Axillobifemoral bypass for total abdominal occlusion secondary to Takayasu's arteritis: A case report

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University of Groningen

Axillobifemoral bypass for total abdominal occlusion secondary to Takayasu's arteritis

Jiménez-Zarazúa, Omar; Vélez-Ramírez, Lourdes Noemí; Martínez-Rivera, María Andrea;

Hernández-Ramírez, Abraham; Palomares-Anda, Pascual; Alcocer-León, María;

Becerra-Baeza, Angélica Monserrat; Mondragón, Jaime D

Published in:

International journal of surgery case reports

DOI:

10.1016/j.ijscr.2019.07.031

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Jiménez-Zarazúa, O., Vélez-Ramírez, L. N., Martínez-Rivera, M. A., Hernández-Ramírez, A.,

Palomares-Anda, P., Alcocer-León, M., Becerra-Baeza, A. M., & Mondragón, J. D. (2019). Axillobifemoral bypass for

total abdominal occlusion secondary to Takayasu's arteritis: A case report. International journal of surgery

case reports, 61, 147-152. https://doi.org/10.1016/j.ijscr.2019.07.031

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Contents lists available atScienceDirect

International

Journal

of

Surgery

Case

Reports

j o u r n a l h o m e p a g e :w w w . c a s e r e p o r t s . c o m

Axillobifemoral

bypass

for

total

abdominal

occlusion

secondary

to

Takayasu’s

arteritis:

A

case

report

Omar

Jiménez-Zarazúa

a,b

_,

_Lourdes

_Noemí

_{Vélez-Ramírez}

b,c

_,

María

Andrea

Martínez-Rivera

a,b

_,

_Abraham

_{Hernández-Ramírez}

c

_,

Pascual

Palomares-Anda

d

_,

_María

_{Alcocer-León}

b,e

_,

_Angélica

_Monserrat

_{Becerra-Baeza}

b

_,

Jaime

D. Mondragón

f,g,∗

a_Hospital_General_León,_Department_of_Internal_Medicine,_Mexico b_Universidad_de_Guanajuato,_Department_of_Medicine_and_Nutrition,_Mexico c_Hospital_General_León,_Department_of_Radiology,_Mexico

d_Hospital_General_León,_Department_of_Hematology,_Mexico

e_Hospital_Regional_ISSSTE_León,_Department_of_Internal_Medicine,_Mexico

f_University_of_Groningen,_University_Medical_Center_Groningen,_Department_of_Neurology,_the_Netherlands g_University_of_Groningen,_University_Medical_Center_Groningen,_Alzheimer_Research_Center,_the_Netherlands

a

r

t

i

c

l

e

i

n

f

o

Articlehistory: Received23May2019

Receivedinrevisedform11July2019 Accepted12July2019

Availableonline19July2019

Keywords:

Axillobifemoralbypass Casereport

Takayasu’sarteritis Totalabdominalocclusion

a

b

s

t

r

a

c

t

INTRODUCTION:Takayasu’sarteritis(TA)isararediseasethatmainlyaffectslargearteries. Approxi-mately20%ofTApatientswillrequiresurgicalinterventionsecondarytoarterialcomplicationssuchas intermittentclaudication,persistenthypertensionrefractorytotreatment,andheartfailure.

PRESENTATIONOFCASE:Thecaseofa22-year-oldfemalewithTAofﬁveyearsofevolutionispresented. Thepatientdeterioratedclinicallyafterﬁveyearsofcorticosteroidandimmunosuppressantmanagement requiringsurgicalinterventionwithanaxillobifemoralbypassforatotalabdominalocclusion.Onset, pre-surgicalandpost-surgicalDopplerultrasonographyaswellasabdominalangiotomographiesdocument andcorroboratethepatient’sclinicalandhemodynamicimprovement.

DISCUSSION:VerylimitedliteratureexistsregardingsurgicalinterventionsforTApatients.Whilemost reportedcasespresentanendovascularsurgicalmanagement.Opensurgicalprocedureshavelowerrates ofrestenosisthanendovascularmanagement.Althoughendovascularmanagementislessinvasivethan extra-anatomicalaxillobifemoralbypass,thepatientwasnotacandidateforendovascularstentgraft placementduetotheincreasedriskforvascularinjuryandsubsequentperforation.Approximatelya ﬁfthofTApatientsarecandidatesforsurgicalinterventionovertime.

