Disease Activity in Takayasu’s Arteritis Affects Long-term Graft Related Outcomes

Abstract

Introduction - Takayasu’s Arteritis (TA) is a rare, inflammatory large-vessel vasculitis of unknown etiology. This disease occasionally requires surgical intervention. There is a paucity of published data on the long-term outcomes of surgical intervention in these patients. There is limited data on the results of these procedures in patients with or without active disease. Methods - A retrospective review was conducted of patients with Takayasu’s arteritis who underwent open, noncardiac vascular procedures at our institution between 1994 and 2017. Basic demographics, diagnostic workup, treatment and outcomes were reviewed. Active disease was defined by the National Institute of Health or/and the Mayo Clinic criteria. Results - Between 1994 and 2017, 51 patients with Takayasu’s Arteritis underwent open noncardiac vascular surgery. Forty-four patients (86) were female with a mean age of 38 years (range 10-72 years). At the time of surgery 36 patients (77%) were on steroids, with 23 patients (49%) taking an additional immunomodulate pharmaceutical. Twenty patients (42%) had required prior vascular interventions. Six patients (13%) had an additional autoimmune disorder diagnosed previously. The most common location for disease was the aorta (86%) with the subclavian (80%), carotid (69%), innominate (41%), and the renal (33%) arterial lesions also seen. Vascular reconstruction was performed on 82 arterial lesions. The most common locations requiring reconstruction was the carotid artery (28%) followed by the subclavian (22%), aorta (15%) and renal arteries (11%). Mean follow-up was 74 months (range 1-265 months). Early complications (less than 30 days) occurred in 14 patients (31%). Late complications (greater than 31 days) occurred in 22 patients (49%). There were two perioperative mortalities (4%). Eighteen patients (40%) required endovascular and/or surgical reintervention. The primary and primary assisted patency were 72% and 89% respectively. Seventeen patients (35%) had active disease at the time of surgery and three (18%) of these patients developed graft occlusion and underwent revision. Six patients (35%) with active disease required eight additional graft related re-interventions. Thirty-one patients (65%) had quiescent disease with three (10%) of patients occluding their reconstruction follow-up. Four patients (13%) with quiescent disease required four additional graft related re-interventions. The incidence of graft related re-interventions was higher on patients with active disease (p<0.05). Erythrocyte sedimentation rate (ESR) demonstrates a sensitivity rate of 29% with a positive predictive valve of 63% in active disease. 71% of patients with active disease had a normal ESR. Conclusion - The outcome of the intervention appears to be related to the presence of active disease. Patients with active disease had worse graft related outcomes compared to patients with quiescent disease. Normalized ESR is not a good predictor of quiescent disease.