Yusuke Tada

Long-Term Survival After Surgical Treatment of Patients With Takayasu’s Arteritis

Background—Surgical interventions have been performed to ameliorate the complications of Takayasu’s arteritis. However, the efficacy of surgery to increase long-term survival has not been established. Methods and Results—A retrospective review was performed on the survival of 106 consecutive patients with Takayasu’s arteritis who underwent surgical treatment during the past 40 years. Their ages ranged from 5 to 69 years (mean±SEM, 31.7±1.3 years). Survival was compared with the reported results of medically treated patients according to Ishikawa’s prognostic classification. There were 12 hospital deaths, and the remaining 94 patients were followed up from 8 months to 41.8 years (mean, 19.8 years). A serious long-term complication was anastomotic aneurysm, with a cumulative incidence at 20 years of 13.8%. Thirty-one late deaths were observed, and the major cause was congestive heart failure. The overall cumulative survival rate at 20 years was 73.5%. The prognostic classification by Ishikawa had little influence on the survival of surgically treated patients. For stage 3 patients, surgery seemed to increase survival; however, surgery-related complications conversely decreased the survival of stage 1 patients. Conclusions—Surgery seems to increase the long-term survival of patients with stage 3 Takayasu’s arteritis, whereas conservative treatment is recommended for those with stage 1 or 2 disease. An anastomotic aneurysm may occur at any time after surgery, and regular follow-up using imaging modalities such as multi-detector CT, MRI, or ultrasonography at least once every several years for the rest of the patient’s life is mandatory for the early detection of anastomotic aneurysm.

Restricted Usage of T-Cell Receptor Vα-Vβ Genes in Infiltrating Cells in Aortic Tissue of Patients With Takayasu’s Arteritis

Background Infiltration by perforin-secreting killer lymphocytes, such as T cells and natural killer cells, has been shown to be involved in the pathogenesis of vascular cell damage in Takayasu’s arteritis. Methods and Results To investigate the immunological mechanisms involved, especially the nature of T-cell infiltration in Takayasu’s arteritis as well as atherosclerosis, we analyzed the expression of T-cell receptor (TCR) Vα and Vβ genes in infiltrating cells in the aortic tissue of patients with Takayasu’s arteritis and atherosclerotic aortic aneurysm by polymerase chain reaction (PCR). We also analyzed the expression of cytokine genes by PCR. We found that the repertoires of TCR Vα as well as Vβ gene transcripts in Takayasu’s arteritis were restricted. The infiltrating cells expressing Vα2, Vα16, Vα17, Vβ7, and Vβ13.1 were found in 3 of 4 patients. In contrast, TCR Vα-Vβ repertoires in atherosclerotic aortic aneurysm were polyclonal. There was no significant difference in the pattern of cytokine gene expression between the two diseases. Conclusions The restricted usage of TCR Vα as well as Vβ genes by infiltrating T cells in Takayasu’s arteritis may indicate that a specific antigen in the aortic tissue was targeted. Our findings provide the evidence that distinct immunological mechanisms are involved in the pathogenesis of Takayasu’s arteritis and atherosclerotic aortic aneurysm.

Anastomotic aneurysms after surgical treatment of Takayasu's arteritis: A 40-year experience☆☆☆★

PURPOSE To evaluate the clinical characteristics of anastomotic aneurysms that develop in surgically treated patients with Takayasus arteritis. METHODS Among 103 patients with Takayasus arteritis treated surgically over 40 years, 91 patients with 259 anastomoses (allowing for exclusion of 12 operative deaths) participated in follow-up study from 1 month to 37.3 years with a mean value +/- SEM of 17.3 +/- 1.1 years with a follow-up completion rate of 93% at 30 years. The clinical characteristics of anastomotic aneurysms were clarified, and the influences of several factors (sites of anastomoses, occlusive or aneurysmal disease, suture material, preoperative systemic inflammation, and administration of corticosteroids) on formation of anastomotic aneurysms were analyzed by means of life-table method and Cox regression analysis. RESULTS Twenty-two uninfected anastomotic aneurysms were found among 14 patients (22 of 259 anastomoses, 8.5%). The interval between the previous operation and diagnosis varied from 1.6 to 30 years with a mean value +/- SEM of 9.8 +/- 1.8 years. The cumulative incidence of anastomotic aneurysm at 20 years was 12.0%. Systemic inflammation or steroid administration had little influence on formation of anastomotic aneurysm. Instead, anastomotic aneurysm tended to occur after operations for aneurysmal lesions. CONCLUSIONS Anastomotic aneurysm can occur anytime after operations for Takayasus arteritis. The development of anastomotic aneurysm is not influenced by any factor specific to this disease except the presence of an aneurysmal lesion.

Surgical treatment of Takayasu arteritis

SummaryFrom 1959 to 1991, 93 patients underwent vascular reconstruction for Takayasu arteritis at our institution. The details of the cases were as follows: 16 were of type I (brachiocephalic ischemia), 48 type II (hypertension), 13 type III (extensive lesions with cerebral ischemia and hypertension), and 16 type IV (aneurysms). Carotid reconstruction, repair of atypical aortic coarctation, renovascular reconstruction, and aneurysm repair were performed independently or in combination. Nine operative deaths occurred, 8 cases of which were operated before 1970. The most serious of the delayed complications was suture line aneurysm formation, which was encountered in ten cases. The aneurysms were often found long after the operation, some of them developing even after more than 20 years. Takayasu arteritis is characterized by extensive inflammation and destruction of the medial elastic fibers and long term postoperative observation is mandatory to improve the late survival rate.

