its rarity and the presence of concomitant “masking” ailments. With damage to the brain and lungs, it becomes even harder to identify the syndrome. The doctor prescribes a comprehensive examination, which can stretch for several weeks.

The final diagnosis is made only in the presence of the following symptoms:

  • weakness / disappearance of the pulse on the hands;
  • difference Blood pressure on the hands of more than 10 millimeters of mercury;
  • intermittent claudication;
  • noises audible in the aorta;
  • patient age (up to 40 years);
  • aortic valve insufficiency;
  • arterial occlusion;
  • prolonged growth of ESR;
  • chronic increase in blood pressure.

As you can see, long-term monitoring of the patient’s condition is required. Instrumental and biochemical studies, as well as anamnesis, play a role. At an early stage of observation, a preliminary diagnosis is made.

After this, a number of additional studies are prescribed:

  • General / biochemical blood test. Doctors are interested in qualitative abnormalities in your blood composition.
  • Angiography. A contrast agent is introduced into the affected vessels, which allows to detect occlusions and narrowing of the arteries by the radiographic method.
  • Ultrasound of blood vessels. Blood flow velocity and the degree of damage to the coronary vessels is assessed by scanning.
  • X-ray examination. Doctors examine the chest in search of pathologies of the pulmonary artery and aortic trunk.
  • Electroencephalography and rheoencephalography. Vascular disorders affecting the area of ​​the brain are evaluated.
  • Echocardiography. The functioning of the heart muscle is being studied.

Treatment of ailment

Treatment
aortoarteritis is aimed at suppressing active inflammation in the wall
vessel. Currently, there are many approaches to conservative
treatment of patients with nonspecific aortoarteritis. The basis of treatment is
taking glucocorticoids (prednisone, methylprednisolone) and cytostatics and
other immunosuppressive drugs.

According to a number of treatment specialists
nonspecific aortoarteritis, indications for surgical treatment
occur in 12-60% of patients [8].

Surgical treatment of NAA has certain features in
compared with atherosclerotic lesion. According to A.The. Pokrovsky and
et al. [4], there are 3 main aspects of surgical treatment of NAA:

  1. Preoperative problems – primarily, the correction of the inflammatory process.
  2. Intraoperative problems. Given that with aortoarteritis
    the affected arterial wall loses differentiation into layers, in
    features in patients with acute and subacute course of the disease,
    performing endarterectomy from arteries becomes extremely difficult.
    That is why shunting and prosthetic surgery in patients
    nonspecific aortoarteritis are the main type of arterial
    reconstruction.
  3. Postoperative problems – include stabilization
    inflammatory process and prevention of further progression
    disease.

To surgical intervention for BCA lesion in patients
aortoarteritis after TIA and / or ischemic stroke
resort in the presence of stenosis (70% or more) of the brachiocephalic trunk,
common carotid arteries. With an asymptomatic course of the disease, an indication of
critical stenosis (90% or more) can serve as reconstruction of arteries
or occlusion of the brachiocephalic trunk, common carotid arteries.

Pulse therapy with methylprednisolone and cyclophosphamide is effective
a method of reducing the activity of inflammation and can be recommended as
in the preoperative period and in the distant period after the operative
treatment.

Level of evidence C

In the presence of stenosis (70% or more) of the brachiocephalic trunk or common
carotid arteries in patients with NAA after TIA and / or ischemic stroke
in the carotid pool, reconstructive surgery is recommended
operation.

Asymptomatic patients with NAA surgery on
brachiocephalic arteries recommended in the presence of critical stenosis
(90% or more) or occlusions of the brachiocephalic trunk, common carotid
arteries.

With syndrome of vertebral subclavian robbery and upper ischemia
limbs in the stage of subcompensation and decompensation is recommended
surgical treatment for subclavian artery occlusion in the proximal
segment.

