Surgery Safer Than Endovascular Procedure for Form of Chronic Arteritis

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Patients who undergo bypass surgery for the chronic inflammatory condition Takayasu arteritis experience fewer complications over 5 to 10 years compared with those who receive endovascular repair, according to the first study to evaluate the long-term results of revascularization for the disorder. The findings were published online January 9, 2012, ahead of print in Circulation.

David Saadoun, MD, PhD, of Hôpital Pitié-Salpétrière (Paris, France), and colleagues looked at 79 consecutive patients with Takayasu arteritis, which affects mainly large vessels such as the aorta. The study was conducted at 3 French institutions between 1992 and 2010. Patients underwent 106 vascular procedures (62.4% bypass surgery, 37.3% angioplasty) for arterial stenosis or occlusion across a wide range of vascular territories including aortic (18.7%), subclavian (14.4%), renal (13.2%), carotid (11.4%), and several others.

Surgical approaches included prosthetic bypass (65.4%) and vein bypass (34.6%), while roughly two-thirds of the endovascular procedures (67.7%) involved stenting. The decision between surgery and angioplasty was at the treating physician’s discretion.

Half of Endovascular Repairs Yield Complications

The overall 5-year arterial complication rate was 44%. Half of the endovascular procedures resulted in a complication either early (< 30 days) or late (> 30 days) compared with 37.5% of the surgical procedures. Of those patients who received stents (n = 42), 47.6% experienced a vascular complication. When biological inflammation was present, the complication rate was 61.5% and 64% for endovascular repair and surgery, respectively. By far the primary major complication was restenosis, occurring at an overall rate of 31%. Restenosis accounted for 75.7% of all complications, followed by thrombosis (10%), bleeding (8.6%), and stroke (5.7%).

Over a median 6.5 years of follow-up, there were 4 deaths (1 surgery; 3 endovascular repair). Kaplan-Meier survival rates were high at various intervals out to 10 years, while complication-free survival rates favored surgery over endovascular revascularization (table 1).

Table 1. Survival Rates After Revascularization for Takayasu Arteritis

 

1 Year

3 Years

5 Years

10 Years

Survival

97%

96%

96%

92%

Complication-Free Survival
   Surgical
   Endovascular

78%
NA
NA

67%
NA
NA

56%
60%a
49%

45%
57%a
29%

a P < 0.05 for surgery vs. endovascular complication-free survival.

On multivariable analysis, biological inflammation at the time of revascularization was an independent predictor of complications (OR 7.48; 95% CI 1.42-39.39; P = 0.04), as was endovascular repair (OR 3.61; 95% CI 1.3-10.3; P = 0.021).

The authors acknowledge the limitations of their study, including its retrospective nature and potential for baseline differences between the 2 groups. Nevertheless, they conclude that “[s]trikingly, our results are likely to be clinically meaningful for clinicians in charge of patients with [Takayasu arteritis].”

Surgery Preferred

In particular, Dr. Saadoun indicated in an e-mail communication with TCTMD that clinicians “should take into account that in the [Takayasu arteritis] setting, revascularization should be postponed in case of biological inflammatory syndrome, and surgery should be preferred to endovascular procedures.”

While the difference in complications between surgery and revascularization was surprising, Dr. Saadoun added, “revascularization was [still] efficient, although in patients with biological inflammation at the time of the procedure, the complication rate increased significantly in more than 60% of cases.”

Maya J. Salameh, MD, of Johns Hopkins University Medical Center (Baltimore, MD), pointed out that it is unclear at what stage of the disease the patients were in when treated. She also agreed with the study authors that there may have been differences in their baseline characteristics that may have led clinicians to choose one type of therapy over another.

Nevertheless, “the results do suggest to me that more research is needed prior to considering endovascular repair as a first-line option for invasive treatment in patients with [Takayasu arteritis],” she said in an e-mail communication with TCTMD.”

Pathology of Arteritis Different from Atherosclerosis

This makes sense, Dr. Salameh continued, since the underlying pathology of the condition is different from that of atherosclerosis. Takayasu arteritis “is mainly a chronic disease characterized by inflammation. As stated in the paper, this results in ‘extensive periarterial fibrosis, thickening, and adhesions,’” she said. “This in turn leads to rigid vessel walls, and I would expect that treating such lesions with endovascular therapy would be more complicated than stenting the typical atherosclerotic lesion.”

The primary risk would be restenosis as opposed to surgery, which “involves simply bypassing the affected segment,” she added.

However, even though surgery should remain the first-line option for Takayasu arteritis, Dr. Salameh said, that does not mean endovascular repair is never appropriate. One example would be “in a patient who is considered too high risk to undergo surgery,” she noted.

Just as important as the difference between surgery and endovascular repair, though, “is that patients in the study who underwent a procedure—regardless of whether it was surgical or endovascular—had much higher complication rates if active biological inflammation was present at the time of the procedure,” Dr. Salameh stressed.

Study Details

Most patients were female (79.9%), with a median age at diagnosis of 45. The main presenting feature was arterial claudication of the lower limbs.

 


Source:
Saadoun D, Lambert M, Mirault T, et al. Retrospective analysis of surgery versus endovascular intervention in Takayasu arteritis: A multicenter experience. Circulation. 2012;Epub ahead of print.

 

Jason R. Kahn, the former News Editor of TCTMD, worked at CRF for 11 years until his death in 2014…

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Disclosures
  • Drs. Saadoun and Salameh report no relevant conflicts of interest.

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