All of the techniques currently available for vein-sparing strategies, including novel endovenous options, are clearly described and illustrated, with explanation of the role and value of recent technical innovations. In addition, the literature on relevant diagnostic and therapeutic protocols is thoroughly reviewed, covering all significant publications to the present day. The content is kept as simple as possible to help those new to the field.
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BMC Fam Pract ; Ankle-brachial index performance among internal medicine residents. Vasc Med ; Training to measure ankle-brachial index at the undergraduate level: can it be successful? Int J Low Extrem Wounds ; Different calculations of ankle-brachial index and their impact on cardiovascular risk prediction. The ankle-brachial index for peripheral artery disease screening and cardiovascular disease prediction among asymptomatic adults: a systematic evidence review for the U. Preventive Services Task Force. Ann Intern Med ; Aspirin for prevention of cardiovascular events in a general population screened for a low ankle brachial index: a randomized controlled trial.
JAMA ; Ponka D, Baddar F. Ankle-brachial index. Can Fam Physician ; Correspondence address PD Dr. Ludwig Caspary Angiologische Praxis Luisenstr. Endovascular-first strategy for acute and subacute limb ischaemia: Potential benefits of a pure mechanical thrombectomy approach Comment on Stanek et al, p. Acute limb ischaemia is a challenging situation for every specialist in the vascular field since, depending on its severity, it may pose a threat for the affected limb or even the entire organism.
Ischaemia of the limb is initially reversible, but if left untreated, results in irreversible tissue death. The extent of organ damage depends on the ischaemic tolerance of the affected tissue. Exceedance of the tolerance limit results in lasting tissue injury, involving potential amputation and mortality. In view of demographic developments and the rising prevalence of cardiovascular risk factors, approximately 2.
These facts constitute a major challenge for the healthcare system. Acute limb ischaemia has been associated with high rates of morbidity and mortality. The same is true of ampu-. In the s, local thrombolytic therapy was used alongside the established vascular surgery technique of direct thrombectomy. New thrombolytic agents and modified forms of administration, such as pulse-spray thrombolysis, have markedly enhanced the speed of thrombolysis and its effectiveness. Over the years, various techniques of local thrombolysis have been developed.
A mechanical component pharmacomechanical thrombectomy was introduced in the form of infiltration techniques, which reduced the time until recanalisation Tab. I and enhanced the efficacy of the treatment. However, infiltration techniques are associated with the well-known complication of bleeding and consequent costs of monitoring patients at the intensive care unit.
The prognosis of clinically severe forms of ischaemia depends on the timely initiation of appropriate treatment and earliest possible revascularisation. Since this is not ensured by local thrombolysis, additional or alternative procedures such as pure mechanical thrombectomy must be.
Table II. Technical and clinical outcomes after treatment with thrombolysis, surgical thrombectomy, and mechanical thrombectomy rotational thrombectomy Publication. Extrapolated to endovascular therapy, a rotating helix inside the catheter produces suction and removes the thrombotic material. Depending of the lumen size of the catheter, vessels of various diameters can be treated with various rates of suction.
The advantage of a pure mechanical thrombectomy procedure is that it avoids additional thrombolysis therapy and thus reduces bleeding complications as well as prolonged intensive care surveillance. The authors conclude that, even in patients with limb-threatening acute ischaemia, mechanical percutaneous thrombectomy is superior to surgery in that it can be performed rapidly and easily without extensive preparation, and thus achieves rapid reperfusion. The economy of this approach for healthcare systems is also worthy of mention. Direct comparisons of the existing mechanical or pharmacomechanical thrombectomy devices do not exist.
Prospective randomised controlled studies would be needed to demonstrate the superiority of one thrombectomy system over another, but studies of this nature seem to be unlikely for several reasons. Apart from the complexity of such trials, each system has its limitations. Moreover, a French system is now available for arteries or grafts with a large lumen.
The latter employs thrombolysis medication in conjunction with a mechanical approach, which signifies potentially higher bleeding rates. Comparisons of thromboembolectomy by the vascular surgery approach with percutaneous thrombectomy systems have also not been published. Indirect comparisons of the relevant endpoint — amputation-free survival after 12 months — revealed better results with the mechanical treatment procedure than with local thrombolysis or surgical intervention Tab.