CONCLUSION:VascularsurgeryinTAcasesbecomesanoptionwhenthepatientdoesnotimprove clinicallyafteradministrationofmedicaltreatment.Althoughendovascular managementhasfewer complications,therateofrestenosisishigher.Patientsatriskofrestenosisandwhohaveincreased perioperativevascularriskcanbeneﬁtfromopensurgicalprocedures.Surgicalmanagementshouldbe tailoredtothepatient’sneeds.

1. Introduction

Takayasu’sarteritis (TA)is a chronic,inflammatory, granulo-matous,idiopathicdiseasethataffectsarteriessuchastheaorta anditsramifications,aswellasthepulmonaryartery[1,2]. Arte-rialvasculitisinTAischaracterizedbybothdilationandstenosis. Histopathological findings include a panarteritis which shows inflammationaroundthevasorumvesselaswellasthe

adventi-∗ Correspondingauthorat:UniversityMedicalCenterGroningen,Departmentof Neurology,POBox30001,9700RBGroningen,theNetherlands.

E-mailaddress:j.d.mondragon.uribe@umcg.nl(J.D.Mondragón).

tia,withaperivascularmononuclearinﬁltrate,composedmainlyof CD4+/CD8+lymphocytes,plasmacells,andmacrophages[1].TAis ararediseaseanditismoreprevalentinCentralandSouth Amer-ica,Africa,India,andtheFarEast[3].TAhasaprevalenceinthe Japanesepopulationof0.004%andayearlyincidenceofbetween 0.7–4.7casespermillion[3–6].

TheclinicalpresentationassociatedwithTAisunspeciﬁc. Symp-tomscanrangefromconstitutionalsymptoms(e.g.fatigue,fever, andweightloss)toclaudication,cephalalgia,syncope,angina pec-toris,andabdominalpainwhichareassociatedtovascularterritory affectedbythearteritis[6,7].Althoughthereisnoimagingor lab-oratorygoldstandardswithadequatesensitivityofspeciﬁcityfor TA,theAmericanCollegeofRheumatologyandIshikawadiagnostic https://doi.org/10.1016/j.ijscr.2019.07.031

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148 O.Jiménez-Zarazúaetal./InternationalJournalofSurgeryCaseReports61(2019)147–152 criteriaarethemostwidelyadoptedcriteria[7–9].Thesecriteria

incorporateageat diseaseonset, muscular and arterial tender-ness,claudication,pulsecharacteristics,bloodpressuredifferences, ﬁndingsrelatedtoarterialauscultation,arteriogramﬁndings,and echocardiographicalterations[8,9].While20%ofTApatientshave aself-limiteddiseaseprogression,upto20%willrequiresurgical interventionsecondarytoarterialcomplications[7].Intermittent claudication,persistenthypertensionrefractorytotreatment,and heartfailureareamongthemostcommonindicationsforsurgical interventioninTA[10].

WepresentthecasereportinlinewiththeSCAREcriteria[11] ofa patientwithTA treatedin a universityhospital,who after ﬁveyearsofcorticosteroidandimmunosuppressantmanagement deterioratedclinicallyrequiringsurgicalinterventionwithan axil-lobifemoralbypassforatotalabdominalocclusion.Verylimited literatureexistsregardingsurgicalinterventionsforTApatients. Thiscasecontributes totheexistingliteraturewithasuccessful surgicalcasethatdocumentedthroughvariousimagingmodalities apatientforoverﬁveyears.

2. Casepresentation

A 22-year-oldfemale arrived at theEmergency Department presentingclaudicationwhenwalkinglessthan300maswellas increasedparesthesiaand dysesthesia inboth pelviclimbs.The claudication,paresthesia,anddysesthesiabeganﬁveyearsearlier. Atthetime of onset, theclaudicationwas bilateralafter walk-ing approximately 1500m with improvement after rest, while theparesthesia and dysesthesia werebilateraland involved all fourextremities. At that time, the patient wasdiagnosed with Takayasu’sarteritis(TA) bytheRheumatologydepartmentfrom this institution based on immunological proﬁle (i.e. rheuma-toidfactor,antinuclearantibodies,anticardiolipinantibodies,and antineutrophilcytoplasmicantibodies(ANCA),theAmerican Col-legeofRheumatologyandIshikawacriteria.[8,9]Sixmonthsprior tothepatient’svisittothishospital,claudicationprogressed(i.e. reductioninthedistanceabletowalkto500m,increasing pares-thesia and dysesthesia frequency).The patienthad no relevant familyandpersonalnon-pathologicalhistorytohercurrent condi-tion.Thepatientdeniedtheuseofcontrolledsubstances,allergies, pastbloodtransfusions,travelingtoregionswithendemicdiseases withinthelastthreemonths,tattoosandbodypiercings.

