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CASE REPORT
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May 2017 E123
The diseased aorta in Takayasu’s arteritis features areas of
ectasia and stenosis;the aorta is left with very little elastic
tissue due to diffuse fibrosis of the intima, media, and
externa.1,2
Stent-supported endovascular aortoplasty and sur-
gical revascularization are associated with higher complication
and recurrence rates,3,4
even with regular immunomodulation
follow-up.5
Unlike atheromatous disease, the inflexible artery6
is vulnerable to dissection, and is as “brittle as glass” during bal-
loon angioplasty.7
Therefore, some authors suggest self-expand-
ing stent or stent-graft supported angioplasty for this condition,
with high-pressure dilation8,9
to overcome fibrosis caused by
panarteritis. However, the incidence of dissection in this situa-
tion appears to be under-reported.
CASE REPORT
A 38-year-old female with known Takayasu’s arteritis was re-
ferredtousforuncontrollablehypertensionbecauseofmiddleaortic
syndrome. She was under regular treatment with immunosuppres-
sion. On examination, she had abdominal bruit and weak femoral
pulses. Her blood pressure was 210/110 mm Hg in both arms and
120/70mmHginthelowerlimbsinsupineposition.Investigations
ABSTRACT: Balloon angioplasty of a critically or completely occluded segment of the aorta in Takayasu’s arteritis is
challenging because of extensive panarteritis and diffuse fibrosis. In contrast to atheromatous disease, the aorta is left
with very little elastic tissue, leading to higher incidence of dissection during intervention. Neither the profile of the angio-
plasty balloon (compliant vs non-compliant, length, diameter) nor the stent type (covered vs self-expanding) have been
defined in performing angioplasty in this situation. We report the case of a 38-year-old female with aortoarteritis. The
diseased aorta had diffuse narrowing in its thoracoabdominal part with critical stenosis at the level of the 11th thoracic
vertebra. The stenotic segment suffered full-length dissection after balloon dilatation. A self-expanding stent was deployed
to contain the dissection. At 12-month follow-up exam, the dissection was healed, without significant lumen loss.
VASCULAR DISEASE MANAGEMENT 2017;14(5):E123-E126
Key words: Takayasu’s arteritis; thoracoabdominal aorta; balloon aortoplasty; dissection
Sheshagiri Rao Damera
Ramachandra Barik, DNB
Department of Cardiology, Nizam’s Institute of Medical Sciences, Hyderabad, Telengana, India.
Aorta in Takayasu’s Arteritis is as Brittle as Glass:
A Case Report
Figure 1. Aortic pressures (A) proximal and (B) distal to the obstruction.
A B
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CASE REPORT
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showed inactive phase of disease as suggested by normal level of
erythrocyte sedimentation rate and C-reactive protein. The pull-
back gradient across the distal thoracic aorta revealed a significant
gradient of 110 mm Hg (Figure 1). Aortogram confirmed areas
of diffuse stenosis and ectasia in the thoracoabdominal aorta, with
significant stenosis of the aorta at the level of intervertebral disc
between T-11 and T-12 (Figure 2, Video 1). Informed consent for
aortoplasty to control secondary hypertension was obtained. Using
rightfemoralarterialaccess,theoccludedsegmentwascrossedusing
a straight-tip, exchange-length wire (Terumo) and 5 Fr multipur-
pose diagnostic catheter. The aortic lesion was dilated using an 8
mm x 4 cm Ravel balloon (Bard Peripheral Vascular) at 4 atm;
this size was chosen because the narrowest lesion diameter was 5.2
mm (balloon to lesion ratio of 150%). The patient had mild back
pain during and after dilation. The pull-back gradient reduced to
50 mm Hg. A dose of 100 mg intravenous tramadol was given.