An indirect comparison Tab. II of relevant endpoint data clearly shows the effectiveness and superiority of the pure mechanical thrombectomy approach. This, in addition to the availability of more effective and safer endovascular thrombectomy procedures for acute and subacute limb ischemia, will help to incorporate these endovascular technologies in future guidelines.
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Vascular surgery-based thromboembolectomy, which provides no additional benefits in terms of efficacy, safety or hospital stay, as well as catheter-directed thrombolysis with potential life-threatening complications, should only be considered in cases of failed or incomplete mechanical thrombectomy. Acute limb ischemia. Early and five-year amputation and survival rate of diabetic patients with critical limb ischemia: Data of a cohort study of Patients. Peripheral arterial disease morbidity and mortality implications. Prevalence, incidence and outcomes of critical limb ischemia in the US Medicare population.
Early experience and midterm follow-up results with a new, rotational thrombectomy catheter. Recanalisation of acute and subacute femoropopliteal artery occlusions with the Rotarex catheter: one year follow-up, single centre experience. The Straub-Rotarex thrombectomy system: initial experiences. Recanalisation of acute and subacute venous and synthetic Bypass-graft occlusions with a mechanical rotational catheter. Retrograde rotational thrombectomy with the Rotarex catheter system: treatment option for an acute thrombotic occlusion of a subclavian artery.
Percutaneous mechanical thrombectomy for treatment of acute femoropopliteal bypass occlusion. Stanek F, Ouhrabkova R, Prochazka D: Percutaneous mechanical thrombectomy using the Rotarex catheter in the treatment of acute and subacute occlusions of the peripheral arteries and bypasses — Analysis of failures, complications, and long-term outcomes.
VASA ; 45 Mechanical rotational thrombectomy for treatment thrombolysis in acute and subacute occlusion of femoropopliteal arteries: retrospective analysis of the results from to A comparison of recombinant urokinase with vascular surgery as initial treatment for acute arterial occlusion of the legs. Results of a prospective randomized trial evaluating surgery versus thrombolysis for ischemia of the lower extremity.
There are no conflicts of interest existing. Correspondence address Dr. Inhaltlich unterscheiden die Autoren zwischen Makro-, Meso- und Mikroebene. Auf der Makroebene werden die Trends der Gesundheitsversorgung und des Gesundheitsmarktes analysiert. Die Mesoebene nimmt das Gesundheitsmanagement in Gesundheitsorganisationen und -unternehmen unter die Lupe. Summary: This overview analyses gender differences in prevalence, epidemiology, risk factors and therapy in patients with carotid stenosis in a systematic review.
The stroke-protective effect of carotid endarterectomy is greater in men. Men have lower peri-procedural stroke and death rates. Particularly men with carotid stenosis and a life expectancy of at least 5 years benefit from surgical treatment. Also, the recurrence rate of ipsilateral stroke 5 years after initial surgery is lower in men than in women.
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It is not yet fully clarified whether there are significant gender differences regarding the outcome after endovascular versus surgical treatment. Gender differences in the outcome of carotid artery repair may be caused by biological, anatomical smaller vessel diameter in women or hormonal differences as well as a protracted development of atherosclerotic changes in women and different plaque morphology. Moreover, women are on average older at the time of surgery and their surgical treatment is often delayed. To reduce the risk of stroke and to improve treatment outcome especially for women, further research on gender differences and their causes is mandatory and promising.
Key words: Carotid stenosis, sex, gender, prevalence, carotid artery stenting, carotid endarterectomy. In Western societies, stroke is a leading cause of death and hospitalisation. The average age-adjusted incidence per , is and for women. In advanced age, however, the risk of stroke adjusts for both sexes [1, 2]. In general, the extracranial carotid artery is concerned .
As most studies on carotid stenoses have been conducted with men, little is known about gender specifics regarding this disease. Here, we have examined publication records from until December to outline gender-specific differences in carotid artery stenosis. In a meta-analysis of 29 studies involving 22, patients, the pooled prevalence of moderate stenosis was 4. In a meta-analysis of 4 studies with patients, the prevalence of high-grade stenosis was 1. Methods The article reviews relevant studies, reviews, meta-analyses and consensus papers on carotid stenoses whether they deal with gender differences.
