Stent-based percutaneous intervention (PI) strategies can safely treat most vascular lesions in patients with Takayasu arteritis (TAK), a new study suggests, contrary to prior TAK treatment guidelines.
The study also suggests that repeated treatment of restenotic lesions substantially increases the success rate in patients with TAK.
These data were reported by George Joseph, DM, of Christian Medical College, Vellore, India, and colleagues in a review published Monday online and in the Jan. 3/10 issue of Journal of the American College of Cardiology.
TAK is a rare condition that effects the aorta and its surrounding arteries and branches. Lesions are the primary cause of morbidity and mortality in TAK. The current guidelines suggest that patients not undergo PI or open surgery to reduce the symptoms and risks associated with TAK, instead recommending medical therapy except in serious or life-threatening cases.
This study focused on various unresolved PI outcomes and issues — such as the role of cutting balloons and drug-eluting stents and management of restenosis — in patients who received PI for TAK.
TAK PI procedures were recorded at one facility in India from 1996 to 2022 and retrospectively analyzed. Immunosuppressive therapy was used before and after the procedure for most patients. Deflazacort was the primary steroid given for the first line of immunosuppressive treatment. Elective stenting, balloon angioplasty or cutting-balloon angioplasty were used to treat TAK obstructive lesions. Covered stents or endografts were used to treat aneurysms and spontaneous aortic dissections.
PI was used to treat 2,365 stenoses or occlusions and 85 aneurysms or dissections in 942 patients. The median age of the patients was 28 years (range = 21-38). Female patients made up 74.7% of the participants. American College of Rheumatology criteria were met in 85.5% of patients, 99.4% of patients met clinical criteria, 17.5% of patients had coronary involvement and 18.5% of patients had pulmonary involvement. Some clinical features included carotidynia (7.4%), neurologic symptoms (39.3%), upper- and lower-limb claudication (40.8%, 27.3%), mesenteric ischemia (6.8%) and abortions (3.4%).
The study included 3,805 PIs performed on 2,450 arterial lesions in 942 patients. There were 630 subclavian or axillary arterial lesions, 586 renal, 463 aortic, 333 carotid, 188 mesenteric, 116 iliac, 71 coronary and 63 other arteries. Early success was seen in 92.3% of patients, while 84.5% of 1,272 had late success with a follow-up median of 39 months.
PIs that were repeated for obstructive lesions increased late success from 48.6% to 83.3%. Out of the 1,687 lesions that were stented electively, 88% had late success, with 1.49 PIs per lesion. Covered stents (1.18 PIs per lesion) restenosed less than bare stents (1.51 PIs per lesion, P < 0.001). Of the 513 lesions treated with balloon angioplasty, 36% had good outcomes in 36% without adjunctive stenting. Of the 122 lesions treated with cutting balloon angioplasty, 19% had dissections and 8% had ruptures or pseudoaneurysm formations. Aneurysms or dissections had late success after PI in 91.3% of lesions. Complications occurred in 17% of lesions, and 79% were fixed.
The investigators concluded that even major vascular lesions associated with TAK can be treated with PI procedures, and the outlook for patients with TAK can be greatly improved with the use of stent-based intervention and lesion-specific strategies.
In an accompanying editorial, Neeraj Dhaun, MBChB, PhD, of the British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Scotland, and colleagues discussed the setbacks of current TAK treatment and the progress in the research presented by Joseph and colleagues.
The editorialists acknowledged that this study included many more PI procedures than previous studies, and the outcomes provided a positive outlook for TAK patients.
“Repeat PI procedures were associated with a 6-fold lower complication rate than the primary procedure, suggesting that this practice might be adopted relatively safely. The authors point out that restenosis should not be considered a failure, but rather an opportunity to perform a repeat PI in order to attain the desired result. Perhaps, in prior studies, the interventionists gave up too early, explaining the poor outcomes,” Dhaun and colleagues wrote.
The editorialists went on to note that this study gives solid evidence for future clinical practice in treating TAK, but more studies are needed to define the management of these procedures.
“While such an undertaking might have been unthinkable even 10 years ago (at a time when there had been no randomized clinical trials in TAK at all), the scope of the work presented here by Joseph et al gives hope that such a study may now be possible,” the editorialists said.
Joseph G, Thomson VS, Attumalil TV, et al. Outcomes of Percutaneous Intervention in Patients With Takayasu Arteritis. J Am Coll Cardiol 2023;81:49–64.
Dhaun N, Pugh D, Youngstein T. Percutaneous Intervention in Takayasu Arteritis: Potential Advantages of Procedural Perseverance. J Am Coll Cardiol 2023;81:65–67.
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