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Presentation given during the 10th Annual Convention of the Philippine Society of Vascular Medicine.
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TAKAYASU ARTERITIS
SIDNEY ERWIN T. MANAHAN, MD, FPCP, FPRA
Internal Medicine - Rheumatology
Challenges in Managing
Scenarios
• Among patients in “clinical remission” and on stable
medical therapy, what do we do if there is disease
progression?
• Among patients with fixed stenosis not amenable to
medical treatment, when do we send for intervention?
Early Onset Granulomatous Arteritis
TAKAYASU ARTERITIS (TAK)
Giant Cell Arteritis (GCA)
Polyarteritis Nodosa (PAN)
Kawasaki Disease (KD)
Cryoglobulinemic Vasculitis (CV)
IgA Vasculitis (IgAV)
Urticarial Vasculitis (HUV)
Microscopic Polyangiitis (MPA)
Granulomatosis with Polyangiitis (GPA)
Eosinophilic Granulomatosis with Polyangiitis (EGPA)
Behcet’s Disease (BD)
Cogan’s Syndrome (CS)
Disease Course
TIME COURSE
DIS
EA
SE A
CT
IVIT
Y
SYSTEMIC
(Pre-vasculitic)
VASCULAR BURNOUT
Constitutional
Symptoms
Inflammatory
Features
Vascular
Insufficiency
(stenosis,
aneurysms) Remission
Diagnosing Takayasu Arteritis
1990 ACR
• Age <40years
• Limb claudication
• Decreased brachial pulse
• SBP difference >10mmHg
• Bruit over the subclavian or aorta
• Arteriogram abnormality
1996 Sharma Modified
• Left midsubclavian artery lesion
• Right midsubclavian artery
lesion
• Characteristic s/sx for >1 month
• ESR >20mm/Hr
• Carotid artery tenderness
• Hypertension
• Aortic regurgitation or
Annuloaortic ectasia
• Pulmonary artery lesion
• Left mid CCA lesion
• Distal inominate artery lesion
• Descending thoracic aorta lesion
• Abdominal aorta lesion
• Coronary Artery lesion
Biomarkers in Diagnosis
Ishihara T, et al. Circulation J 2012: doi: 10.1253/circj.CJ-12-0131
TAK Disease Course
TIME COURSE
DIS
EA
SE A
CTIV
ITY
• Control Inflammation
• Relieve symptoms
• Limit extent of vessel involvement
• Monitor disease activity
• Corrective vascular interventions
20%
80%
Ma J, et al. J Vasc Surg 2010; 51: 700-6. Subramanyan R, et al. Circulation 1989, 80: 429-37
Biomarkers of Activity
Useful in Monitoring
• ESR
• CRP (>2050ng/ml)
• Serum Amyloid A (SAA)
• C4 Binding Protein (C4BP)
• Pentraxin3 (PTX3)
• Matrix Metalloproteinase-9
(MMP-9)
Not Useful
• Fibrinogen, Haptoglobin
• CRP
• -Acid glycoprotein
• Serum Amyloid P
• C4a, C3c
• Transthyretin
• 1-microglobin
• MMP-2, MMP-3
Ishihara T, et al. Circulation J 2012: doi: 10.1253/circj.CJ-12-0131. Ma J, et al. J Vasc Surg 2010; 51: 700-6.
Biomarkers of Activity
Biomarker Active TA Inactive TA Controls P-value
ESR 39.1 + 24.8 15.2 + 9.6 11.3 + 5.1 <0.05
Elevated ESR (%) 83 28 0
SAA 95.9 (51.9) 49.2 (82) 23.9 (50.1) <0.005
C4BP 88.5 (72.6) 61.7 (57.7) 32.6 (32.1) <0.005
CRP 6.65 (18.1) 2.3 (5.75) 2.28 (1.58) 0.116
C4a 13.3 (13.6) 14.9 (10.4) 16 (23.9) 0.784
C3c 689.8 + 263 780.8 + 231 793 + 225 0.513
Values listed as Mean + SD or Median (Interquartile range)
Ma J, et al. J Vasc Surg 2010; 51: 700-6.