For this purpose, Medline PubMed was searched for such studies etc. Epidemiology and risk factors for stroke Although the prevalence for carotid stenosis is higher in men, the risk of stroke is higher in women. In Western societies, one out of every 5 women and one out of every 6 men will suffer from a stroke during their lifetime .
In addition to the classical risk factors concerning both genders such as arterial hypertension, diabetes mellitus type II, obesity, smoking, lack of exercise, hyperlipidaemia, positive family history and age, women face specific risks such as pregnancy complications pre-eclampsia, gestational diabetes or pregnancy-induced hypertension , as well as autoimmune diseases and rheumatoid arthritis .
In particular, both polycystic ovary syndrome and preeclampsia are associated with an increased risk for hypertension, coronary heart disease, diabetes mellitus and stroke . Moreover, age may be an influencing factor, as age is a risk factor for atherosclerosis and in average, women become older than men. The incidence of stroke in menopausal women increases significantly , possibly due to decreasing oestrogen levels, as oestrogen protects from cardiovascular disease.
Women also have smaller arteries than men which may predispose them to stroke. In contrast, men generally have more comorbidities compared to women, including cigarette smoking, diabetes mellitus, myocardial infarction with or without coronary bypass surgery, and peripheral arterial disease. Therefore, the American Heart Association AHA expert group has published separate guidelines about stroke in women with atrial fibrillation. Plaque morphology by analysis of endarterectomy specimen The reasons for gender differences in the incidence rates of stroke and outcome after carotid endarterectomy CEA are poorly understood and certainly multifactorial.
One contributing factor may be differences in carotid plaque morphology. Analysis of plaque morphology The Doppler and color-coded duplex ultrasound is the method of choice for screening of carotid stenosis Level of Evidence 1 . In general, the incidence of carotid stenosis in men is more often and the plaque area is larger than in women . Assessment of carotid plaques by duplex ultrasound revealed that a high ratio of fat to necrotic core, a thin or ruptured fibrinous cap, plaque haemorrhage and a larger wall thickness all are associated with a higher risk for an ischemic cerebrovascular event.
MRI diagnostics of carotid arteries in patients with carotid artery stenosis resolves detailed plaque morphology as has been demonstrated by subsequent ex-vivo histological analysis of plaques following CEA. Multiple studies have addressed the issue of gender differences in plaque morphology using imaging methods on patients duplex ultrasound, magnetic resonance imaging or computer tomography angiography or histological examinations of excised plaque material.
The studies show that carotid plaques in men have a greater intima-media thickness than in women . Hellings et al. This study reports that plaques in women show higher smooth muscle cell content, contain less fat and are less inflamed, as concluded from lower IL-8 concentration, lower MMP8 activity and lower macrophage content . Clearly, plaques in women are generally more stable than in men. The gender-associated differences in plaque morphology are most evident in women with asymptomatic carotid artery stenosis, which may explain why they in particular have lower long-term stroke reduction after CEA .
Gender-specific therapy of carotid artery stenosis and stroke Sex-related differences in pharmacokinetics and pharmacodynamics are of major importance. These differences have obvious relevance to the efficacy and side effects profiles. Likewise, different enzyme formations and drug compatibilities play a role . In general, treatment of carotid stenosis depends on the severity of the disease.
Conservative treatment of asymptomatic carotid stenosis includes the elimination of cardiovascular risk factors, and medical therapy with antithrombotic platelet aggregation inhibitors and cholesterol lowering statins. More severe disease is treated by interventional or surgical approaches to enlarge vessel lumen. Almost identical results were obtained by a study by Berger et al. The gender-specific effects of aspirin may at least in part be due to the contrary effects of sex hormones on platelet aggregation which is stimulated by testosterone and inhibited by oestrogen and progesterone, respectively .
These observations clearly demonstrate the need for gender-specific treatment of cardiovascular diseases. While the gender-specific effects of aspirin or the contrary effects of sex-hormones on platelet aggregation cannot explain the higher risk for women than men to suffer from stroke, one reason for this difference may simply be that women take less medication aspirin, statins and ACE-inhibitors than men. It must be noted, however, that no significant gender differences have been found for aspirin as secondary stroke prevention [5, 19].
