Follow-up vascular ultrasounds in patients with giant cell arteritis.

OBJECTIVES: Literature describing follow-up vascular ultrasound (VUS) in giant cell arteritis (GCA) is limited. We report our experience with follow-up VUS obtained in clinical care of patients with GCA. METHODS: We retrospectively identified GCA patients with an abnormal initial VUS, defined as circumferential hypoechoic wall thickening ("halo sign"), or circumferential hyperechoic wall thickening without evidence of arteriosclerosis or arteritis, who subsequently underwent follow-up VUS during 2013-2018. Studies were interpreted as active arteritis, hyperechoic wall thickening without active arteritis, or no arteritis. We compared clinical and laboratory characteristics at time of initial VUS among patients with active arteritis vs. hyperechoic wall thickening without active arteritis. We described whether and how VUS interpretation changed from initial to follow-up VUS. Among individual vessels, we tested whether abnormal findings (e.g. halo sign) persisted at follow-up VUS using McNemar's test. RESULTS: 42 patients fulfilled study criteria. Median time between initial and follow-up VUS was 5.1 (IQR 2.6-7.9) months. Characteristics at initial VUS did not differ according to VUS interpretation. Among 36 patients with active arteritis on initial VUS, follow-up VUS showed active arteritis in 25.0%, hyperechoic wall thickening in 33.3% and no arteritis in 41.7%. Among 6 patients with hyperechoic wall thickening on initial VUS, half had no arteritis on follow-up VUS. Sonographic findings tended to persist in axillary arteries and were more likely to change in the superficial temporal arteries. CONCLUSIONS: Among 42 GCA patients, the majority had a change in VUS interpretation between initial and follow-up VUS. Sonographic findings in the temporal circulation more frequently changed than findings in axillary arteries.

Infrequent origin of a peripheral embolism: Arterial thoracic outlet syndrome in a young woman.

Arterial thoracic outlet syndrome (TOS) is caused by the compression of the subclavian or axillary artery between the ribs and the scalene muscles. Patients may present with various clinical conditions. Herein, we report a case of arterial TOS who presented with peripheral embolism. Arterial TOS is an uncommon cause of peripheral embolism. The diagnostic approach and treatment methods used are discussed. Clinicians should keep this diagnosis in mind and manage these cases according to the clinical appearance.

Percutaneous AXillary Artery (PAXA) Access at the First Segment During Fenestrated and Branched Endovascular Aortic Procedures.

OBJECTIVE: The aim of this study was to assess the feasibility and safety of percutaneous axillary access with vessel closure device closure after puncturing the first segment during endovascular treatment of complex aneurysms with fenestrated and branched endografts (F/BEVAR). METHODS: The PAXA (Percutaneous AXillary Access) study is a physician initiated, single centre, ambispective, non-randomised study (clinicaltrials.gov: NCT03223311). The primary endpoint was the closure success rate defined as the absence of any vascular injury to achieve haemostasis at the puncture site, requiring any treatment other than manual compression or adjunctive endovascular ballooning. The secondary endpoints were minor access complications, cerebrovascular complication rate, short term access vessel patency, and study cohort anatomical evaluation of the axillary artery. RESULTS: Sixty-four patients required an upper extremity access during F/BEVAR procedure during study period (November 2016 to July 2019) and were screened for the PAXA study: 59 patients (47 males; median age: 75 years, IQR 69-78) met the study inclusion criteria and were enrolled (one patient had bilateral access). Closure success was obtained in 54 cases (90%) with no open conversion required: five patients received a bare or covered stenting to the AXA and in one patient mechanical failure of the delivery system was recorded. No 30 day permanent peripheral nerve injuries and two non-ipsilateral ischaemic strokes (3.4%) were recorded. Seven patients (12%) had access haematomas managed conservatively associated with closure failure (p = .002), oral anticoagulants therapy (p = .005) and procedure length (p = .028). At short term follow up (6 months), no late complications were observed, and all access vessels were patent. CONCLUSION: PAXA on the first segment using a large sheath (10-16F) is technically feasible, relatively safe with no need for open conversion but it may require access related secondary endovascular procedures. Further prospective studies are needed to modify the device instruction for use and to put the procedure on label.

The impact of disease extent and severity detected by quantitative ultrasound analysis in the diagnosis and outcome of giant cell arteritis.

