Takayasu arteritis, a rare granulomatous vasculitis affecting young people, is associated with considerable morbidity and premature mortality. In most patients the diagnosis is delayed until after the development of substantial arterial injury. Studies of noninvasive imaging techniques suggest that these approaches might facilitate earlier diagnosis and have a role in monitoring disease progress; however, they remain limited in their ability to accurately quantify inflammatory disease activity in the arterial wall. A lack of controlled clinical trial data complicates the choice of therapy for Takayasu arteritis, and clinical indices for monitoring disease activity are currently suboptimal. Increasing knowledge of the pathogenesis of the large vessel vasculitides might eventually lead to novel targeted therapies. Preliminary data from open-label trials of anti-tumor necrosis factor therapy are encouraging, but there is an urgent need for controlled clinical trials to establish optimum therapeutic approaches for this disease. These trials should include a prospective assessment of the use of noninvasive imaging modalities in the diagnosis and subsequent management of Takayasu arteritis.

Takayasu arteritis—advances in diagnosis and management

Fluorine-18 fluorodeoxyglucose positron emission tomography ((18)FDG PET) plays a major role in the management of oncology patients. Owing to the singular properties of the glucose tracer, many patients suffering from non-malignant diseases such as inflammatory or infectious diseases may also derive clinical benefit from the appropriate use of metabolic imaging. Large vessel vasculitides such as giant cell arteritis and Takayasu arteritis are other examples that may potentially extend the field of (18)FDG PET indications. The purpose of the present article is to assess the feasibility of metabolic imaging in vasculitis on the basis of the current literature data. In particular, the clinical context and the (18)FDG imaging patterns seen in patients with large vessel vasculitis are analysed in order to identify potential indications for metabolic imaging.

Imaging of large vessel vasculitis with 18 FDG PET: illusion or reality? A critical review of the literature data

Pathogenesis and treatment of the antiphospholipid antibody syndrome.

We describe a case in which fludeoxyglucose F 18 positron emission tomography (PET) led directly to the diagnosis of giant cell arteritis in an elderly woman with a fever of unknown origin.The patient presented with a 3-month history of fatigue, fever, headache, visual disturbance, jaw claudication, and anemia. A computed tomographic scan showed an anterior mediastinal mass that was suspected of being malignant. A fludeoxyglucose F 18 PET scan performed for preoperative evaluation identified striking uptake of fludeoxyglucose F 18 in the walls of the entire aorta, left main coronary artery, and subclavian, carotid, and common iliac arteries bilaterally, suggestive of an arteritis, a diagnosis subsequently confirmed by the findings of an arterial biopsy. Her erythrocyte sedimentation rate was 129 mm/h. There was normalizaton of the PET scan 2 weeks following treatment with prednisolone. This case suggests that fludeoxyglucose F 18 PET contributes to the noninvasive diagnosis of giant cell arteritis, as well as to the evaluation of the extent of disease, response to therapy, and disease recurrence.

Fludeoxyglucose positron emission tomography in the diagnosis of giant cell arteritis.

Between June 1979 and May 1994, I performed 148 unilateral or bilateral sympathectomies on 247 limbs in 110 patients using a percutaneous radiofrequency technique, usually on an outpatient surgery basis. Patient ages ranged from 10 to 81 years, with 45 male and 65 female patients. Four patients had unsuccessfully undergone prior open surgical sympathectomy. Patients suffered from hyperhidrosis, vascular occlusion, Raynaud's disease or other chronic vasculopathies, painful causalgia or reflex sympathetic dystrophy, or Prinzmetal's angina. The sympathectomy technique has evolved over this 15-year period and is currently in its third phase. Changes in the procedure were based on anatomic and clinical/radiographic correlations and careful patient follow-up. Current modifications have reduced the frequency of both early and late failures. The present technique (Phase III) relies on neuroleptanalgesia with superficial local anesthesia only and does not require general anesthesia, intubation, or lung collapse. Two 18-gauge radiofrequency TIC needle electrodes (Radionics, Burlington, MA) are used. A series of three lesions is rostrocaudally made at each of the ganglion sites selected in an attempt to destroy the entire fusiform ganglion. Lesion sites are targeted by C-arm fluoroscopy and electrical stimulation, which produces a threshold of sensory awareness of > 1.0 V. Lesion effectiveness is monitored by bilateral finger plethysmography and hand skin temperature measurement. With the Phase III technique, the sympathetic activity in 96% of operated limbs after 2 years and in 91% of operated limbs after 3 years continues to be completely or largely interrupted. By comparison, I achieved similar success in 83 and 72% operated limbs with the Phase I technique and in 77 and 71% with the Phase II technique. Symptomatic pneumothorax, in six patients, has been the only serious complication. When necessary, a subsequent operation can easily be performed and is effective.

Percutaneous radiofrequency upper thoracic sympathectomy.