Uponinitialphysicalexamination,wefoundapatient recum-bentwithfreelychosenbodyposition,Glasgowcomascoreof15, withoutfocal neurologicdeﬁcitsnormeningeal sings,aware of hisenvironment, withreferencetoplace,time,andpeople.The patient’sintegumentarysystemwashydratedandwithout alter-ations,whiletheheadandneckexplorationhad noalterations. Uponinspection,palpation,andpercussionthecardio-respiratory systemandabdomenhadnoabnormalﬁndings.Precordial aus-cultation revealed tachycardia, but no aggregate phenomena. AbdominalauscultationrevealedasystolicmurmurgradeIII/IVat themesogastrium.Rightupperlimbexplorationrevealednormal axillar,humeral,andradialpulses(i.e.presenceofrhythmic,with normalintensity+++/+++, normalamplitude, andhavinga syn-chronousfrequencywithheartrate).Therightulnararterypulse wasabsent.Uponleftupperlimbexploration,palpationshowed thepresenceofnormalaxillarandhumeralpulses;whileradialand ulnarpulseswereabsent.Lowerlimbexplorationshowedabsence ofbilateralfemoral,poplitealandposteriortibialpulses.Theskin presentedcyanoticappearance,especiallyofthetoesofbothfeet. Uponpalpation,reducedskintemperaturewasnoticedandabsence ofedema.Uponadmission,thepatienthadthefollowingvitalsigns: bloodpressure100/70mmHgintherightarm,80/60mmHginthe leftarm,bloodpressureintherightlegandtheleftlegwerenot

detectable;heartrate85bpm;respiratoryrate17rpm; tempera-ture36◦C;weight65kg;height167cm;bodymassindex23.3kg/m [2].LaboratoryresultsatadmissionarepresentedinTable1andthe follow-uplaboratoryresultsinTable2.

Table1

LaboratorytestresultsuponadmissiontheEmergencyDepartment.

FullBloodCount

Hemoglobinatadmission 14.5g/dL

Hematocrit 44.5%

Erythrocytecount 5300␮L

Plateletcount 296,000␮L

Meancorpuscularvolume 85fL

Meancorpuscularhemoglobinconcentration 27.30g/dL

Leukocytecount 9200␮L Lymphocytes 18.8% Neutrophils 69.9% Monocytes 9.1% Eosinophils 2.1% Basophils 0.1% BloodChemistry Glucose 88mg/dL Albumin 2.42gr/dL Ureanitrogen 0.60mg/dL

Bloodureanitrogen 12.9mg/dL

Uricacid 3.6mg/dL

Cholesterol 130mg/dL

Triglycerides 140mg/dL

LiverFunctionEnzymes

Aspartatetransaminase 9U/L

Alaninetransaminase 12U/L

Lactatedehydrogenase 10U/L

Albumin 3.5mg/dL

Alkalinephosphatase 66.8U/L

Gamma-glutamyltranspeptidase 10U/L BloodCoagulation

Prothrombinetime 18Sec

Partialthromboplastintime 40Sec Internationalnormalizedratio 1.36 Electrolytes Sodium mEq/dL Potassium mE/dL Chlorine mEq/dL Calcium mg/dL Phosphorus mg/dL Magnesium mEq/dL Table2

Complementarylaboratorytestresults. Follow-up

Immunologicalassay

Anti-double-strandeddeoxyribonucleicacid 0.9UI/mL Anti-cardiolipinIgG 1.0UI/mL Anti-cardiolipinIgMantibody 3.0UI/mL Erythrocytesedimentationrate 15mm/h

C-reactiveprotein 3.80mg/dL

Viralassay

HepatitisBvirus Negative

HepatitisCvirus Negative

Humanimmunodeﬁciencyvirus Negative Urinalysis

Appearance Crystalline

pH 6.5

Speciﬁcgravity 1.020

Proteins 30mg/dL

Ketones,glucose,andnitrite Negative

Leukocytes 2perhighpowerﬁeld

Erythrocytes 3perhighpowerﬁeld

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Fig.1.Abdominalangiotomographyshowingaorticandmultiplevesselstenosesatthetimeofdiagnosis.A)Coronalreconstructionshowingemergenceofaorticartery 27mmfromtherenalarterieswithstenosissuperiorto50%.Thelengthofthestenosisofapproximately64mm(markedbyarrow).B)Coronal3-Dreconstruction.Multiple collateralarteriesarepresentwithaprominentanddilatedarcofRiolanwithvascularredistributiontotheiliacarteries.Stenosismarkedbyarrow.

