Carotid artery stenting in Takayasu arteritis – Intermediate term follow up
Carotid angioplasty and stenting are increasingly becoming a safe and efficacious modality of treatment in the management of carotid artery stenosis. Although atherosclerosis is the predominant cause of this morbid disease, Takayasu arteritis assumes special importance in south-east Asia. The diffuse nature of this disease with associated inflammation and scarring of the vessel make revascularisation difficult. We report a case of Takayasu arteritis in which a successful bilateral common carotid stenting was done in a single sitting.
The success of carotid angioplasty and stenting continue to be fraught with the risks of transient ischemic attacks, strokes and distal embolization. The risks are even greater when the disease is bilateral. Bilateral carotid stenting in our patient of Takayasu arteritis was done successfully with excellent symptomatic and angiographic results. The single stage procedure reduced the cost of therapy, avoided repeated trauma to the femoral vessel, decreased the need and cost of repeated hospitalizations, and ensured complete revascularization.
A 32-year-old female presented with a two-month history of repeated episodes of giddiness and presyncope. She had to worsen symptoms on walking or getting up from lying position. She had no syncope but had one epidose of transient blurring of vision during an episode of giddiness. The vision improved spontaneously in less than a minute. She had no fever or arthralgia. On examination she was afebrile. She had absent pulsations in both upper limbs, a weekly palpable left carotid artery and bruit in both the subclavian arteries and left common carotid artery. Her hemoglobin was 12.8 gm% and erythrocyte sedimentation rate (ESR) of 42 mm in the first hour. Liver and kidney functions tests were normal. Blood pressure in the lower limbs was normal (140/80 mmHg). There was no renal bruit. The electrocardiogram and chest x-rays were also normal. Angiography using a 6F Judkins Right catheter revealed normal ascending aorta and the arch. The right subclavian was totally occluded just beyond the origin of the vertebral artery, which itself had a 60% stenosis at its ostium. The left subclavian was totally occluded in its proximal portion with only a thin antegrade flow in the vertebral artery. The left common carotid artery was diffusely diseased with a uniformly narrow lumen from ostium to its bifurcation. There was 90% occlusion just after the ostium and 99% stenosis just before the bifurcation. The internal carotid artery (ICA) was faintly seen and the external carotid artery (ECA) and its branches were not seen [Figure 1a] and [Figure 2a]. The right common carotid artery had a 70% stenosis just before its bifurcation [Figure 3a]. She was given prednisolone, 80 mg/day for 6 weeks, along with aspirin (325 mg/day). The ESR fell to 16 mm in the first hour. She was taken up for an angioplasty and stenting of both the carotid arteries was done. Ticlopidine was started 2 days prior to the procedure. A percutaneous femoral access was achieved with a 9Fr sheath. 8Fr Judkins right guiding catheter was used to hook the ostium of the left carotid artery. A 0.014 inches extra support wire was used to cross the lesion and guided into the ICA. Multiple tandem balloon dilatations were given with a 3.0x20 mm coronary balloon. This wire was then exchanged with a 0.018 inches roadrunner guide wire and multiple dilatations were given extending right from the ostium to the bifurcation. Subsequently, an 8x40 mm easy wall stent (Schneider, Minneapolis, Minnesota) was deployed in the left CCA, starting just beyond the origin of the left ICA. As this stent failed to cover the proximal tight lesion, a second 8x20 mm Symphony stent was deployed at the ostium. Subsequently, dilatation was done with a 6x20 mm balloon, within the stent for obtaining an optimal result. The angiogram showed a complete reconstruction of the left CCA extending right from its ostium up to the ICA [Figure 1b] and [Figure 2b]. The ECA and its branches were also well seen with a normal caliber and flow.
The right carotid artery was then hooked with a Judkins right 8Fr guiding catheter and taken to the base of the lesion in the right CCA. A 0.018 inches Roadrunner guide wire was passed across the lesion into the ICA. A direct stenting of the lesion was done using an 8x20 mm easy wall stent (Schneider, Minneapolis, Minnesota). The stent had a small waist at the site of the lesion so it was post-dilated with a 6 x20 mm balloon. There was no residual stenosis with the good distal flow in both the ICA and the CCA [Figure 3b]. Throughout the procedure, the patient was given heparin to maintain the activated coagulation time (ACT) between 250 to 300 seconds. The femoral sheath was removed after five hours when the ACT fell below 180 seconds. The patient was continued on aspirin and ticlopidine. She completely recovered from her symptoms of dizziness and presyncope.
Takayasu arteritis is a chronic inflammatory disorder of unknown etiology involving the aorta and its branches leading to narrowing and occlusion of the vessels. Lesions are often bilateral and not infrequently involving the ostium, producing irregularity, stenosis or even total occlusion. Unlike atherosclerotic lesions, the vessels are firm, scarred, non-ulcerated and fibrotic. Takayasu arteritis is a common cause of carotid arteritis with its involvement in 6-69% patients.,, The left side is more commonly involved than the right. Patients usually present with transient ischaemic episodes, seizures, altered sensorium, syncope or loss of vision. Lupi et al showed that 6.8% of these patients developed hemiplegia and 4.5% had loss of vision at a mean follow up of 33.2+37 months. Cerebrovascular events contribute to 20% of the mortality in these patients.
The diffuse, ostial and multifocal involvement of the vessels in Takayasu arteritis makes revascularisation difficult in these patients. Carotid angioplasty and stenting, has emerged as a major therapeutic modality in the treatment of carotid artery stenosis. This percutaneous technique is safe, cost-effective and usable in patients with co-morbid risks. However, most of this data is limited mainly to patients with atherosclerotic carotid artery involvement. The experience with carotid angioplasty in Takayasu arteritis is limited to short series and case reports.,,, We have attempted carotid angioplasty and stenting in patients with Takayasu arteritis with excellent immediate and gratifying intermediate-term results. The long-term results are better if the disease activity is under control.
The presence of bilateral disease, contralateral occlusion and diffuse disease in carotid artery stenosis are associated with higher risk of neurological complications. Although such predisposing factors pose bigger challenges to the interventionalist, successful bilateral carotid stenting, has been reported recently. There are also reports of successful carotid stenting in the presence of a contralateral occlusion with minor complication rates. However, all these reports are in patients with atherosclerotic carotid artery involvement. We report the first case of a bilateral common carotid artery stenting in a patient with Takayasu arteritis, with the diffuse disease on one side and the procedure successfully completed in a single sitting. The single stage procedure cuts down the hospital costs, trauma to the femoral vessels dose of radiation and contrast media used.
Carotid artery stenosis is a common presentation of Takayasu arteritis. Carotid angioplasty and stenting is an excellent modality of therapy for these patients. Although the risks in a patient with the diffuse and bilateral disease are high, it is likely that this percutaneous approach may be a viable mode of therapy for such patients also.
Bali HK, Bhargava M, Banerjee S. Bhatta YK, Sharma BK. Carotid artery stenting in Takayasu arteritis – Intermediate term follow up. ISHR abstracts 2001: P-113.