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Received:Revised:Accepted:

August 13, 2013 November 5, 2013November 8, 2013

Corresponding Author: Myung Ho Jeong, Director of the Cardiovascular Convergence Research Center Nominatedby Korea Ministry of Health and Welfare, Chonnam National University Hospital, 42 Jaebong-ro, Donggu, Gwangju501-757, KoreaTel: +82-62-2206243, Fax: +82-62-2287174, E-mail: myungho@chollian.net

This is an Open Access article distributed under the terms of the creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Case Report

http://dx.doi.org/10.12997/jla.2013.2.2.97pISSN 2287-2892 • eISSN 2288-2561 JLASuccessful Endovascular Aortic Repair in a Young Female with Takayasu's Arteritis Presenting with Uncontrolled HypertensionSang Hun Park, Hae Chang Jeong, Keun Ho Park, Doo Sun Sim, Young Joon Hong, Ju Han Kim, Youngkeun Ahn, Myung Ho Jeong

Cardiovascular Research Center, Chonnam National University Hospital, Gwangju, Regeneromics Research Center, Chonnam National University, Gwangju, Korea

A 21-year-old female presented with uncontrolled hypertension. Neck, abdomen, chest computed tomography angiogram showed moderate stenosis in the left common carotid artery and the left subclavian artery, and multiple severe stenosis in the transitional area between the descending thoracic aorta and the abdominal aorta. Transthoracic echocardiography and aortography revealed that the pressure gradient between the descending thoracic aorta and the abdominal aorta was 80 mmHg. She underwent angioplasty with stent implantation. After stent implantation, claudication improved significantly, and the pressure gradient decreased to 18 mmHg. The blood pressure was normalized with single anti-hypertensive medication, and no adverse clinical event occurred during five-year follow-up.

Key Words: Arteritis, Hypertension, Angioplasty

INTRODUCTION

Takayasu’s arteritis is associated with vascular stenosis

involving the aorta, carotid and renal arteries, and

pulmonary artery.1 In hypertensive patients due to

Takayasu’s arteritis, who do not respond to medical

treatment, interventional treatment such as angioplasty

or surgical treatment such as bypass surgery should be

considered. Stent implantation 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 arteritis.1-3

Here, we report a case of successful stent implantation

for severe hypertension due to stenosis in the thoracic

aorta in a young female patient with Takayasu’s arteritis.

CASE REPORT

A 21-year-old female came to undergo evaluation for

the cause of hypertension which was incidentally detected

during health checkup 3 weeks before. The secondary

cause of hypertension was not found at the local clinic.

On arrival, the patient had a heart rate of 72 beats/min

and blood pressure of 150/100 mmHg. On physical

examination, a bruit was auscultated over the epigastric

area and left neck. Radial arterial pulse was stronger on

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Fig. 1. The doppler ultrasonography showed stenosis and increased peak velocity of the left common carotid artery (peakvelocity=2.5 m/s) (left) and left subclavian artery (peak velocity=2.2 m/s) (right).

Fig. 2. The ultrasonography of the left common carotid artery showed intima-media thickness of 1.94 mm.

the right than on the left. In addition, pulses in both

femoral, popliteal, dorsalis pedis arteries were weak

compared with those in brachial and radial arteries (right

arm 150/80 mmHg, left arm 110/70 mmHg, right leg 85/50

mmHg, left leg 80/50 mmHg, respectively). In laboratory

tests, erythrocyte sedimentation rate (ESR) to 69 mm/hr

and C-reactive protein (CRP) to 1.1 mg/dL. Ankle brachial

index (ABI) was 0.53 on the right side and 0.50 on the

left side, which suggested the presence of aortic or

peripheral arterial disease. In echocardiography, conti-

nuous flow was detected in the left common carotid artery

and left subclavian artery with increased velocity, which

implicated vascular stenosis (Fig. 1). The intima-media

thickness (IMT) of the left common carotid artery was

1.94 mm (Fig. 2). In addition, severe stenosis was detected

in the transitional area between the descending thoracic

aorta and the abdominal aorta (Fig. 3). The peak systolic

velocity and the mean pressure gradient were 4.49 m/sec

and 80 mmHg, respectively. In neck CT angiography,

moderate stenosis was found in the left common carotid

artery and in the left subclavian artery (Fig. 4). In chest

and abdomen CT angiography, multiple stenotic lesions

were detected between the descending thoracic aorta

and the abdominal aorta (Fig. 5).

