Stent treatment for pseudocoarctation and refractory hypertension in an elderly patient with Takayasu's arteritis
Anne-Paule Gimenez-Roqueplo1,
Elisabeth Tomkiewicz1,
Agnès La Batide-Alanore1,
Isabelle Moreau1,
Jean-François Paul2,
Alain Raynaud2 and
Pierre-François Plouin1
1 Hypertension Clinic and
2 Department of Vascular Radiology, Broussais Hospital, Paris, France
Correspondence and offprint requests to:
Dr A.-P. Gimenez-Roqueplo, Service d'Hypertension Artérielle, Hôpital Broussais, 96 rue Didot, F-75014 Paris, France.
Keywords: hypertension; stent; Takayasu's arteritis; transluminal angioplasty
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Introduction
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Takayasu's disease is an idiopathic inflammatory arteriopathy that affects the aorta and its main branches. The lesions show typical stenosis and occlusions, but aneurysms and dilatations are also observed. Takayasu's arteritis occurs most frequently in young Asian women. The estimated incidence is 2.6 cases per million inhabitants per year in North America [1]. The disease is uncommon in elderly Caucasian subjects. Surgical repair is the normal treatment in symptomatic cases, but correction of aortic or peripheral artery stenosis using stent placement has recently been reported [2]. We report a case of aorta pseudocoarctation in a 63-year-old Caucasian woman with Takayasu's arteritis, detected due to resistant hypertension, successfully treated by percutaneous transluminal angioplasty and stent placement.
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Case
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A 63-year-old Caucasian woman was admitted for investigation of long-standing severe hypertension. Hypertension was diagnosed in 1982 and blood pressure had never been brought under control. In 1991 she had a stroke, due to a lacuna of the left capsulo-thalamic area, resulting in right hemiplegia. Cardiovascular risk factors included obesity (body mass index of 30), cigarette smoking (80 packets/year) and hypercholesterolaemia normalized with simvastatin. Her predicted 10 years coronary heart disease risk was 36.1% [3]. She had previously received intermittent glucocorticoid treatment for asthma.
On admission (Table 1
) the patient was taking five antihypertensive agents (60 mg/day furosemide, 10 mg/day bisoprolol, 120 mg/day urapidil, 5 mg/day amlodipine and 1 mg/day guanfacine). The right brachial blood pressure was 212/94 mmHg and blood pressure in the left arm was 192/99 mmHg. There was significant anisotension because blood pressure was 121/73 mmHg in the right leg and 137/75 mmHg in the left leg. Physical examination revealed vascular bruits on the abdominal aorta and no femoral pulses. Laboratory evaluations revealed a serum creatinine concentration of 83 µmol/l and a creatinine clearance of 77 ml/mn with no proteinuria. The erythrocyte sedimentation rate was slightly fast (34 mm/h) and the amount of reactive C-protein was high (16 mg/l). Tests for antinuclear antibodies were negative. Active renin and plasma aldosterone levels were low due to beta blocker treatment. Fundoscopic examination demonstrated arteriolar narrowing and arteriovenous crossing. Echocardiography disclosed concentric left ventricular remodelling. A Doppler ultrasound of the abdominal aorta revealed a small aorta with damped blood fluxes suggestive of thoracic aorta stenosis. Thoraco-abdominal computed tomography angiography revealed a calcified thickening of the wall of the thoracic descending aorta, resulting in tight aortic coarctaction at the diaphragm. There was also an aneurysm of the brachiocephalic-arterial trunk but no lesion on the abdominal aorta. Mediastinal and pulmonary calcified lymphatic ganglia were observed, probably due to a previous tuberculosis infection. Aortography showed that the lesion on the thoracic descending aorta was unique and 10 cm long (Figure 1A
). A pressure gradient of 130 mmHg across the stenosis was measured. The abdominal aorta and its branches (including renal arteries) were normal. Renal scintigraphy showed a bilateral hypoperfusion. A presumptive diagnosis of Takayasu's arteritis of angiographic type IIb [4] was made based on the American National Institutes of Health criteria [1]: features of vascular ischaemia (femoral pulse absents, asymmetric blood pressure, multiple vascular bruits), typical angiographic features (aortic stenotic lesion and aneurysm of brachiocephalic-arterial trunk) and high erythrocyte sedimentation rate. Percutaneous arterial endovascular treatment was selected because surgery was potentially hazardous for this patient with a high risk of coronary heart