Open surgical revascularization after IL-6 blockade for Takayasu arteritis: A case report

Takayasu arteritis (TAK) is a rare large-vessel vasculitis that may cause critical supra-aortic stenosis and cerebral ischaemia. Guidance on the optimal sequencing of biologic therapy and open revascularisation remains limited.

A 27-year-old woman with a decade-long history of systemic symptoms and limb claudication developed headaches, dizziness and presyncope. Examination showed asymmetric blood pressure, diminished pulses and widespread bruits. CT angiography demonstrated diffuse aortic wall thickening with critical bilateral carotid stenosis; PET/CT confirmed active vasculitis. High-dose methylprednisolone was started, followed by tapering prednisolone and methotrexate. Persisting symptoms and critical carotid disease prompted starting tocilizumab at week 4, achieving remission at week 10. Three months following therapy initiation, an ascending aorta-to-left carotid bypass with a 12-mm graft was performed via partial upper sternotomy without complications. Neurological symptoms resolved and cerebral flow normalised; she remains relapse-free two years later on tocilizumab, methotrexate and low-dose prednisolone.

Intravenous tocilizumab rapidly induces remission in TAK and shows lower relapse rates than the subcutaneous route. For long-segment supra-aortic lesions in TAK, open bypass avoids inflamed segments and offers greater durability than endovascular techniques, but should be scheduled during metabolic quiescence to minimise restenosis. This case illustrates the benefit of combining IL-6 blockade with timely surgery.

Open surgical revascularisation offers superior long-term patency in extensive Takayasu arteritis, and can be safely performed once remission has been induced with tocilizumab in refractory disease. Multidisciplinary coordination of biologic therapy and open revascularisation may optimise neurological and vascular outcomes in complex supra-aortic TAK.