OBJECTIVES: To develop a quantitative score based on colour duplex sonography (CDS) to predict the diagnosis and outcome of GCA. METHODS: We selected patients with positive CDS and confirmed diagnosis of GCA recruited into the TA Biopsy (TAB) vs Ultrasound in Diagnosis of GCA (TABUL) study and in a validation, independent cohort. We fitted four CDS models including combinations of the following: number and distribution of halos at the TA branches, average and maximum intima-media thickness of TA and axillary arteries. We fitted four clinical/laboratory models. The combined CDS and clinical models were used to develop a score to predict risk of positive TAB and clinical outcome at 6 months. RESULTS: We included 135 GCA patients from TABUL (female: 68%, age 73 (8) years) and 72 patients from the independent cohort (female: 46%, age 75 (7) years). The best-fitting CDS model for TAB used maximum intima-media thickness size and bilaterality of TA and axillary arteries' halos. The best-fitting clinical model included raised inflammatory markers, PMR, headache and ischaemic symptoms. By combining CDS and clinical models we derived a score to compute the probability of a positive TAB. Model discrimination was fair (area under the receiver operating characteristic curve 0.77, 95% CI: 0.68, 0.84). No significant association was found for prediction of clinical outcome at 6 months. CONCLUSION: A quantitative analysis of CDS and clinical characteristics is useful to identify patients with a positive biopsy, supporting the use of CDS as a surrogate tool to replace TAB. No predictive role was found for worse prognosis.

Painful shoulder in a patient receiving anticoagulation therapy with rivaroxaban. / Hombro doloroso en paciente anticoagulado con rivaroxabán.

We report the case of an 83-year-old man on rivaroxaban treatment, with pain in right shoulder, back of the upper arm, forearm and wrist, and inability to extend the wrist and fingers, as the result of an injury. The radiographs were normal, but thoracic CT showed an axillary artery pseudoaneurysm and a secondary hematoma that compressed the brachial plexus. This should be borne in mind in patients with painful shoulder, treated with anticoagulant therapy and without associated radiographic changes.

Axillary arterial angiosarcoma in a nonfunctioning arteriovenous fistula limb of a patient undergoing hemodialysis: case report with literature review.

A 54-year-old man was admitted to our hospital with a painful left axillary mass. He had a 27-year history of hemodialysis for end-stage kidney disease because of chronic glomerulonephritis. He had a right radial artery-cephalic vein arteriovenous fistula and left nonfunctioning arteriovenous fistula. Computed tomography imaging showed a left axillary arterial mass with peripheral hematoma and multiple lung tumors. On hospital day 3, he showed disturbances in consciousness as well as enlargement of the axillary mass and hematoma. We performed emergency surgery to resect the left axillary tumor. The patient was diagnosed with angiosarcoma upon histopathological examination of the resected specimen on hospital day 15. Because his condition was extremely poor, we provided supportive care to him, not chemotherapy. He expired on hospital day 25. Angiosarcoma remains a rare disease; however, this case highlights the importance of including angiosarcoma in the differential diagnosis for upper extremity pain in patients undergoing hemodialysis.

An unusual case of asymmetrical combined variations of the subclavian and axillary artery with clinical significance.

In a Greek Caucasian male cadaver, a combination of the following arterial variations were observed: an aberrant right subclavian artery originating as a last branch of the aortic arch and coursed posterior to the oesophagus, a right non-recurrent laryngeal nerve, an atypical origin of the left suprascapular artery from the axillary artery, an unusual emersion of the lateral thoracic artery from the subscapular artery and a separate origin of the left thoracodorsal artery from the axillary artery. According to the available literature the corresponding incidences of the referred variants are: 0.7% for the aberrant right subclavian artery, 1.6-3.8% for the origin of the suprascapular artery from the axillary artery, 3% for the origin of the left thoracodorsal artery from the axillary artery and 30% for the origin of the lateral thoracic artery from the subscapular artery. Such unusual coexistence of arterial variations may developmentally be explained and has important clinical significance.

MMP (Matrix Metalloprotease)-9-Producing Monocytes Enable T Cells to Invade the Vessel Wall and Cause Vasculitis.

