TOI 8. Takayasu Arteritis: Panarterial Involvement: A Challenge to Offer Cure as a Vascular Surgeon

Abstract

Takayasu arteritis is a rare disease. We report a case of Takayasu arteritis in a patient who was being treated for a long time for uncontrolled hypertension without proper investigation, which resulted in a cerebrovascular accident twice. A 38-year-old woman with known comorbidities of hypertension and cerebrovascular accident, with a history of 11 abortions as a consequence of uncontrolled blood pressure, was diagnosed with Takayasu arteritis after extensive workup. She presented with claudication of the left upper arm for 16 months. On examination, significant pressure difference was noted in the arms. The right carotid was weakly palpable. No pulse was palpable in the left arm. Bilateral pulses in the lower limb had decreased volume. Laboratory workup showed the following: RA factor, nonreactive; lupus anticoagulant, negative; anticardiolipin immunoglobulin G, normal; anticardiolipin immunoglobulin M, normal; deranged protein C level, 173%; antinuclear antibody anti-double-stranded DNA, negative. Echocardiography showed mild left ventricular hypertrophy, normal-size ventricles, and ejection fraction of 60%. Magnetic resonance imaging of the brain showed ischemic infarcts in the right frontal lobe and basal ganglia and mild beaded appearance of vessels of the anterior and posterior circulation. Computed tomography angiography of the thoracic aorta showed total occlusion of the right common carotid artery and severe diffuse stenosis of the left common carotid artery, total occlusion of the left subclavian artery, and aberrant right subclavian artery. Digital subtraction angiography through the right femoral artery approach showed multiple atherosclerotic changes of the infrarenal aorta and weak common iliac bifurcations, with inability to negotiate the catheter upward; we then took the right brachial approach, which showed multiple atherosclerotic changes of the arch of the aorta, nearly complete occlusion of the left subclavian artery, dual supply of both kidneys, multiple collaterals from superior and inferior mesenteric arteries, and nearly complete obstruction of the infrarenal aorta. Left subclavian artery balloon angioplasty was done with good flow to the radial artery. Takayasu arteritis is a chronic idiopathic, granulomatous, systemic disease requiring long-term follow-up. Clinical presentation is from asymptomatic to pulselessness and ischemia. Providing cure to patients with such extensive disease is a dilemma.