3. Clinicalhistory

Duringinitialsymptomonset(i.e.ﬁveyearspriortothis hospi-taladmission)thepatienthadabsentleftupperlimbdistalpulses (i.e.radialandulnarpulse).Therightupperlimbpulses(i.e. axil-lar,humeral,ulnar,andradial)andleftaxillarandhumeralpulses hadwerepresent,rhythmic,withnormalintensity(i.e.+++/+++), andhavingasynchronousfrequencywithheartrate.Lowerlimb explorationshowednormalleftlimbpulses(i.e.femoral,popliteal, posterior tibial and dorsal pedis) and decreased right femoral (i.e.present, decreased frequency and amplitude,and intensity ++/+++),rightpopliteal(i.e.present,rhythmic,intensity+/+++,and decreasedamplitude)pulsesandabsentrightlimbdistalpulses(i.e. posteriortibialanddorsalispedis).

During theinitialonset, thepatientunderwent pulsed-wave Doppler ultrasonography(i.e. spectral) of the lower limbs.The reported arterial blood flow velocities of the common femoral artery, right superficial femoral artery, left superficial femoral artery,rightpoplitealartery,andleftpoplitealarterywere dimin-ishedandarefoundinTable3.Thewaveformwasmonophasicwith adampenedpatterncompatiblewithabilateralfemoropopliteal insufficiency.Dopplerultrasonographyoftheabdominalaortahad a50%diameterreductionbelowtherenalarterieslevel.An abdom-inalangiotomographyreportedaorticandmultiplevesselstenoses (Fig.1a).

Initialtreatmentwasprednisone50mgorally(peros,PO)every (quaque,q)24h, methotrexate20mgPO q7days,and folicacid 10mgPOq7d.Aftersixmonthsandclinicalimprovementthe pred-nisonedosewasadjusted(i.e.prednisone7.5mgPOq24h)fortwo years.Afterwithstandingaboutofpurpuricpigmented dermato-sisthedoseofprednisonewasadjustedto15mgPOq7dandtopic clioquinolandclindamycinfortwoweekswasadministered.

4. Clinicalevolutionandsurgicalmanagement

Transesophageal echocardiography (TEE) was performed to assesspresenceaorticrootabnormalities.TheTEEreportedaleft

Table3

Bloodﬂowvelocitiesattimeofdiagnosis.

Anatomicalregion Velocity(cm/sec)

Upperlimbs Right Left

Axillaryartery 77 87

Proximalsegmentbrachialartery 76 82 Middlesegmentbrachialartery 70 75 Distalsegmentbrachialartery 62 51 Proximalsegmentradialartery 45 37

Distalsegmentradialartery 31 35

Proximalsegmentulnarartery 43 33

Distalsegmentulnarartery 42 33

Abdominalaorta

Suprarenalsegment 160

Infrarrenalproximalsegment 253 Infrarrenaldistalsegment 288

Externaliliacartery 230 153

Lowerlimbs Right Left

Commonfemoralartery 36 25

Proximalsegmentsuperficialfemoralartery 21 16 Middlesegmentsuperficialfemoralartery 17 15 Distalsegmentsuperficialfemoralartery 13 11

Poplitealartery 12 11

Proximalsegmentanteriortibialartery 12 19 Middlesegmentanteriortibialartery 12 6 Distalsegmentanteriortibialartery 7 7 Proximalsegmentposteriortibialartery 10 10 Middlesegmentposteriortibialartery 8 6 Distalsegmentposteriortibialartery 10 8 Proximalsegmentﬁbularartery 7 13

Middlesegmentﬁbularartery 6 7

Distalsegmentﬁbularartery 6 6

ventricularejectionfractionof66%,withoutthepresenceof intra-cavitarythrombi.Supra-aorticDopplerultrasonographyrevealeda tardus-parvuswaveformattherightvertebralarterysuggestiveof stenosisattherightsubclavianartery.Therightcommoncarotid arteryshowedahyperechoicimage(i.e.22mmx3mm) compati-blewithanatheroma,withoutreductionofbloodﬂowvelocity(i.e. 20cm/secand30%stenosis).Anabdominalangiotomographywas performed,reportingirregularwallthickeningoftheabdominal aortawitha5.8cmextension(i.e.originatingbelowtheemergence

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150 O.Jiménez-Zarazúaetal./InternationalJournalofSurgeryCaseReports61(2019)147–152

Fig.2. Post-surgicalabdominalangiotomographyshowingapermeableaxillobifemoralprostheticgraft.AandB)3-Dreconstructioncomputedtomography.

ofthesuperiormesentericarteryandextendingtothebifurcation oftheiliacarteries)andbothiliacarteriespresentedatotal occlu-sionofapproximately4.3cm(Fig.1aandb).However,thearcof Riolanwaspermeableinitsentirety(Fig.1b).