Expression of Costimulatory Molecules (4-1BBL and Fas) and Major Histocompatibility Class I Chain-Related A (MICA) in Aortic Tissue with Takayasu’s Arteritis

To further investigate the immunological mechanisms involved, we analyzed the expression of costimulatory molecules in aortic tissue and their counterpart molecules on infiltrating cells of patients with Takayasu’s arteritis. We also examined the expression of major histocompatibility complex (MHC) class I chain-related (MIC) A in aortic tissue, which is known to be induced by external stress, and its counterpart NKG2D receptors on infiltrating cells. Among these costimulatory molecules, strong expression of 4-1BBL and Fas was induced in the aortic tissue, and most of the infiltrating cells expressed 4-1BB and FasL, suggesting these pathways play critical roles in T-cell-mediated vascular injury. We also found that MICA was strongly induced in the aortic tissue and that at least part of the infiltrating cells expressed NKG2D receptors. Some infiltrating cells – but not vascular smooth muscle cells – seemed to have undergone apoptosis. Our findings strongly suggest that 4-1BB/4-1BBL and Fas/FasL pathways play important roles in vascular injury in Takayasu’s arteritis. We assume that γδ T cells infiltrated aortic tissue recognizing MICA, resulting in the induction of MHC antigens and costimulatory molecules, and then αβ T-cells infiltrated recognizing some auto-antigens presented by MHC antigens, leading to chronic inflammation.

Restricted usage of T-cell receptor Vγ–Vδ genes and expression of costimulatory molecules in Takayasu’s arteritis

Abstract To further investigate the immunological mechanisms involved in Takayasus arteritis, we analyzed the T-cell receptor (TCR) Vγ and Vδ gene usage by infiltrating γδ T-cells and the expression of costimulatory molecules B7-1, B7-2, CD40, CD27 ligand (CD27L), CD30L, OX40L in the arterial tissue of a patient with Takayasus arteritis. We found that the repertoires of TCR Vγ as well as Vδ gene transcripts of the infiltrating cells were restricted as compared with those of peripheral blood lymphocytes from a patient with Takayasus arteritis. This strongly suggests that γδ T-cells as well as αβ T-cells, as we previously reported, were specifically involved in the pathogenesis of Takayasus arteritis. We also found that B7-1, B7-2, CD40, CD27L, CD30L, and OX40L were expressed in the arterial tissue, suggesting the roles for these costimulatory molecules in T-cell-mediated vascular injury in Takayasus arteritis. Our findings strongly support the involvement of T-cell-mediated immunological mechanisms in the pathogenesis of Takayasus arteritis.

Aortobronchial fistula after an aortic operations

A 71-year-old man with a postoperative aortobronchial fistula was successfully treated. The fistula occurred between the left lower lobe and the descending thoracic aorta, to which a distal anastomosis of a temporary bypass graft had been placed during thoracic aortic aneurysmectomy 3 years before. For saving patients with this complication, early surgical treatment during episodes of intermittent hemoptysis is important. The use of an omentum pedicle flap for the isolation of the suture line is a important adjunct.

Rupture of an Isolated Internal Iliac Artery Aneurysm into the Rectum : Report of a Case

Aneurysmal rupture into the intestinal tract is a rare but disastrous complication of an internal iliac artery aneurysm. We report herein the successful surgical repair of a fistula between a huge aneurysm of the right internal iliac artery and the rectum in an 81-year-old man. After a femoro-femoral cross-over bypass had been performed, the aneurysm was opened and its patent arterial branches were ligated with sutures. The fistula was then intra-aneurysmally sutured and covered with an omental flap. The diagnostic and therapeutic approaches to this severe complication are discussed with a review of the literature following the presentation of this case.

Surgical Treatment of Retroperitoneal Leiomyosarcoma Invading the Inferior Vena Cava: Report of Three Cases

Abstract.Retroperitoneal leiomyosarcoma is a rare neoplasm for which complete surgical removal provides the only effective treatment, as local recurrence adversely affects prognosis. However, invasion of major vessels may occur, making complete resection difficult. This report describes the cases of three patients who required concomitant resection of parts of the inferior vena cava because of direct tumor invasion. The major vessels should be isolated in preference to the tumor capsule during surgery to prevent sudden exsanguination or incomplete tumor resection. Resection of a recurrent sarcoma or a solitary metastasis can be effective in selected patients.

Successful surgical treatment of a patient with multiple visceral artery aneurysms due to fibromuscular dysplasia

Multiple visceral artery aneurysms due to fibromuscular dysplasia are rare. A 43-yr-old man with a pulsatile abdominal mass detected by ultrasonography had multiple visceral artery aneurysms diagnosed by angiography. This included a huge superior mesenteric artery aneurysm. Aneurysm resection and arterial reconstruction was performed successfully. Pathologic examination revealed fibromuscular dysplasia of the medial fibroplasia type.