RATIONALE: Giant cell arteritis (GCA)-a primary vasculitis of medium and large arteries-is associated with vessel wall damage, elastic membrane fragmentation, and vascular remodeling. Proteinases are believed to contribute to pathogenesis by degrading extracellular matrix and causing tissue injury. OBJECTIVE: The MMP (matrix metalloproteinase)-9-a type IV collagenase-is produced in the vasculitic lesions of GCA. It is unknown which pathogenic processes are MMP-9 dependent. METHODS AND RESULTS: The tissue transcriptome of GCA-affected temporal arteries contained high amounts of MMP-9 transcripts, and immunostaining for pro-MMP-9 localized the enzyme to wall-infiltrating macrophages. MMP-2 and MMP-9 transcripts were also abundant in monocytes and monocyte-derived macrophages from patients with GCA. Patient-derived monocytes outperformed healthy monocytes in passing through engineered basement membranes. GCA CD (cluster of differentiation) 4+ T cells required MMP-9-producing monocytes to penetrate through matrix built from type IV collagen. In vivo functions of MMP-9 were tested in a human artery-SCID (severe combined immunodeficiency) chimera model by blocking enzyme activity with a highly specific monoclonal antibody or by injecting rMMP-9 (recombinant MMP-9). Inhibiting MMP-9 activity profoundly suppressed vascular injury, decreased the density of inflammatory infiltrates ( P<0.001), reduced intramural neoangiogenesis ( P<0.001), and prevented intimal layer hyperplasia ( P<0.001). rMMP-9 amplified all domains of vasculitic activity, promoted assembly of T-cell infiltrates ( P<0.05), intensified formation of new microvessels ( P<0.001), and worsened intimal thickening ( P<0.001). Systemic delivery of N-acetyl-proline-glycine-proline-a matrikine produced by MMP-9-mediated gelatinolysis-had limited vasculitogenic effects. CONCLUSIONS: In large vessel vasculitis, MMP-9 controls the access of monocytes and T cells to the vascular wall. T cells depend on MMP-9-producing monocytes to pass through collagen IV-containing basement membrane. Invasion of vasculitogenic T cells and monocytes, formation of neoangiogenic networks, and neointimal growth all require the enzymatic activity of MMP-9, identifying this protease as a potential therapeutic target to restore the immunoprivilege of the arterial wall in large vessel vasculitis.

Ultrasound cut-off values for intima-media thickness of temporal, facial and axillary arteries in giant cell arteritis.

Objective: To evaluate the intima-media thickness (IMT) of arteries involved in GCA for determining cut-off values. Methods: Forty newly diagnosed GCA patients in a fast-track GCA clinic and 40 age- and sex-matched controls were included. IMT measurement was performed at or within 24 h after diagnosis. The common superficial temporal arteries with their frontal and parietal branches and the facial arteries were bilaterally examined with a 10-22 MHz probe and the axillary artery with a 6-18 MHz probe. Receiver operating characteristics analysis was performed for estimating cut-off values. Results: The mean age was 72 years (s.d. 9) and 68% were females. In the control group, IMT was 0.23 mm (s.d. 0.04), 0.19 mm (s.d. 0.03), 0.20 mm (s.d. 0.03), 0.24 mm (s.d. 0.05) and 0.59 mm (s.d. 0.10) for the common superficial temporal arteries, the frontal and parietal branches, the facial arteries and the axillary arteries, respectively. In vasculitic segments of GCA patients, IMT was 0.65 mm (s.d. 0.18), 0.54 mm (s.d. 0.18), 0.50 mm (s.d. 0.17), 0.53 mm (s.d. 0.16) and 1.7 mm (s.d. 0.41), respectively. Cut-off values are 0.42, 0.34, 0.29, 0.37 and 1.0 mm, respectively, with 100% sensitivities and specificities for common superficial temporal arteries, for frontal branches and for axillary arteries and sensitivities of 97.2 and 87.5% and specificities of 98.7 and 98.8% for parietal branches and facial arteries, respectively. The intraclass correlation coefficient was between 0.87 and 0.98. Conclusion: IMT measurement can correctly distinguish vasculitic from normal arteries in suspected GCA.

Variante de ramas de la arteria axilar / Variant of axillary artery branches

Resumen:Este trabajo describe la presencia de la variante anatómica de la arteria axilar en un caso incidental de disección del Departamento de ciencias morfológicas de la Escuela de Medicina de la Universidad de Ciencias Médicas, dicha variante se presenta en menos de un 0.2% de la población. Así mismo se revisa el tema y su importancia clínica.

Abstract:This work describes the presence of anatomical variant of the axillary artery in an incidental case dissecting the Department of Morphological Sciences , School of Medicine, Universidad de Ciencias Médicas, said variant occurs in less than 0.2 % of the population. Also the subject and its clinical significance is reviewed.

Double localization of a non-anastomotic pseudoaneurysm after an axillofemoral bypass: a case report and review of the literature.