Law et al. Therefore, statin therapy might be recommended independent of the basal LDL cholesterol levels. No genderspecific recommendations were found. Presumably, this difference is due to the higher rate of perioperative complications in women 3. Subgroup analyses in both trials revealed that surgery is significantly more advantageous for men ARR 4. However, after 10 years, women also benefited perioperative stroke: 5. There are no gender-specific adaptations in these guidelines. Generally for the management of asymptomatic carotid stenosis also the non-invasive treatment with bestavailable medical therapy is an option , although at present there is limited evidence that this therapy alone is the best choice .
However, this difference may be explained by the fact that in women, a CEA is performed less frequently and often only at a late stage . A study by Kapral et al. Although there was no gender-specific difference in the frequencies of perioperative complications, within a 2-year follow-up, women had a higher risk of recurrent stroke than men, which may be attributable to a higher number of women in this study suffering from arterial hypertension.
In contrast, men were at higher risk of mortality, possibly because of a higher prevalence of coronary artery disease . All studies agree that protection from stroke by CEA is significantly higher for men than for women. Whether gender plays a role in the endovascular therapy appears to be controversial. After 2. A systematic review consisting of studies reported an association of female gender with a higher risk of procedural stroke or death after CEA but not after CAS . These results suggest that the long-term perspective of an increased peri-procedural risk of stroke or death in women after CEA should be taken into account when selecting treatment for carotid artery stenosis.
Jim et al. Since the data concerning CEA and CAS remain inconsistent in regard of the impact of gender further research with a focus on the gender aspect is required. Conclusions Although the surveyed studies come to different conclusions in part, there is general agreement that men benefit more from a CEA than women.
Studies comparing CEA to pure medication therapy found less favourable results for women than for men with respect to revascularisation.
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With respect to CEA, men have lower peri-procedural stroke and death rates. Also, the 5-year recurrence rate of ipsilateral stroke after surgery is higher in women. The reasons for such differences are not yet clear. They may be caused by biological, anatomical smaller vessel diameter or hormonal reasons as well as a protracted development of atherosclerotic changes in women. Also, different plaque morphology may be a cause. Furthermore, the higher age of women at the time of first diagnosis and of surgical treatment can be an influential factor.
To reduce the risk of stroke and improve treatment results, especially for women, further research on gender differences and their causes is mandatory and promising. Sex differences in stroke epidemiology: a systematic review. In: Rieder A, Lohff B eds. Springer, 2. Prevalence of asymptomatic carotid artery stenosis according to age and sex: systematic review and meta-regression analysis.
Gender Differences in stroke. In: Legato MA. Principles of gender-specific medicine. Gender medicine: a task for the third millennium. Development and validation of improved algorithms for the assessment of global cardiovascular risk in women: the Reynold Risk Score. Ringleb P, Eckstein H-H. Sex differences in carotid plaque and stenosis. Moderate carotid artery stenosis: MR imaging depicted intraplaque haemorrhage predicts risk of cerebrovascular ischemic events in asymptomatic men.
Association between carotid plaque characteristics and subsequent ischemic cerebrovascular events: a prospective assessment with MRI- initial results. MRI-derived measurements of fibrous-cap and lipid-core thickness: the potential for identifying vulnerable carotid plaques in vivo. Sex differences in patients with asymptomatic carotid atherosclerotic plaque: in vivo 3.
Gender-associated differences in plaque phenotype of patients undergoing carotid endarterectomy.
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A randomised trial of lowdose aspirin in the primary prevention of cardiovascular disease in women. Aspirin for the primary prevention of cardiovascular events in women and men: a sex-specific meta-analysis of randomized controlled trials. Cerebrovasc Dis ;25 4 Indications for early aspirin use in acute ischemic stroke: a combined analysis of 40, randomised patients from the Chinese acute stroke trial and the international stroke trial.
Stroke ; 31 6 : Quantifying effect of statins on low density lipoprotein cholesterol, ischaemic heart disease, and stroke: systematic review and meta-analysis. Br Med J ; Endarterectomy for asymptomatic carotid artery stenosis. Prevention of disabling and fatal strokes by successful carotid endarterectomy in patients without recent neurological symptoms: randomised controlled trial. TESC Guidelines on the diagnosis and treatment of peripheral artery diseases: Document covering atherosclerotic disease of extracranial carotid artery.