The IDEAL Imaging Modality in TAK
• Facilitate early diagnosis
• Provide assessment of disease extent
• Provide assessment of inflammatory activity
• Demonstrate response to treatment
• Distinguish vs. atherosclerotic plaques
Mason J. Nature Rev Rheum 2010.
Performance of Imaging Modalities
CT/ MR
Angiography
High Resolution
Ultrasound
18F-FDG PET
Scan
Early diagnosis
Disease extent
Disease activity
Evaluate response
Differentiate vs.
atherosclerosis
Mason J. Nature Rev Rheum 2010.
Monitor every
6 MONTHS
for evidence of
progressive
vascular disease
No SINGLE modality provides all the
information required. Modalities may have distinct or
complementary roles in care.
Determining TAK Activity
National Institutes of Health (NIH) Criteria
• Systemic Features
• Elevated ESR or CRP
• Symptoms of Vascular Ischemia
• Typical Angiographic Features
New onset OR Worsening of any two of the above criteria reflects disease activity.
Kerr GS, et al. Ann Int Med 1994.
Determining TAK Activity
REMISSION
• Absence of symptoms
• Normal inflammatory
markers
• No new imaging findings
SUSTAINED REMISSION
• Remission criteria for AT
LEAST 6 months
• Steroid dose <10mg/day
Controlling Disease Activity
Prednisone
Japan Guidelines
• Starting dose: 20-30 mg/d
• Maximum dose: 60 mg/d
American College of Rheumatology
• Max starting dose: 60 mg/d
DMARDs
MTX
AZA
CsA
CYC
MMF
BIOLOGICS
Infliximab*
Etanercept*
Tocilizumab
* Open-label trials
JCS Joint Working Group. Circ J 2011; 75: 474-503. Mukhtyar C, et al. Ann Rheum Dis 2008; doi:
10.1136/ard.2008.088351. Johnston SL, et al. J Clin Path 2002; 55: 481-486
Prednisone 0.5 – 1 mkd
Is disease
INACTIVE?
(Can taper steroids)
MTX 7.5 – 25mg/wk
AZA 2 mkd
CsA 3 mkd
CYC PO 50-100 mg/d
(IV 300-750 mg/m2 /mo)
MMF 1.5 – 3 mg/d
Infliximab 5mg/kg/dose
Etanercept 25 mg 2/wk
Ineffective
Ineffective
Difficult to taper
Tocilizumab 8 mg/kg/mo
Ineffective
Medical Management of TAK
JCS Joint Working Group. Circ J 2011; 75: 474-503. Johnston SL, et al. J Clin Path 2002; 55: 481-486
TAK Surgery
Best done during Inactive Phase
• Prevent restenosis, anastomotic failure, thrombosis,
hemorrhage and infection
If Urgent surgery during Active Phase
• ESR <30mm/hr
• CRP <1mg/dl
JCS Joint Working Group. Circ J 2011; 75: 474-503. Johnston SL, et al. J Clin Path 2002; 55: 481-486
Indications for TAK Surgery
• Aortic root dilation >50mm on CT
• Aortic coarctation
• Aortic valve regurgitation >75% EF
• Dilatation of branches of aorta >30mm
• Symptomatic cerebral ischemia
• Critical stenosis of >3 cerebral vessels
• Cardiac ischemia w/ confirmed CAD
• Renal artery lesions – esp those with HF, unstable angina,
renovascular HPN, decreased renal function
JCS Joint Working Group. Circ J 2011; 75: 474-503. Johnston SL, et al. J Clin Path 2002; 55: 481-486
Summary
• Reviewed the course of Takayasu Arteritis
• Discussed definitions of disease activity and remission
– Role of biomarkers
– Role of imaging studies
• Presented the medical management of Takayasu Arteritis
• Enumerated indications for surgical intervention