disease. A 16x75 mm Easy Wallstent premounted on a 5-F angioplasty catheter was inserted and the stenotic segment was dilatated further using a 12-mm balloon. The post-stenting angiography was satisfactory but the stent was too short to entirely cover the lesion. Thus, a second identical stent was expanded. The final angiogram revealed mild residual stenosis. A residual post-stenting gradient of 25 mmHg was measured. Following the procedure, femoral pulses were detected. Immediately after the procedure, the patient experienced severe diuresis (10 l during the first 24 h). Post-interventional anticoagulant treatment consisted of 250 mg of acetylsalicylic acid. The antihypertensive treatment was reduced and blood pressure decreased to 140/65 mmHg while taking four antihypertensive drugs (80 mg/day furosemide, 50 mg/day losartan, 47.5 mg/day of metoprolol succinate and 5 mg/day felodipine). The patient was followed up 6 months after stent placement. Her blood pressure was 132/80 mmHg without anisotension while taking four antihypertensive agents (80 mg/day furosemide, 5 mg/day amlodipine, 8 mg/day candesartan and 200 mg/day metoprolol). Computed tomography revealed a slight residual narrowing 5 mm below the prosthesis. Aortography showed a patent stented aortic lumen (Figure 1B
). Aortic pressure means were equal across the stent. There was no evidence for intimal hyperplasia in the stented region.
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Table 1. Clinical and biological characteristics of patient at diagnosis, discharge and after 6 months of follow-up
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Fig. 1. A 63-year-old Caucasian woman with aortic pseudocoarctation. (A) Aortography showing long segment of severe stenosis of descending thoracic aorta (brachial blood pressure was 212/94 mmHg). (B) Aortography check-up 6 months after angioplasty and stenting (brachial blood pressure was 132/80 mmHg).
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Discussion
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This elderly Caucasian patient had severe ischaemic hypertension due to a tight aortic stenosis, probably associated with Takayasu's disease. Aortic dilatation and stenting gave excellent control of blood pressure. This patient presented several signs of ischaemic renal hypertension: resistance to treatment, renal bilateral hypoperfusion on scintigraphy, aortic stenosis on imaging, severe diuresis following revascularisation and control of blood pressure after dilatation. The absence of secondary hyperaldosteronism was due to antihypertensive treatment.
The diagnosis of Takayasu's arteritis was established based on clinical symptoms of vascular ischaemia (asymmetric blood pressure, femoral pulse absents, multiple vascular bruits), typical angiographic features (aortic stenotic lesion and aneurysm of brachiocephalic-arterial trunk) and secondarily a slightly high erythrocyte sedimentation rate and on the suspicion of previous undetected tuberculosis. The delay in diagnosis may be due to asthma glucocorticoid therapy. This may have masked the early systemic phase of the disease, induced remission of Takayasu's aortitis and may account for the detection in this elderly woman of the inactive or `burned out' form of Takayasu's arteritis. It has been reported that the clinical features of Takayasu's aortitis are significantly different in the elderly: hypertension, calcifications of the aorta, left ventricular hypertrophy, erythrocyte sedimentation rate normal or slightly high [5]. Recent reports have also indicated that the systemic phase of the disease is relatively rare and that the vast majority of patients with Takayasu's arteritis are first seen in the advanced ischaemic stage of the disease [6]. Typical angiographic lesions (diffuse calcifications and marked narrowing of the descending aorta) similar to those in our patient were described in two patients in whom aortitis syndrome was diagnosed by autopsy and pathological examination [7]. However, in this tabagic and hypercholesterolaemic patient, the differential diagnosis of calcifying obstructive disease of the descending thoracic aorta (obliterative atherosclerosis) [8] was possible. The multiplicity of sites (descending thoracic aorta and brachiocephalic trunk) and the association of different types (stenosis, aneurysm and calcifications) of lesion in our patient were, however, more consistent with Takayasu's disease. The preservation of the distal abdominal aorta, bifurcation, iliac and femoral arteries in our patient are not consistent with atherosclerosis [6]. Evidently, the diagnosis cannot be definitive in the absence of a pathological examination.
