1、腔内治疗是否是大动脉炎（TA）的 禁忌,北京大学第三医院,TA 是一种病因未知的慢性炎症性疾病1. TA包括主动脉及主要分支 (常见)冠状动脉, 肺动脉, 主动脉瓣(不常见) TA在亚洲和拉丁美洲更常见 TA大多数见于年轻女性患者.,1.Kerr Gs. Rheum Dis Clin Notth Am 1995; 21: 1041-1058,TA 的治疗,外科手术,传统搭桥 2,3 累积存活率: 81.4% (10 年) 73.5% (20 年) 再狭窄率: 2030%.,腔内介入,PTA 和/或 支架 累积技术成功率4: 82% (一期)90% (二期) 再狭窄率5: 19%-78%,2.
2、Endo M, Tomizawa Y, Nishida H et al. Angiographic findings and surgical treatments of coronary artery involvement in Takayasu arteritis. J Thorac Cardiovasc Surg 2003;125:5707. 3. Miyata T, Sato O, Koyama H, Shigematsu H, Tada Y. Long-term survival after surgical treatment of patients with Takayasus
3、 arteritis. Circulation 2003;108:147480.,4. Pil-Ki Min, Sungha Park, Jae-Hun Jung, Young-Guk Ko, Donghoon Choi, Yangsoo Jang, Won-Heum Shim, Endovascular Therapy Combined With Immunosuppressive Treatment for OcclusiveArterial Disease in Patients With Takayasus Arteritis. J Endovasc Ther 2005;12:2834
4、,5. Sharma BK, Jain S, Bali HK, Jain A, Kumari S. A follow-up study of balloon angioplasty and de-novo stenting in Takayasu arteritis. Int J Cardiol 2000;75(Suppl 1):S147,目前没有明确的指南确定手术或介入治疗6 首选手术治疗：长段狭窄或闭塞病变TA晚期动脉壁完全纤维化病变 首选介入治疗：TA并发症危及生命（高血压脑病、充血性心衰）,6. Lee BB, Laredo J, Neville R, Villavicencio JL
5、. Endovascular management of takayasu arteritis: is it a durable option? Vascular. 2009 May-Jun;17(3):138-46.,1.临床缺血症状 肾血管性高血压 肢体缺血 颅内血管缺血 慢性肠系膜缺血 2. 动脉狭窄大于50 3. 临床非活动期,TA介入治疗指征:,左颈总,讨论一 ：TA腔内治疗的效果如何,颈内动脉直接穿刺, 置入颈动脉保护伞.,逆行穿刺颈总动脉.,颈总动脉开通,支架植入前,5年后（CTA）,手术后（DSA）,Right common carotid artery,restenosis
6、13th month,restenosis 5th month,not stable with corticosteroids and immunosuppression after the treatment,Horie N, Hayashi K, Morikawa M, et al. Acta Neurochir . 2011 May;153(5):1135-9,Horie N, Hayashi K, Morikawa M, et al. Acta Neurochir . 2011 May;153(5):1135-9,Right common carotid artery,stable w
7、ith corticosteroids and immunosuppression after the treatment,restenosis 3th month,8th month,15th month,第一次介入治疗,第一次介入治疗,动脉期,实质期,第一次介入治疗3月后,第一次介入治疗15月后,第二次介入治疗（2011.9）,TA腔内治疗的效果,弓上动脉TA介入 （颈总、锁骨下、颈内）,3年通畅率: 83% (一期) 95% (二期),肾动脉TA介入,5年通畅率: 49% (一期)83% (二期),Kim HJ, Lee CS, Kim JS, et al. Outcomes after
8、 endovascular treatment of symptomatic patients with Takayasus arteritis. Interv Neuroradiol. 2011 Jun;17(2):252-60. Epub 2011 Jun 20.,Ham SW, Kumar SR, Wang BR, et al. Late outcomes of endovascular and open revascularization for nonatherosclerotic renal artery disease. Arch Surg. 2010 Sep;145(9):83
9、2-9.,胸降主动脉TA介入,3年通畅率: 100% (一期),Bali HK, Bhargava M, Jain AK, et al. De novo stenting of descending thoracic aorta in Takayasu arteritis: intermediate-term follow-up results.J Invasive Cardiol. 2000 Dec;12(12):612-7.,TA腔内治疗的效果,效果与病变动脉直径相关效果与病变活动性相关活动性病变必要时应用激素治疗TA腔内治疗近期效果较良好；远期效果有待进一步明确TA腔内治疗优先选择PTA
10、,讨论二 ：如何判断TA的活动期,TA活动性的评估是困难的,急性反应介质（ESR/CRP）和临床表现的一致性仅为50. ESR正常的TA经常发现影像学表现活动的病例. 单一的指标判断TA的活动性是不可靠的.,1. Kerr GS, Hallahan CW, Giordano J, Leavitt RY, Fauci AS,Rottem M, et al. Takayasu arteritis. Ann Intern Med 1994;120:91929. 2. Hoffman GS, Ahmed AE. Surrogate markers of disease activity in pati
11、ents with Takayasu arteritis: a preliminary report from The International Network for the Study of the Systemic Vasculitides (INSSYS). Int J Cardiol 1998;66 Suppl 1:S1914.,1. Systemic features (such as fever or musculoskeletal features) withno other cause identified 2. Elevated erythrocyte sedimenta
12、tion rate 3. Features of vascular ischemia or inflammation, such asA. ClaudicationB. Diminished or absent pulsesC. BruitD. Vascular pain (carotodynia)E. Asymmetric blood pressure in either the upper or lower limbs(or both) 4. Typical angiographic features,Table . NIH criteria for active disease in T
13、akayasu arteritisNonvalidated,NIH criteria define active disease as new onset or worsening of 2 or more of the following features:,Arnaud L, Haroche J, Malek Z, et al . Is (18)F-fluorodeoxyglucose positron emission tomography scanning a reliable way to assess disease activity in Takayasu arteritis?
14、Arthritis Rheum. 2009 Apr;60(4):1193-200.,临床评估系统性症状（发热、肌肉酸痛）新出现或加重的缺血症状 生物学评估ESR、CRP 放射学评估MRI（动脉壁增厚大于3mm、T1相增强）PET-CT（F-18 FDG ）,综合评估TA的活动性,FIG. Axial T1-weighted gadolinium-enhanced MR image (500/20) shows extensive enhancement of abnormally thickened right brachiocephalic artery wall (arrowheads).
15、,Gotway MB, Araoz PA, Macedo TA, et al. AJR Am J Roentgenol. 2005 Jun;184(6):1945-50.,FIG. (A) Colour Doppler ultrasonography of the common carotid artery of a patient with large-vessel arteritis showing the typical halo sign, i.e. a concentric hypoechogenic mural thickening representing vessel wall
16、 oedema. (B) CT angiography of the same patient, showing a symmetrical circumferential thickening of both carotid vessel walls (3.5 mm) and narrowing of the lumen.,Pipitone N, Versari A, Salvarani C. Rheumatology (Oxford). 2008 Apr;47(4):403-8.,临床评估系统性症状（发热、肌肉酸痛）新出现或加重的缺血症状 生物学评估ESR、CRP 放射学评估MRI（动脉壁增厚大于3mm、T1相增强）PET-CT（F-18 FDG ）,综合评估TA的活动性,thanks,