Extra-anatomicalrevascularization was performed, withthe placement of an 8mm axillobifemoral poly-tetraﬂuoroethylene (PTFE)-basedprostheticgraft.Steriletechniquewasprocuredat alltimes.Thevascularaccessfortheprostheticgraftplacement wastheleftinfra-clavicularregion,witharightfemoral end-to-end anastomosis.The graftwas tunneled subcutaneouslyalong themidaxillarylinetopreventgraftentanglementdue totorso ﬂexion.Upperandlowerlimbpulseswerepresentafterarterial unclamping.Minimal hemorrhage (i.e. less than 400cc)and no complicationswerereportedduringandaftersurgery. Seventy-twohoursaftertheprocedurethepatientwasdischargedfromthe hospitalwithclinicalimprovement.

Twoweeksafterthesurgicalprocedurethepatientwas clini-callyevaluated.Thepatientreportedsymptomimprovement(i.e. paresthesia,dysesthesia,andclaudication).Uponphysical exami-nation,bothinferiorlimbshadfemoral,popliteal,posteriortibial, anddorsalpedispulsespresent,symmetric,rhythmic,withlow amplitude,intensity++/+++,andinsynchronywiththeheartrate. Theskinshowednodistalcyanosis,temperaturechangesoredema. Thepatientunderwentpulsed-waveDopplerultrasonographyof thelowerlimbswithadequatebloodﬂow.Apost-surgical abdom-inalangiotomographywasperformedwhichshowedapermeable axillobifemoralprostheticgraft(Fig.2).Thepostoperativeblood ﬂowvelocitiesarereportedinTable4.Thepatientwasmanaged withprednisone10mgPOq24handrivaroxaban20mgPOq24h, withoutreportingadverseeffects(i.e.3monthspost-surgery).

5. Discussion

We present thecase report of a patientwithTA, who after ﬁveyearsofcorticosteroidandimmunosuppressantmanagement deterioratedclinicallyrequiringsurgicalinterventionwithan

axil-Table4

Post-operativebloodﬂowvelocitiesofmajorlowerextremityarteries.

Anatomicalregion Velocity(cm/sec)

Lowerlimbs Right Left

Commonfemoralartery 44 44

Proximalsegmentsuperficialfemoralartery 27 29 Middlesegmentsuperficialfemoralartery 23 25 Distalsegmentsuperficialfemoralartery 18 22

Poplitealartery 16 20

Proximalsegmentanteriortibialartery 14 19 Middlesegmentanteriortibialartery 10 13 Distalsegmentanteriortibialartery 9 11 Proximalsegmentposteriortibialartery 16 12 Middlesegmentposteriortibialartery 14 10 Distalsegmentposteriortibialartery 13 9 Proximalsegmentﬁbularartery 10 12

Middlesegmentﬁbularartery 8 9

Distalsegmentﬁbularartery 7 7

lobifemoralbypassforatotalabdominalocclusion.Verylimited literatureexistsregardingsurgicalinterventionsforTApatients. Mostreportedcasespresentendovascularsurgicalmanagement. Althoughendovascularmanagementislessinvasivethan extra-anatomicalaxillofemoralbypass,thepatientwasnotacandidate forendovascularstentgraftplacementduetotheincreasedriskfor vascularinjuryandsubsequentperforation.Consideringtheageof thepatient,22-years,openaorticrepairisthepreferredoptionand consideringthataxillobifemoralbypasssurgeryhasthesame long-termpatencyregardlessofage,astrongargumentcanbemadethat thisprocedureshouldbeavoidedinyoungerpopulations.However, duetothepatient’soverallﬁtnessandafterapreoperative assess-mentfromtheInternalMedicineandAnesthesiologydepartments aconsensuswasreachedbetweenthesetwodepartmentsandthe Surgerydepartment(i.e.thepositionofthesurgicalteamwasto performanaorticrepair)thatopenaorticrepairwasnota suit-ableprocedureduetothehighintraoperativerisk.Theleftaxillary arterywaschosenasinﬂowvesselovertherightevenafterhaving lowersystolicbloodpressurebecausetherightsubclavianartery

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hadDopplerultrasonographyﬁndingssuggestiveofstenosisand nodistalaorticarchorleftsubclavianarterystenosiswasdetected throughthesameprocedure.Thiscasecontributestotheexisting literaturewithasuccessfulsurgicalcasethatdocumentedthrough variousimagingmodalitiesapatientforoverﬁveyears.