This is the first report of a successful stent placement in an elderly Caucasian patient with pseudocoarctation due to Takayasu's aortitis. Nevertheless, our patient was not normotensive without treatment after the procedure because of her age and the long history of hypertension [9]. During the last decade, percutaneous transluminal angioplasty of aortic stenosis caused by non-specific aortitis has an alternative to bypass surgery. Stent placement has been reported for the treatment of stenosis of the abdominal aorta and small arteries such as the carotid, mesenteric or renal arteries in Takayasu's disease. Vascular stent placement in the thoracic aorta has been described in treatment of complications (obstructing dissection or recurrent stenosis) of balloon angioplasty [2,10]. Angioplasty and stent placement in the aorta has recently been reported in four young patients [11]. We used stent placement as a first line treatment because our patient had several unfavourable features (eccentricity and lenght of stenosis, diffuse adjacent disease with calcifications) for complicated angioplasty and had a high operative risk.
In conclusion, this observation demonstrates that primary vascular stent placement is a safe and effective alternative to surgical bypass in ischaemic hypertension associated with aortic pseudocoarctation.
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References
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Kerr GS, Hallahan CW, Giordano J et al. Takayasu arteritis. Ann Int Med 1994; 120: 919929[Abstract/Free Full Text]
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Sharma S, Bahl VK, Saxena A, Kotari SS, Talwar KK, Rajani, M. Stenosis in the aorta caused by non-specific aortitis: results of treatment by percutaneous stent placement. Clin Radiol 1999; 54: 4650[ISI][Medline]
-
Anderson KM, Odell PM, Wilson PW, Kannel WB. Cardiovascular disease risk profiles. Am Heart J 1991; 121: 293298[ISI][Medline]
-
Hata A, Noda M, Moriwaki R, Numano F. Angiographic findings of Takayasu arteritis: new classification. Int J Cardiol 1996; 54: S155S163[Medline]
-
Morooka S, Saito Y, Nonaka Y, Gyotoku Y, Sugimoto T. Clinical features and course of aortitis syndrome in Japanese women older than 40 years. Am J Cardiol 1984; 53: 859861[ISI][Medline]
-
Lande A. Abdominal Takayasu's aortitis, the middle aortic syndrome and atherosclerosis. A critical review. Int Angiol 1998; 17: 19[ISI][Medline]
-
Suzuki I, Kuwajima I, Ohkawa S et al. Two autopsy cases of aortitis syndrome in the elderly. Nippon Ronen Igakkai Zasshi 1992; 29: 579585[Medline]
-
Sadony V, Kayambo GH, Walz M, Serdarevic M. Acquired coarctation due to calcified thrombus in atherosclerosis of the descending thoracic aorta. Two cases and a review. Eur J Cardio Thorac Surg 1989; 3: 464467[Abstract]
-
Streeten DH, Anderson GH, Wagner S. Effect of age on response of secondary hypertension to specific treatment. Am J Hypertens 1990; 3: 360365[ISI][Medline]
-
Tyagi S, Sharma VP, Arora R. Stenting of aorta for recurrent, long stenosis due to Takayasu's arteritis in a child. Pediatr Cardiol 1999; 20: 215217[ISI][Medline]
-
Bali HK, Jain S, Jain A, Sharma BK. Stent supported angioplasty in Takayasu arteritis. Int J Cardiol 1998; 66: S213S217[ISI][Medline]
Received for publication: 7.10.99
Accepted in revised form: 24.11.99