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Progressing takayasu arteritis successfully treated by common carotid-internal carotid crossover bypass grafting:
Takeshi Hiu1, Naoki Kitagawa, Kazuhiko Suyama
1Department of Neurosurgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan.
Insights
Takayasu arteritis can cause severe carotid artery occlusion. A unique crossover bypass grafting procedure using saphenous vein successfully restored blood flow in a patient with complex arterial blockages.
Area of Science:
- Vascular Surgery
- Cardiology
- Neurology
Background:
- Takayasu arteritis is a rare, chronic inflammatory disease affecting large arteries, primarily the aorta and its branches.
- Occlusion of major cerebral arteries, such as the carotid arteries, can lead to severe neurological deficits.
Observation:
- A 63-year-old woman with Takayasu arteritis presented with symptoms of cerebral hypoperfusion due to occlusion of the left common carotid artery (CCA) and right internal carotid artery (ICA).
- Previous bypass grafting with a Gore-Tex prosthesis had failed, leading to critical stenosis and occlusion of major cerebral vessels.
- Cerebral angiography revealed extensive arterial occlusion, and I-iodoamphetamine single-photon emission computed tomography indicated reduced cerebrovascular reactivity.
Findings:
- Successful surgical intervention involved a right CCA-left ICA crossover bypass graft using the patient's saphenous vein.
- Histological examination of the explanted Gore-Tex graft showed myointimal hypertrophy and an inflammatory response.
- Postoperative imaging demonstrated normalized cerebrovascular reserve in both cerebral hemispheres.
Implications:
- Crossover bypass grafting with saphenous vein is a viable and effective treatment option for complex carotid artery occlusions in patients with Takayasu arteritis.
- This case highlights the importance of considering alternative surgical strategies when conventional bypass grafts fail in managing Takayasu arteritis-related cerebrovascular complications.
- Successful revascularization can significantly improve neurological function and cerebrovascular reserve in affected patients.
Objective:
This report describes a unique case of Takayasu arteritis with occlusion of the left common carotid artery (CCA) and the right internal carotid artery (ICA), which was successfully treated by right CCA-left ICA crossover bypass grafting using the saphenous vein. The histological findings of the original occluded prosthetic graft are also described.
Clinical Presentation:
A 63-year-old woman with a history of Takayasu arteritis was admitted to our hospital with a history of progressive dizziness, frequent syncopal attacks, and repetitive blurred vision in the left eye. She had undergone repeat transthoracic bypass surgeries, including grafting with the use of a Gore-Tex (W.L. Gore & Associates, Inc., Flagstaff, AZ) prosthesis between the left external ilioaxillary bypass and the left CCA. However, cerebral angiography demonstrated total occlusion of the left CCA, the right ICA, and the bilateral subclavian arteries. On admission, I-iodoamphetamine single-photon emission computed tomography showed a decreased cerebrovascular reactivity to acetazolamide in the bilateral cerebral hemispheres. Moreover, cerebral angiography revealed an occlusion of the Gore-Tex graft, whereas the left ICA was opacified through the retrograde filling in the left external carotid artery.
Intervention:
Crossover bypass grafting was performed using the saphenous vein between the right CCA and the left ICA. The Gore-Tex graft was partially removed, and myointimal hypertrophy with an inflammatory response around the wall was found histologically. The postoperative course was uneventful. A normalized cerebrovascular reserve in both cerebral hemispheres was demonstrated on I-iodoamphetamine single-photon emission computed tomography.
Conclusion:
Although it is not frequently indicated, crossover bypass grafting using the saphenous vein between bilateral carotid arteries is considered to be a feasible alternative procedure in patients with Takayasu arteritis.