Vascular surgery in TA cases becomes an option when the patientdoesnotimproveclinicallyafteradministrationofmedical treatment. Corticosteroids are the mainstay of the therapeu-tic management for TA, while immunosuppressant drugs (e.g. azathioprine, methotrexate, cyclophosphamide,mycophenolate, tacrolimus,andleflunomide)arewidelyusedasmaintenance ther-apy[7].Furthermore,biopharmaceuticalssuchasinfliximaband etanerceptaretherapeuticoptionsforselectedcases[12,13].Over time abouta fifthof thepatientsrequire surgicalmanagement andendovascularalternativesarepreferredduetotheirless inva-siveness.Percutaneous transluminal angioplastyand stent-graft placementareamongtheendovascularoptionsavailableforTA, while surgical revascularization can be performed via surgical bypassgrafting,patchangioplastyforshort-segmentlesionsand endarterectomy[14].

Extra-anatomicalaxillofemoralbypasssurgeryisa procedure thatisperformedinotherpathologiessuchasaorticcoarctation, aortic aneurysm, aortoiliac occlusive disease, and TA. In 2004, a case similar to the one presented by our group successfully performedanaxillobifemoralbypassforatotalabdominalaorta occlusion [15]. Another example in the literature of successful axillobifemoral bypass in TA to treat both atypical coarctation andbrachiocephalicinvolvement[16].Thecasepresentedcanbe assessedasasuccessfulprocedurebasedonpost-surgicalclinical andimaginghemodynamicimprovement.Althoughno intraoper-ativeorperioperativecomplicationswerereported,theseinclude brachialplexusinjury,axillarypulloutsyndrome,graftthrombosis, delayedpseudoaneurysmofthegraft,andgraftinfection.Clinically thepatienthad detectablebilaterallowerextremity pulses,had reducedparesthesiaanddysesthesia,aswellasnotreporting clau-dicationduringthethreemonthsafterthesurgicalprocedure.The patientalsohadincreasedpost-surgicalvascularvelocitiesinboth lowerextremities,aswellasanabdominalangiotomographywith apermeableaxillobifemoralprostheticgraft.

6. Limitations

Diseaseactivityisakeyfactorthatinfluencesthedecisionto proceed withrevascularization. Both endovascularand surgical revascularizationshouldbeavoidedduringacuteTAdisease activ-ityasreocclusionandcomplicationsduringthesurgicalprocedure [17].Diseaseactivityisdefinedbyacombinationofclinicalsigns andsymptoms,laboratoryassessmentand vascularimaging[7]. Bothacutephase reactants,erythrocytesedimentationrate,and C-reactiveproteinareusefultomonitorTAdiseaseactivity; how-ever,ontheirown,theseserologicaltestsprovetobeinsufficient to assesTA disease activity [18]. Although thepatient did not haveimagingorlaboratoryindicatorsforacuteTAdisease activ-ity,activevasculitiscannotbecompletelydismissed.Amongthe twosurgicalapproaches, opensurgicalintervention hasalower riskfor restenosisthanendovascularproceduresasa late com-plication(i.e.10-yearfollow-up),witharateofrestenosisof37% versus62%,respectively[6,19–21].Anotherlimitationofthestudy istheexclusionofotherpossibledifferentialdiagnoses.Middle aor-ticsyndrome(MAS)couldnotbecompletelydismissedduetothe patient’syoungage.MAScanbeduetocongenitalsyndromes neu-rofibromatosis,mucopolysaccharidoses,Williamssyndromeand, Alagillesyndrome[22].Nogenetictestswereperformedonour patient,henceageneticcausecouldbetheetiologybehindthe aorticstenosis.

7. Conclusion

OneinﬁveTApatientsovertimebecomerefractoryto med-icaltreatment.Vascularsurgery isanoptionin theserefractory cases.Twotypesofsurgicalinterventionsareavailable endovas-cular and open surgical procedures. Among the endovascular optionsavailableforTAarepercutaneoustransluminalangioplasty and stent-graft placement, while surgical revascularization can beperformedviasurgicalbypassgrafting,patchangioplastyfor short-segmentlesionsandendarterectomy.Although endovascu-larmanagementhasfewercomplications,therateofrestenosisis higher.Patientsatriskofrestenosisandwhohaveincreased peri-operativevascularcanbeneﬁtfromopensurgicalprocedures.The surgicalmanagementshouldbetailoredtothepatient’sneeds, tak-ingintoaccounttheextensionofthelesion,availableresources,and thetreatingsurgeon’sexperience.