BACKGROUND: A traumatic non-anastomotic pseudoaneurysm is a rare complication of an axillofemoral bypass graft. Fewer than 20 cases have been reported in the literature. Our case is unusual in that we report a double localization of this complication. CASE PRESENTATION: We report the case of a 60-year-old Arabic male patient who was diagnosed with two hematomas in the trajectory of his axillofemoral bypass secondary to a traumatism. The diagnosis of a non-anastomotic pseudoaneurysm was retained considering the results of a computed tomography angiography scan, which showed the double localization of the pseudoaneurysm. Surgical management consisted of flattening the pseudoaneurysm along with the interposition of a prosthetic segment. There were no postoperative complications and our patient was well 3 years after discharge. CONCLUSIONS: Non-anastomotic pseudoaneurysm is a rarely described complication of a axillofemoral bypass graft. To the best of our knowledge, a double localization has not been described in the literature before. Minimally invasive techniques as a treatment option are being widely used as an alternative to open repair.

Extracranial giant cell arteritis: A narrative review.

A systematic literature search was performed to summarise current knowledge on extracranial giant cell arteritis (GCA), i.e. large-artery involvement in patients with or without clinically apparent temporal arteritis (cranial GCA). Extracranial GCA is increasingly recognised, both in patients with cranial GCA and with solitary extracranial GCA, due to increased awareness among physicians and development of modern imaging modalities. The literature on the pathogenesis and histopathology of extracranial GCA is scarce. It is considered to be similar to cranial GCA. Patients with solitary extracranial GCA often present with non-specific signs and symptoms, although vascular manifestations, mostly secondary to stenosis, may occur. Due to the non-specific clinical presentation and low sensitivity of temporal artery biopsies, extracranial GCA is usually diagnosed by imaging. 18F-FDG-PET, MRI, CT angiography and ultrasound are used for this purpose. At present, the optimal diagnostic strategy is undetermined. The choice for a particular modality can be guided by the clinical scenario that raises suspicion of extracranial GCA, in addition to local availability and expertise. Extracranial complications in GCA consist of aortic aneurysm or dissection (mainly the ascending aorta), aortic arch syndrome, arm claudication and posterior stroke (although this is technically a cranial complication, it often results from stenosis of the vertebrobasilar arteries). Mortality is generally not increased in patients with GCA. Treatment of patients with solitary extracranial and those with extracranial and cranial GCA has been debated in the recent literature. In general, the same strategy is applied as in patients with temporal arteritis, although criteria regarding who to treat are unclear. Surgical procedures may be indicated, in which case optimal medical treatment prior to surgery is important.

Brachiomedian artery (arteria brachiomediana) revisited: a comprehensive review.

This article reviews in detail the superficial brachiomedian artery (arteria brachiomediana superficialis), a very rare variant of the main arterial trunks of the upper limb. It branches either from the axillary artery or the brachial artery, descends superficially in the arm (similar to the course of the superficial brachial artery) and continues across the cubital fossa, runs superficially in the forearm, approaches the median nerve and enters the carpal canal to reach the hand. It usually terminates in the superficial palmar arch. The first drawing was published, in 1830, and the first description was published, in 1844. Altogether, to our knowledge, only 31 cases of a true, superficial brachiomedian artery have been reported (Some cases are incorrectly reported as superficial brachioradiomedian artery or superficial brachioulnomedian artery). Based on a meta-analysis of known, available studies, the incidence is 0.23% in Caucasians and 1.48% in Mongolians. Knowing whether or not this arterial variant is present is important in clinical medicine and relevant for: The catheterization via the radial or ulnar artery; harvesting the vascular pedicle for a forearm flap based on the radial, ulnar or superficial brachiomedian arteries; the possible collateral circulation in cases of the arterial closure; and the surgical management of carpal tunnel syndrome. Its presence can elevate the danger of an injury to the superficially located variant artery or of an accidental injection.

Role of TGF-ß Signaling in Remodeling of Noncoronary Artery Aneurysms in Kawasaki Disease.

Coronary artery aneurysms (CAA) remain an important complication of Kawasaki disease (KD), the most common form of pediatric acquired heart disease in developed countries. Potentially life-threatening CAA develop in 25% of untreated children and 5% of children treated with high-dose intravenous immunoglobulin during the acute phase of the self-limited vasculitis. Noncoronary artery aneurysms (NCAA) in extraparenchymal, muscular arteries occur in a minority of patients with KD who also have CAA, yet little is understood about their formation and remodeling. We postulated that activation of the transforming growth factor-ß (TGF-ß) pathway in KD may influence formation and remodeling of aneurysms in iliac, femoral, and axillary arteries, the most common sites for NCAA. We studied a resected axillary artery from one adult and endarterectomy tissue from the femoral artery from a second adult, both with a history of CAA and NCAA following KD in infancy. Histology of the axillary artery aneurysm revealed destruction of the internal elastic lamina and recanalization of organized thrombus, while the endarterectomy specimen showed dense calcification and luminal myofibroblastic proliferation. Immunohistochemistry for molecules in the TGF-ß signaling pathway revealed increased expression of TGF-ß2, TGF-ß receptor 2, and phosphorylated SMAD3. These findings suggest ongoing tissue remodeling of the aneurysms decades after the acute injury and demonstrate the importance of the TGF-ß signaling pathway in this process.