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Fig. 3. The ultrasonography of the thoracoabdominal aorta showed continuous flow. The peak systolic velocity was 4.49m/sec and the mean pressure gradient was 80 mmHg.

Fig. 4. Neck CTA showed moderate stenosis in the left common carotid artery and in the left subclavian artery.

She was diagnosed to have Takayasu’s arteritis on the

basis of multiple vascular stenosis with no risk factors of

cardiovascular diseases, elevated ESR, age and ethnicity

(Asian woman). She had no other symptoms associated

with vascular stenosis except hypertension. At first, she

was treated with corticosteroid in the outpatient

department. However, she developed claudication after

2 months. Aortogram showed diffuse stenosis in left

common carotid artery and left subclavian artery, but distal

run-off was maintained. Between the descending thoracic

aorta and the abdominal aorta, long diffuse stenosis was

observed and the pressure gradient was 80 mmHg, which

was thought to be the cause of claudication. Because

medical treatment did not reduce or improve disease

progression, percutaneous intervention was performed

using a 18x100 mm NitinolⓇ stent (all in one type, 12

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Fig. 5. Chest and abdomen CTA showed multiple stenotic lesions, especially in the transitional area between the descendingthoracic aorta and the abdominal aorta.

Fig. 6. After angioplasty with stent insertion, the pressure gradient (PG) decreased to 18 mmHg.

French, Johnson & Johnson) (Fig. 6). After the inter-

vention, the pressure gradient decreased from 80 mmHg

to 18 mmHg and her claudication improved. Follow-up

CT angiogram 2 days after stent-graft implantation

showed patent aorta lumen and good distal flow (Fig.

7). Her blood pressure was normalized with single

anti-hypertensive medication and clinical course was

uneventful during five-year clinical follow-up.

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Fig. 7. (A) CT angiogram before stent implantation, (B) Follow-up CT angiogram 2 days after stent graft showed a patentlumen with good distal flow.

DISCUSSION

In the case of Takayasu’s arteritis with vascular stenosis

which does not respond to medical therapy, interventional

treatment such as angioplasty or surgical treatment such

as bypass surgery should be considered if coronary artery,

renal artery or cerebral artery is involved or if ischemia

that hinders daily life occurs. Angioplasty has recently been

used for treatment along with invasive surgical operations.

Surgical bypass of the stenosed segment is often

complicated by graft reocclusion, anastomotic site

aneurysm and morbidity. Angioplasty offers a less invasive,

cost-effective, and safe method for relief of stenotic lesions

in patients with Takayasu’s arteritis. Stent implantation

has been reported for the treatment of stenosis of the

abdominal aorta and small arteries such as the carotid,

mesenteric, or renal arteries.4-7 Open surgical treatment

is currently the gold standard for treating occlusive aortic

lesions, yet postoperative morbidity and mortality have

remained high.8 On the other hand, endovascular inter-

vention using stenting is less invasive compared to surgical

options, resulting in fewer procedural complications and

lower mortality.9,10 Good results are seen in the treatment

of short focal stenosis in the presence of inactive

disease.11,12 The main complications of all intervention,

both open surgery and endovascular techniques, include

restenosis (75.7%), thrombosis (10%), bleeding (8.6%),

and stroke (5.7%).13

In our case, blood pressure was normalized with single

anti-hypertensive medication and clinical course was

uneventful during five-year clinical follow-up. Secondary

hypertension due to aortic stenosis could be managed

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by a thoracoabdominal endovascular stent in a young

female patient with Takayasu’s arteritis.

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