DeclarationofCompetingInterest

Theauthorsdeclarethattherearenoconﬂictsofinterest rele-vanttothiswork.

Sourcesoffunding

ThisstudywassupportedbyCONACyT(ConsejoNacionalde CienciayTecnología)Grant#440591(Dr.JaimeMondragón).This researchdidnotreceiveanyspeciﬁcgrantfromfundingagencies inthecommercialsector.

EthicalApproval

Approvalfromtheethicalcommitteewasnotrequireddueto thenatureofthiscasereport.AbidingbytheDeclarationofHelsinki, patientanonymitywasguaranteed.

Consent

Uponhospitaladmission,thepatientsignedaninformed con-sentpermittingtheuseofherclinicalﬁleinformationfordidactic andresearchpurposes.

Authorcontribution

Studyconceptanddesign:OJZ,JDM

Acquisitionofdata:LNVR,AHR,MAL,MAMR,AMBB Analysisandinterpretationofdata:OJZ,JDM,GAFS,PPA Criticalrevision ofthe manuscriptfor important intellectual content:Allauthors.

Allauthorsreadandapprovedtheﬁnalmanuscript.

RegistrationofResearchStudies

Alldatanecessaryfortheinterpretationofthiscaseisfoundin thetext.Nodatadepositoryor

registrywasused.

Guarantor

JaimeD.MondragonandOmarJiménez-Zarazúa

Provenanceandpeerreview

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152 O.Jiménez-Zarazúaetal./InternationalJournalofSurgeryCaseReports61(2019)147–152

Acknowledgements

ThisstudywassupportedbyCONACyT(ConsejoNacionalde CienciayTecnología)Grant#440591.

References

[1]M.Hotchi,PathologicalstudiesonTakayasuarteritis,HeartVesselsSuppl.7 (1992)11–17,PMID:1360954.

[2]Y.Seko,S.Minota,A.Kawasaki,Y.Shinkai,K.Maeda,H.Yagita,K.Okumura,O. Sato,A.Takagi,Y.Tada,etal.,Perforin-secretingkillercellinﬁltrationand expressionofa65-kDheat-shockproteininaortictissueofpatientswith Takayasu’sarteritis,J.Clin.Invest.93(2)(1994)750–758,http://dx.doi.org/ 10.1172/JCI117029,PMID:7906697.

[3]R.A.G.Russo,M.M.Katsicas,Takayasuarteritis,Front.Pediatr.6(2018)265,

http://dx.doi.org/10.3389/fped.2018.00265,eCollection2018.PMID: 30338248.

[4]C.Terao,H.Yoshifuji,T.Mimori,RecentadvancesinTakayasuarteritis,Int.J. Rheum.Dis.17(2014)238–247,http://dx.doi.org/10.1111/1756-185X.12309, PMID:24548718.

[5]R.Watts,A.Al-Taiar,J.Mooney,D.Scott,A.Macgregor,Theepidemiologyof TakayasuarteritisintheUK,Rheumatology.48(8)(2009)1008–1011,http:// dx.doi.org/10.1093/rheumatology/kep153,Epub2009Jun19.PMID: 19542212.

[6]E.Seyahi,Takayasuarteritis:anupdate,Curr.Opin.Rheumatol.29(1)(2017) 51–56,http://dx.doi.org/10.1097/BOR.0000000000000343,PMID:27748689. [7]E.S.H.Kim,J.Beckman,Takayasuarteritis:challengesindiagnosisand

management,Heart104(7)(2018)558–565,http://dx.doi.org/10.1136/ heartjnl-2016-310848,PMID:29175979.

[8]W.P.Arend,B.A.Michel,D.A.Bloch,G.G.Hunder,L.H.Calabrese,S.M. Edworthy,A.S.Fauci,R.Y.Leavitt,J.T.Lie,R.W.LightfootJr,etal.,TheAmerican CollegeofRheumatology1990criteriafortheclassiﬁcationofTakayasu arteritis,ArthritisRheum.33(8)(1990)1129–1134,PMID:1975175.

[9]K.Ishikawa,Diagnosticapproachandproposedcriteriafortheclinical diagnosisofTakayasu’sarteriopathy,J.Am.Coll.Cardiol.12(4)(1988) 964–972,PMID:2901440.