Management strategies for asymptomatic carotid stenosis. A systematic review and meta-analysis. Management of carotid stenosis in women. Consensus document. European Stroke Organisation Writing Committee.
Guidelines for management of ischaemic stroke and transient ischaemic attack. Reanalysis of the final results of the European carotid surgery trial. Carotid Endarterectomy Trialists Collaboration. Endarterectomy for symptomatic carotid stenosis in relation to clinical subgroups and timing of surgery. Sex difference in the effect of time from symptoms to surgery on benefit from carotid endarterectomy for transient ischemic attack and non-disabling stroke. Gender differences in treatment of severe carotid stenosis after transient ischemic attack.
Carotid endarterectomy for asymptomatic carotid stenosis. Sex differences in carotid endarterectomy outcomes results from the Ontario carotid endarterectomy registry. Stenting versus endarterectomy for treatment of carotid-artery stenosis. Influence of sex on outcomes of stenting versus endarterectomy: a subgroup analysis of the carotid revascularisation endarterectomy versus Stenting trial CREST.
International Carotid Stenting Investigators. Carotid artery stenting compared with endarterectomy in patients with symptomatic carotid stenosis International Carotid Stenting Study : an interim analysis of a randomised controlled trial. Systematic review of perioperative risks of stroke or death after carotid angioplasty and stenting. A clinical rule sex, contralateral occlusion, age, and restenosis to select patients for stenting versus carotid endarterectomy: systematic review of observational studies with validation in randomised trials. Short-term outcome after stenting versus endarterectomy for symptomatic carotid stenosis: a pre-planned meta-analysis of individual patient data.
Gender-specific 30day outcomes after carotid endarterectomy and carotid artery. No gender influences on clinical outcomes or durability of repair following carotid angioplasty with stenting and carotid endarterectomy. Carotid revascularization using endarterectomy or stenting systems caress :4 year outcomes. Results of the stentprotected angioplasty versus carotid endarterectomy SPACE study to treat symptomatic stenoses at 2 years: a multinational, prospective, randomised trial. Submitted: Summary: Inflammatory aortic diseases may occur with and without dilatation and are complicated by obstruction, rupture and dissection.
Infections originate from periaortic foci or septicaemia and tend to result in the rapid development of aneurysms. Large vessel vasculitis due to Takayasu arteritis in younger and giant cell arteritis GCA in older patients is located in all layers of the aortic wall and prevails in the thoracic section. GCA patients are prone to developing aortic complications in the late course of disease. The diagnosis of aortitis is usually obtained by vascular imaging, but partly made only by biopsy on occasion of an operation, especially in case of isolated aortitis of the ascending aorta which mostly remains inapparent until dissection or large aneurysms have developed.
Periaortitis typically occurs in the abdominal aorta and may lead to inflammatory aortic aneurysm IAA. It is looked upon as a special form of vasculitis, with an overlap to primary retroperitoneal fibrosis RF. An identical pathology is discussed for the three diseases. Periaortitis also is observed after treatment of aortic aneurysms by stent-graft implantation. Once infection is ruled out, immunosuppression is applied to all forms of inflammatory aortic diseases, primarily with glucocorticoids. However, after successful surgery for isolated thoracic aortitis or inflammatory aortic aneurysm immunosuppression may be dispensable and it is not required if periaortic tissue enlargement persists in chronic inactive disease.
For some patients with periaortitis and RF, tamoxifen may be a valuable alternative. Introduction Inflammatory diseases of the aorta are rare compared to atherosclerosis, which is the most frequent cause of aortic disease. The underlying pathology is diverse Tab. A clinician is confronted with various kinds of initial symptoms and — in a number of cases — diagnosis is provided by histopathology or made by chance. Inflammation may be located in all layers of the vessel wall or be restricted to the adventitial and periadventitial tissue.
It can be found in the thoracic or abdominal part of the aorta only or spread along the entire length of it. It may be restricted to the aorta or appear in other arteries as well. Vessel inflammation is mostly part of systemic disease.
