Hybrid Endovascular Surgical Repair in Takayasu's Arteritis: Duplex Ultrasound Follow-up

Abstract

Introduction

Takayasu's arteritis (TA), a rare condition occurring primarily in young women, is a granulomatous vasculitis usually affecting the aorta and its branches. Our case report describes the duplex ultrasound findings in a 16-year-old Hispanic woman after a hybrid endovascular procedure.

Patient Description

TA in this patient was diagnosed in 2005 after a pulsatile neck mass developed on the right side of her neck. To date, she has required four vascular interventions in less than 3 years. The first procedure was an aortic root, ascending aorta and aortic arch replacement with Dacron graft replacement of the left common carotid and innominate arteries. She then developed a pseudoaneurysm in the distal left common carotid artery replacement graft, which was excluded with a stent-graft. The third procedure was a balloon angioplasty of an anastomotic stenosis of the aorto-innominate artery graft. This, however, recurred and there was also a small anastomotic pseudoaneurysm at this site. Revascularization was complicated by the fact that the left subclavian artery was occluded, with reversed flow in the left vertebral artery. Consequently, preservation of antegrade flow in the right vertebral artery was a priority. Transposition of the right common carotid artery to the subclavian artery with placement of a balloon expandable stent graft from the aortoinnominate artery graft into the subclavian artery (proximal to the vertebral artery) was performed.

Methods

All available imaging exams and operative reports were reviewed. Bilateral carotid duplex evaluation in addition to duplex examination of all bypasses and the distal native arteries were performed using high resolution ultrasound equipment and probes of varying frequency.

Results

Normal caliber wall thickness was identified in bilateral common carotid arteries. No evidence of intimal hyperplasia could be detected in stented areas. All open surgical or endovascular repair sites were well visualized, with the exception of only the proximal most innominate artery bypass graft and the aortic arch. Primarily retrograde left vertebral artery flow feeds the left subclavian artery. There was no evidence of restenosis or pseudoaneurysm formation.

Discussion

Long-term follow-up of the patient with TA after open surgical or endovascular procedures is extremely important because of the chronic nature of the disease process. Duplex ultrasound is a safe, effective adjunct to the standard radiologic arsenal usually used to follow these high-risk patients.