[10]C.Labarca,A.Makol,C.S.Crowson,Retrospectivecomparisonofopenversus endovascularproceduresfortakayasuarteritis,J.Rheumatol.43(2)(2016) 427–432,http://dx.doi.org/10.3899/jrheum.150447,PMID:26669920. [11]R.A.Agha,M.R.Borrelli,R.Farwana,K.Koshy,A.Fowler,D.P.Orgill,Forthe

SCAREGroup,TheSCARE2018statement:updatingconsensussurgicalCAse

REport(SCARE)guidelines,Int.J.Surg.60(2018)132–136,http://dx.doi.org/ 10.1016/j.ijsu.2018.10.028,PMID:30342279.

[12]G.S.Hoffman,P.A.Merkel,R.D.Brasington,D.J.Lenschow,P.Liang,Anti-tumor necrosisfactortherapyinpatientswithdifﬁculttotreatTakayasuarteritis, ArthritisRheum.50(7)(2004)2296–2304,http://dx.doi.org/10.1002/art. 20300,PMID:15248230.

[13]E.S.Molloy,C.A.Langford,T.M.Clark,C.E.Gota,G.S.Hoffman,Anti-tumour necrosisfactortherapyinpatientswithrefractoryTakayasuarteritis: long-termfollow-up,Ann.Rheum.Dis.67(11)(2008)1567–1569,http://dx. doi.org/10.1136/ard.2008.093260,PMID:18677012.

[14]R.Serra,L.Butrico,F.Fugetto,M.D.Chibireva,A.Malva,G.DeCaridi,M. Massara,A.Barbetta,M.Cannistrà,S.deFranciscis,Updatesin

pathophysiology,diagnosisandmanagementoftakayasuarteritis,Ann.Vasc. Surg.35(2016)210–225,http://dx.doi.org/10.1016/j.avsg.2016.02.011,PMID: 27238990.

[15]H.Kart-Koseoglu,A.E.Yucel,A.Tasdelen,F.Bovyat,Delayeddiagnosisof Takayasu’sarteritis:totalabdominalaortaocclusiontreatedwith axillo-bifemoralbypass,J.Rheumatol.31(2)(2004)393–395,PMID: 14760813.

[16]Y.Sugawara,K.Orihashi,K.Okada,K.Kochi,K.Imai,T.Sueda,Surgical treatmentofaorticcoarctationassociatedwithmulti-vesselbrachiocephalic involvementintakayasu’sarteritis,Ann.Thorac.Cardiovasc.Surg.9(3)(2003) 202–205,PMID:12875645.

[17]G.Keser,H.Direskeneli,K.Aksu,ManagementofTakayasuarteritis:a systematicreview,Rheumatology(Oxford)53(5)(2014)793–801,http://dx. doi.org/10.1093/rheumatology/ket320,Epub2013Oct4.PMID:24097290. [18]J.C.Mason,Takayasuarteritis–advancesindiagnosisandmanagement,Nat.

Rev.Rheumatol.6(7)(2010)406–415,http://dx.doi.org/10.1038/nrrheum. 2010.82,PMID:20596053.

[19]J.H.Jung,Y.H.Lee,G.G.Song,H.S.Jeong,J.H.Kim,S.J.Choi,Endovascular versusopensurgicalinterventioninpatientswithTakayasu’sarteritis:a meta-analysis,Eur.J.Vasc.Endovasc.Surg.55(6)(2018)888–899,http://dx. doi.org/10.1016/j.ejvs.2018.02.030,Epub2018Apr3.PMID:29622513. [20]A.H.Perera,J.C.Mason,J.H.Wolfe,Takayasuarteritis:criteriaforsurgical

interventionshouldnotbeignored,Int.J.Vasc.Med.(2013),618910,http:// dx.doi.org/10.1155/2013/618910,PMID:23986869.

[21]M.A.Qureshi,Z.Martin,R.K.Greenberg,Endovascularmanagementof patientswithTakayasuarteritis:stentsversusstentgrafts,Semin.Vasc.Surg. 24(1)(2011)44–52,http://dx.doi.org/10.1053/j.semvascsurg.2011.04.002, PMID:21718932.

[22]KunalKishorJha,ManojKumar,DurgeshPrasadChaudhary,TshristiRijal, Midaorticsyndrome,BMJCaseRep.2016(2016),http://dx.doi.org/10.1136/ bcr-2016-217139,PMID:27530885pii:bcr2016217139.

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