Resume Propos . — Dans le cadre de l’arterite de Takayasu, il n’existe pas de consensus concernant les explorations vasculaires et la prise en charge therapeutique. L’objectif de notre etude etait d’analyser chez 16 malades souffrant d’arterite de Takayasu les methodes d’exploration les plus adaptees et les traitements employes. Methodes . — Seize patients atteints d’arterite de Takayasu selon les criteres de l’American College of Rheumatology ont ete evalues de facon retrospective de 1975 a 1997, cliniquement, biologiquement, morphologiquement, sur le plan diagnostic et therapeutique. Resultats . — Dans notre serie, la mediane de retard diagnostique etait de 9 mois. L’atteinte aortique et valvulaire aortique etait plus frequente. Les resultats ont montre l’existence d’une correlation statistiquement significative entre l’absence de rechute et l’emploi des corticoides (test exact de Fisher, p = 0,021). L’utilisation de l’angioplastie a entraine une stabilisation des lesions. La prise en charge chirurgicale s'est montree satisfaisante, en dehors des patients ayant une atteinte aortique pour lesquels la survie etait inferieure a 1 an. Conclusion . — L’analyse de notre serie montre la necessite d’un diagnostic precoce afin de proposer une therapeutique adequate, en particulier la corticotherapie. La chirurgie et l’angioplastie sont des recours efficaces en cas de forme occlusive. Les formes diagnostiquees tardivement comportent une atteinte aortique severe dont l’evolution est le plus souvent fatale.

Artérite de Takayasu: explorations vasculaires et prise en charge thérapeutique. Expérience à propos de 16 patients

The authors report a case of primary aspergillus endocarditis with endophthalmitis and vertebral osteomyelitis. No underlying disease and no predisposing factors were found. Valve replacement plus combined antifungal chemotherapy proved to be effective as the patient is asymptomatic 18 months after the first symptoms. 48 cases of aspergillus endocarditis, without prior cardiac surgery have been reported in the literature. Aspergillus endocarditis was valvular or mural. Extracardiac dissemination was common but endophthalmitis and osteomyelitis were infrequent. In 11 cases, the diagnosis was made by histologic examination of embolectomy or ocular, skin biopsy tissue. All patients were febrile. Blood cultures showed no Aspergillus species. Clinical manifestations of endocarditis were described in less than fifty per cent of cases. Echocardiographic visualization of vegetations was obtained in 5 cases. Many patients experienced embolic phenomena. Mortality from Aspergillus endocarditis is extremely high (96%). Surgery is the main treatment, consisting of valve replacement. Antifungal chemotherapy should be combined. The proper duration and dosage and the combination of antifungal drugs have not been clearly defined.

Primary Aspergillus endocarditis. Apropos of a case and review of the international literature

Dans ce travail, nous rapportons les resultats de la mesure de la TcPO 2 au cours d'une epreuve d'effort standardisee, dans un groupe de patients atteints d'une arteriopathie de stade II. L'utilisation simultanee de plusieurs capteurs a permis d'une part une mesure polyetagee: cuisse, mollet, pied, pour tenter de preciser la topographie de l'hypoxie, d'autre part la mise en place d'une electrode precordiale de reference indispensable pour eliminer les variations de TcPO 2 liees a l'adaptat-ion cardio-respiratoire du sujet

Intérêt de l'oxymétrie transcutanée dynamique étagée dans l'artérite des membres inférieurs de stade II.

Resume L'atteinte valvulaire de la maladie lupique est le plus souvent une decouverte echographique et son retentissement hemodynamique reste rare, le remplacement valvulaire exceptionnel. Nous rapportons l'observation d'une patiente ayant eu un double remplacement valvulaire aortique et mitral precedant la decouverte d'anticorps antiphospholipides associes a 4 criteres de l'ARA de maladie lupique. L'etude histopathologique devait confirmer l'endocardite specifique de Libman et Sachs. La presence d'anticorps antiphospholipides fait discuter leur role dans la physiopathologie des atteintes valvulaires et des accidents vasculaires presentes par la patiente. Le chevauchement entre les criteres diagnostiques du lupus et du syndrome primaire des antiphospholipides est discute. L'atteinte valvulaire peut etre un des modes d'entree dans le syndrome des antiphospholipides.

Double remplacement valvulaire révélateur d'un syndrome des antiphospholipides

Acute traumatic rupture of the thoracic aorta (ATRTA) is considered to be an emergency which requires immediate surgery. However surgical mortality is high with an average of 20% in the literature. Twenty-seven patients were observed from 1973 to 1986. Three patients were not operated on (Group I). Twenty patients had immediate surgery (group II) with 60% deaths, 4 patients underwent delayed surgery (Group III) with 25% deaths. Analysis of causes of deaths shows that mortality is mainly due to the severity of associated lesions. Associated lesions were present in 72% of patients who did not survive and in only 37% of the survivors. Associated lesions may be lethal initially (E.G. Brain trauma) or they may be aggravated by the thoracic procedure. Complications from associated lesions may also compromise the outcome of the thoracic procedure. It is well known that the majority of deaths from ATRTA are observed within 24 hours. Immediate repair of the aortic lesion should remain the rule when aortic rupture is isolated or associated with moderate injuries. However, in some cases with severe and multiple associated lesions who survive the initial aortic injury, delayed repair of ATRTA could be considered.

Acute traumatic rupture of the thoracic aorta. Role of delayed surgical treatment

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