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In the course of inflammation, aneurysmatic dilatation may occur with the risk of rupture. On the other hand, dissection is possible despite unchanged vessel diameter. In most cases, immunosuppressive treatment is required, sometimes for a long period of time . Diseases Infectious aortitis Vessel infections may be generated by endocarditis, local perivascular foci such as vertebral osteomyelitis or septicaemia.
A pre-existing atherosclerotic pathology, in the form of a plaque formation or an aneurysm, may facilitate and subsequently host infection. Certain bacteria are known to affect distinct parts of the aorta. Treponema pallidum, however rare, is almost entirely found in the ascending aorta or the aortic arch. In general, gram-positive bacteria such as Staphylococcus or Enterococcus species and Streptococcus pneumonia have a propensity for the thoracic aorta  while gram-negative germs, especially Salmonella species, prevail in the abdominal aorta.
Infection generally leads to the formation of an aneurysm very early. Typically, the aneurysms resulting are excentric and sacciform. Due to their fungous aspect they are called mycotic aneurysms. In the aortic arch, aneurysm formation often occurs on the concave side opposite the supra-aortic branches. In the abdomen, it forms similarly, but at the dorsal side opposite the visceral arteries.
An infectious aortitis rarely may be detected before vessel wall inflammation leads to an aneurysm . Clinical signs are non-specific. Fever of unknown origin is the most frequent symptom, followed by back pain in the case of abdominal localisation. The level of CRP elevation mostly exceeds that of ESR, but this may occur in non-infectious aortic inflammation as well. Samples for blood culture should be drawn repeatedly, but negative results are frequent and do not rule out an infection.
Table I. Echocardiography is crucial to detect an underlying valve endocarditis. Both endocarditis and the aortic infection itself may produce septic embolism with splinter haemorrhages in toes and fingers. The differential diagnosis of bacterial or non-bacterial inflammation may remain difficult. It may reveal a perivascular focus of infection. Gas in the aortic wall is an almost certain sign of infection even before aortic dilatation begins .
Periaortic lymph nodes may be found to be enlarged. In some cases, repetitive investigation could demonstrate rapid aneurysmal growth . Patients with infective aortitis are in danger of aneurysm rupture but also of the formation of aorto-caval or aorto-enteric fistula. Untreated, the infection tends to generalisation and multiorgan failure . Once the infectious nature of aortitis was identified, antibiotic therapy is introduced.
However, if the germ responsible is not known and clinical situation allows for it, spending some time for further sample acquisition might be of value. Untargeted antibiotic treatment will consider the higher prevalence of gram-positive bacilli in the thoracic and enterobacteria in the abdominal part of the aorta. Antibiotic treatment is recommended over a six to eight week period . Aneurysm formation can proceed even after successful antibacterial treatment and regularly leads to rupture.
Surgery is always necessary in that case and often demanded as an emergency. With regard to graft infection, resection of the infected aortic section and extra-anatomical artery reconstruction is propagated as the gold standard. Arterial homografts seem to be an expensive but safer alternative if in situ-reconstruction is chosen.
Replacement of the infected aortic segment by autologous femoral vein was tried with low donor-side morbidity and low graft infection rates . Stenting was discussed as an additional option, especially in emergency situations, leaving the perspective of later open reconstruction of the aorta after the patient was stabilised. Planned as a definitive procedure, the method has best results in abdominal aortic infections due to salmonella species. Development of aorto-enteric or aorto-bronchial fistula in patients with stents is generally lethal.
Long-term monitoring is mandatory, including laboratory controls and imaging, with CT being preferred in the case of stenting. In uncomplicated cases of abdominal repair, CDUS may be sufficient to rule out relapse of infection. Vasculitis The aorta is involved in several of the vasculitides for which the Chapel Hill nomenclature has recently been revised . In addition, the two types of medium-vessel vasculitis, polyarteritis nodosa PAN and Kawasaki disease KD , may in some cases extend to larger vessels, even the aorta; the same holds true for ANCA-associated vasculitides.
Isolated aortic vasculitis is in the category of single organ vasculitis. Giant cell arteritis GCA Giant cell arteritis accounts for the majority of inflammatory aortic diseases . In recent years, important parts of the pathogenesis have been elucidated : Inflammation begins in the vasa vasorum involving dendritic cells, the activation of which induces lymphocyte invasion to the vessel wall normally free of immunological processes.
