Wetstein Paul J, Clark Margaret E, Cafasso Danielle E, Golarz Scott R, Ayubi Farhan S, Kellicut Dwight C
Department of Vascular Surgery, Tripler Army Medical Center, Honolulu, HI.
Hawaii J Med Public Health. 2016 Jan;75(1):4-7.
Takayasu's arteritis is a large vessel vasculitis that can be a challenging diagnosis to make and has a varied clinical presentation. Management largely depends on affected vessel disease severity and individual patient considerations. The diagnosis must be considered in a young patient with large vessel aneurysms. We present a case of a 30 year-old woman of Pacific Islander descent who presented to the Tripler Army medical Center Vascular Surgery Department in Honolulu, Hawai'i seeking repair of her abdominal aortic and renal artery aneurysms prior to conception. A 30 year-old Pacific Islander woman with a history of a saccular abdominal aortic aneurysm and renal artery aneurysms presented to our clinic seeking vascular surgery consultation prior to a planned pregnancy. She had a renal artery stent placed at an outside institution for hypertension. She met the diagnosis of Takayasu's arteritis by Sharma's criteria. Physical exam was significant for a palpable, pulsatile, abdominal mass and CT angiography revealed a saccular irregular-appearing infra-renal abdominal aortic aneurysm, extending to the aortic bifurcation, with a maximum diameter of 3.3 cm. A right renal artery aneurysm was also identified proximally, contiguous with the aorta, with a maximal transverse diameter of 1.7 cm. The patient underwent a supraceliac bypass to the right renal artery with a 7 mm Dacron graft, as well as excision of the right renal artery aneurysm. The abdominal aortic aneurysm was replaced using a Hemashield Dacron bifurcated 14 mm x 7 mm bypass graft. Intraoperative measurements of the renal artery aneurysm were 1.5 x 1.5 cm and the saccular appearing distal abdominal aortic aneurysm measured 3.6 x 3.3 cm. The patient was discharged from the hospital 7 days post-operatively. At 1-year follow up, CT scan of the abdominal aorta revealed the repair was without any evidence of aneurysm formation, anastomotic pseudoaneurysm formation, or areas of stenosis. She has remained normotensive with a normal serum creatinine 18 months after her repair. She has since delivered her second child. It is rare for Takayasu's arteritis to present with aneurysmal disease. It is much more common to present with stenosis or occlusion. It has yet to be proven that Takayasu's truly has a higher incidence in those of Asian descent. Takayasu's can be a difficult diagnosis to make but can be aided with the use of Sharma's criteria. Our particular patient posed unique considerations on the effects of the physiology of pregnancy on her aneurysms and repair. Managing the active phases of disease is imperative, and though medical management is first line, surgical intervention may be necessary. Surgical intervention should be performed in a quiescent period of disease if possible given that biological inflammation at the time of intervention increases the complication rate. Repair of aneurysmal disease in a young female should also be considered prior to pregnancy.
高安动脉炎是一种大血管血管炎，诊断具有挑战性，临床表现多样。治疗很大程度上取决于受累血管疾病的严重程度以及个体患者的具体情况。对于患有大血管动脉瘤的年轻患者必须考虑到这种诊断。我们报告一例30岁的太平洋岛民后裔女性病例，她前往夏威夷檀香山的特里普勒陆军医疗中心血管外科，寻求在怀孕前修复其腹主动脉和肾动脉瘤。一名有囊状腹主动脉瘤和肾动脉瘤病史的30岁太平洋岛民女性到我们诊所，在计划怀孕前寻求血管外科会诊。她在外地机构因高血压置入了肾动脉支架。她根据夏尔马标准符合高安动脉炎的诊断。体格检查发现可触及的搏动性腹部肿块，CT血管造影显示一个囊状、外观不规则的肾下腹主动脉瘤，延伸至主动脉分叉处，最大直径为3.3厘米。还在近端发现一个右肾动脉瘤，与主动脉相邻，最大横径为1.7厘米。患者接受了经膈上至右肾动脉的7毫米涤纶移植血管搭桥术，以及右肾动脉瘤切除术。腹主动脉瘤用一个14毫米×7毫米的Hemashield涤纶分叉搭桥移植血管进行置换。术中测量肾动脉瘤为1.5×1.5厘米，囊状的远端腹主动脉瘤为3.6×3.3厘米。患者术后7天出院。术后1年的腹部主动脉CT扫描显示修复部位没有动脉瘤形成、吻合口假性动脉瘤形成或狭窄区域的任何证据。修复后18个月她一直血压正常，血清肌酐水平正常。此后她生下了第二个孩子。高安动脉炎以动脉瘤疾病形式出现较为罕见。以狭窄或闭塞形式出现更为常见。尚无证据证明高安动脉炎在亚洲血统人群中发病率真的更高。高安动脉炎可能难以诊断，但使用夏尔马标准有助于诊断。我们的这位特殊患者在怀孕生理状况对其动脉瘤及修复的影响方面存在独特的考虑因素。控制疾病的活动期至关重要，虽然药物治疗是一线治疗方法，但可能需要手术干预。如果可能的话，手术干预应在疾病的静止期进行，因为干预时的生物性炎症会增加并发症发生率。对于年轻女性的动脉瘤疾病修复也应在怀孕前予以考虑。