An unusual presentation of thoracoacromial artery pseudoaneurysm following shoulder arthroplasty.

Pseudoaneurysms of peripheral arteries are not an uncommon condition presenting to vascular surgeons. Perioperative injury and infection are two of the commonest causes. We describe a case of an 82-year-old lady, who presented 10 years following right shoulder joint replacement, with a sharply marginated erythematous cutaneous eruption over the right shoulder. Subsequent angiography revealed a pseudoaneurysm of the acromial branch of the thoracoacromial artery. Planned intervention was superseded by a further embolic episode, which prompted immediate percutaneous translumninal embolisation of the aneurysm. The aetiology of a pseudoaneurysm 10 years following shoulder arthroplasty is discussed.

A rare complication after axillofemoral bypass operation: disruption of the proximal anastomosis: single case after 12 years' experience in extra-anatomic bypass surgery.

Axillofemoral bypass operation is an alternative approach for patients at high risk for aortofemoral reconstruction and for patients with comorbid factors. Proximal anastomotic disruption, upper extremity thromboembolism, graft infection and seroma formation are known postoperative complications after axillofemoral bypass. Proximal anastomotic disruption is a severe complication in the early postoperative period and is usually secondary to technical errors in anastomosis, mechanical distress and infections. We performed a left axillofemoral bypass and left femoropopliteal bypass operation under general anesthesia by using an 8 mm full ringed polytetrafluoroethylene graft. On the seventh postoperative day, patient complained a sudden pain and swelling on left subclavian incision after a hyperabduction of the left arm. Patient was taken into operation theatre just after this complaint for suspicion of disruption of the proximal anastomosis. We report a case with proximal anastomotic disruption after axillofemoral bypass operation in accordance with literature data.

Subclavian and axillary arterial aneurysms: two case reports / Aneurismas do segmento subclavio-axilar: relato de dois casos

Aneurysms of the subclavian-axillary segment are rare, but when diagnosed they must be treated. This article describes two cases of aneurysms of the upper extremities, one in a subclavian artery and the other in an axillary artery. The first case was a 71-year-old male with a pulsating supraclavicular bulge on the right and muscle weakness in the ipsilateral extremity. Duplex scanning and arteriography confirmed the diagnosis of aneurysm of the right subclavian artery and the patient underwent aneurysmectomy and end-to-end anastomosis. The second case was a 24-year-old female patient, with no history of comorbidities, who presented with a pulsating mass in the right axillary region and paresthesia of the ipsilateral extremity. Duplex scanning and arteriography confirmed an aneurysm in the right axillary artery, which was successfully treated with aneurysmectomy and end-to-end anastomosis. Pathology findings showed that the first case was an atherosclerotic aneurysm and the second was a congenital aneurysm.

Os aneurismas do segmento subclávio-axilar são de ocorrência rara e, uma vez diagnosticados, devem ser tratados. Neste trabalho, relatamos dois casos de aneurismas de membros superiores, sendo um da artéria subclávia e outro da artéria axilar. No primeiro caso, o paciente de 71 anos, sexo masculino, apresentava abaulamento pulsátil supraclavicular direito associado à fraqueza muscular no membro ipsilateral. Foram realizados duplex scan e arteriografia, que confirmaram o diagnóstico de aneurisma da artéria subclávia direita, sendo o paciente submetido à aneurismectomia com anastomose término-terminal. No segundo caso, uma paciente de 24 anos, do sexo feminino, sem antecedentes mórbidos ou comorbidades, apresentava queixa de massa pulsátil na região axilar direita associada à parestesia no membro ipsilateral. O duplex scan e a arteriografia confirmaram o aneurisma da artéria axilar direita, que foi tratado com aneurismectomia e anastomose término-terminal com sucesso. O diagnóstico anátomo-clínico foi de aneurisma aterosclerótico no primeiro caso e, no segundo caso, de aneurisma congênito.