Constitutional symptoms are frequent in the acute form, sometimes with fever of unknown origin in the beginning. There are no specific laboratory tests. Interleukin-6 and Pentraxin-3 are correlated with disease activity but so far have not reached clinical relevance. Temporal biopsy may prove the disease but is less sensitive in case of large vessel GCA. Colour-coded Doppler ultrasound CDUS is valuable for detection of vessel inflammation both in the temporal artery and in large vessels, showing homogeneous hypoechogenic vessel wall enlargement Fig.
Typical hypodense enlargement of the vessel wall is seen by CT. MR-angiography may reveal increased perfusion within the aortic wall indicating local inflammation . In patients with a subtype of large vessel GCA, inflammation of the aorta is frequent especially in the thoracic part. It is, however, still considerable in cranial-type GCA patients. In all cases, the thoracic aorta was affected, in 19 patients, the abdominal aorta showed vessel wall enlargement as well.
In all but three patients vessel wall thickening was found in aortic branches as well. On the contrary, there was only one patient with large vessel GCA in whom the aorta was spared . PET is of special value if isolated GCA-aortitis is considered and if active inflammation is suspected although laboratory inflammation parameters are normal. If used to clarify unexplained general symptoms as fever of unknown origin, 18FDG enrichment in the aortic wall often gives the first hint at an underlying vasculitis.
Apart from that, if the diagnosis of GCA was established by other means, PET is dispensable; the additional information gained is seldom decisive and its sensitivity rapidly decreases once an immunosuppressive therapy is initiated. Moreover, persisting 18FDG enrichment may correspond to vessel wall remodelling and is not proof of active inflammation . Aortic involvement may produce chest or back pain but is more frequently asymptomatic.
In rare cases, it represents the only manifestation of GCA. Usually, it is found in complementary investigations after other symptoms gave the clue to diagnosis. Anyhow, its disclosure is of importance since patients with initial aortic involvement tend to more frequently experience cardiovascular complications and a higher rate of recurrence , thus probably requiring more intense treatment. On the other hand, aortic manifestation may develop in the course of disease of formerly unaffected patients.
Figure 1. CT shows a non-circular vessel wall thickening A. Diagnosis of GCA was made by the detection of an enlarged vessel wall in the left common carotid artery B and subclinical stenosis of the left axillary artery C. Eight of the patients met the criteria for aortic interventions and one died of dissection . Development of aortic sequelae was unpredictable and more pronounced in patients with good clinical response to initial treatment. The percentage of patients in remission of active disease was considerably higher in patients with aortic involvement than in those without.
Pathological investigation distinguished loss and disorganisation of elastic fibres in all of 6 cases, but sparse active inflammatory infiltrates in only two of them. Late damage of the aorta in GCA may be due to repairing mechanisms as well as to persistent vasculitis. In patients with aortitis due to RCA, immunosuppression with glucocorticoids is the initial treatment of choice.
Constitutional symptoms mostly have resolved by this time. Long-term treatment with glucocorticoids implies considerable side effects, such as a decline of diabetic control, glaucoma, cataract, weight gain and osteoporosis, medication against which is obligatory. There is high interest in steroid sparing co-medication. For this purpose only methotrexate MTX is proposed , which was effective in a meta-analysis of three studies. However, the effect is small and the substance may have side effects itself. Positive results in case reports suggests their use if the re-induction of glucocorticoids and MTX is ineffective to control inflammation.
Cyclophosphamide also may be useful in this situation . Recently, there were encouraging results with the Interleukinantagonist tocilizumab  which is presently tested in larger studies. The risk of infections seems increased under this treatment. No controlled studies are available, but due to the number of cardiovascular events especially in patients with aortic involvement  a benefit of aspirin is expectable. There is no treatment differentiation between patients with or without aortic manifestation.
Aortic vessel wall thickening should be controlled and is likely to decrease during treatment. In the series of Daumas, steroid response in patients with aortitis was better than in those without and time to relapse was more prolonged. This result did not influence the intensity of treatment since no other parameters implied disease activity .
However, it is possible that slow inflammation processes mediated by Th1-lymphocytes are responsible for the development of aortic aneurysm in late disease.