With non-specific aortoarteritis, it is recommended to give
preference for extra thoracic bypass operations. At
the impossibility of extra-thoracic reconstruction, it is advisable
performing transthoracic intervention

Bicarotid prosthesis surgery is not recommended
due to the high risk of developing reperfusion syndrome, especially in
patients with arterial hypertension

Performing endarterectomy from the carotid arteries with nonspecific
aortoarteritis is not recommended due to the lack of layer differentiation
walls of the carotid arteries

There are several factors that influence the treatment of nonspecific aortoarteritis. This is the severity of ischemic disorders, the state of internal organs and the stage of the disease.

Among the tasks of conservative therapy, we single out the treatment of ischemic complications, normalization of hemodynamics and activation of the immune process, correction of heart failure and arterial hypertension. Doctors try to relieve inflammation and normalize blood pressure.

The key drug in the medical treatment of Takayasu syndrome is Prednisolone. This tool successfully fights with acute clinical manifestations of the disease.

The dose is prescribed individually, so do not self-medicate.

After achieving a stable remission, you can again consult with your doctor and stop taking Prednisolone.

If the drug is ineffective (this happens), Methotrexate, an antitumor substance aimed at suppressing DNA synthesis, is connected to the process. The methods of extracorporeal hemocorrection, known under the term “gravitational blood surgery”, are also practiced.

This complex procedure is indicated for systemic disorders in the body. When ischemia affects the brain, doctors are forced to undergo surgical intervention – bypassing the aortic area.

If you have Takayasu’s disease, you should consider preventive measures. In particular, to reduce the risk of vascular atherosclerosis, it is recommended to use blood thinners (in combination with acetylsalicylic acid).

Having discovered non-specific aortoarteritis, get ready for long-term therapy and strict adherence to medical prescriptions. There is a risk of progression of cardiovascular complications – many of them end in a heart attack.

You cannot completely cure the disease, but the state of remission is recognized as significant progress. Take regular examinations to identify the problem at an early stage. Take care of yourself!

Appendix A2. Clinical Gu >Clinical
picture of NAA with lesions of the brachiocephalic arteries is composed of
symptoms caused by systemic inflammation that begins in
early stages of the disease, and from the symptoms of cerebral ischemia.

If patients with aortoarteritis have signs of activity
inflammatory process, as a rule, a prolonged increase is noted
body temperature, usually to subfebrile numbers, weakness, drowsiness,
myalgia and arthralgia, accelerated ESR, increased levels of C-reactive protein
(CRP). One of the characteristic clinical symptoms of the disease, which
help with a high probability of suspecting Takayasu arteritis, is
pain along the arteries, in particular the carotid arteries. [7].

With damage to the branches of the aortic arch in patients with NAA, a marked
discrepancy between the degree of occlusive lesions and clinical
manifestations of the disease.

According to several authors, with nonspecific aortoarteritis rarely
episodes of transient cerebrovascular accident are observed, in
unlike atherosclerosis and rarely are a precursor to stroke
[15].

In Russia, approximately 30% of patients are involved in
pathological process of branches of the aortic arch, in 10-15% of patients
isolated lesion of the thoracoabdominal aorta, in half of the cases
there is a combined lesion of several arterial pools [4].

In order to reduce the frequency of involvement in the pathological process
brachiocephalic arteries are distributed as follows: subclavian
arteries, common carotid arteries, brachiocephalic trunk, external carotid
arteries, internal carotid arteries, vertebral arteries [10, 13].

A feature of the defeat of the subclavian arteries in Takayasu disease
is the primary involvement in the pathological process of medium and
distal portion. For other branches of the aorta, it is more characteristic
involvement of the proximal segments in the pathological process, while
how the distal arteries remain intact [5, 9, 11].

Most authors in patients with stenosis and common occlusions
carotid arteries reveal patency of internal and external carotid
arteries [4]. Preservation of patency of the internal carotid determines
the ability to perform vascular reconstructions [15].

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Editor-in-chief of the Detonic online magazine, cardiologist Yakovenko-Plahotnaya Tatyana. Author of more than 950 scientific articles, including in foreign medical journals. He has been working as a cardiologist in a clinical hospital for over 12 years. He owns modern methods of diagnosis and treatment of cardiovascular diseases and implements them in his professional activities. For example, it uses methods of resuscitation of the heart, decoding of ECG, functional tests, cyclic ergometry and knows echocardiography very well.

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