Immediately, a 12 mm x 6 cm E•Luminex self-expanding stent
(Bard Peripheral Vascular) was deployed, as we had no covered
stent available at the time of intervention. The pull-back gradient
reduced further to less than 20 mm Hg. Repeat aortogram by
pigtail catheter revealed extensive dissection of the aorta beyond
the disease segment (Figures 3 and 4; Videos 2 and 3). No further
dilation was attempted. The patient continued to have mild back
pain. Beta-blocker was further reinforced by increasing the dose
of atenolol to 100 mg twice daily. Her further hospital course was
uneventful. At 12-month follow-up exam, the patient continued
to be asymptomatic and her hypertension was under control.
DISCUSSION
Angioplasty was first performed for aortoarteritis by Yagura
et al in 1984.10
The literature is now robust with a learning
curve of more than three decades. It is generally considered that
aortoplasty is safe and effective for aortoarteritis, with a low inci-
dence of aortic rupture (which is associated with high mortality).8
We feel the true incidence of aortic dissection or rupture after
aortoplasty in Takayasu’s arteritis is under-reported because the
Figure 3. The extension of dissection in the suprarenal part of
the aorta (arrow).
Figure 2. Aortogram of thoracic-abdominal aorta shows
diffuse stenosis from T-9 to T-12 with critical stenosis at the in-
tervertebral disc between T-11 and T-12. The various diameters
are noted. SBP = systolic blood pressure.
Figure 4. The extension of dissection in the juxtarenal part of
the aorta (arrow).
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studies reporting dissection are available mostly in the form of
case reports.11-13
The inelastic vessel wall is tough, non-compliant,
and rigid because of panarteritis, and healing occurs by extensive
fibrosis. It requires prolonged and repeated balloon dilation at a
higher pressure as compared with congenital coarctation or ath-
erosclerosis.14
Balloon angioplasty without a stent in Takayasu’s
arteritis is a double-edged sword in that dissection can be the cost
of overdilation. However, underdilation invites faster restenosis.
The ideal profile of the balloon and the optimum dilation (le-
sion to reference diameter) are unknown for this condition. The
recommendations for balloon sizes in different interventional
procedures have been based on guidelines or larger experiences
(Table 1). However, we could not find proper answers for the
balloon type (compliant vs non-compliant), balloon diameter,
balloon length (for diffusely narrowed aorta with some areas of
critical stenosis as in our case), or staging of the procedure. We
feel it is better to limit the length of balloon to the length of
critically stenosed segment. Therefore, it is extremely important
to keep a stent-graft option on the shelf before proceeding with
aortoplasty. It is also better to inform the on-site surgical team be-
fore the procedure. Balloon oversizing, higher inflation pressure,
balloon rupture, and wire manipulation have all been implicated
in the possible mechanisms of aortic rupture. Accurate sizing of
the stent-graft is important because postdilation would further
add to the dissection in the face of a lesion that included diffuse
stenosis with aneurysmal segments in between.
CONCLUSION
Aortic dissection is an inherent risk of aortoplasty for patients
with Takayasu’s arteritis. We suggest limiting the length of balloon
to the critically stenosed segment and a staged procedure when
the aorta is diffusely involved with areas of stenosis and aneurysm.
Ensure that a covered stent is available for cases of complex lesions.
We hope the proper definition of the balloon used for aortoplasty
in Takayasu’s arteritis with respect to nature (compliant or non-
compliant), size (length and diameter), and inflation pressure will
be elucidated by future observations. n
Disclosure: The authors have completed and returned the ICMJE Form
for Disclosure of Potential Conflicts of Interest. The authors report no
conflicts of interest regarding the content herein.
Manuscript submitted January 6, 2017, provisional acceptance given
February 28, 2017, final version accepted March 19, 2017.
Address for correspondence: Ramachandra Barik, DNB (Cardiol-
ogy), Associate Professor, Department of Cardiology, Nizam’s Institute
of Medical Sciences, Hyderabad-500082, Telengana, India. Email:
cardioramachandra@gmail.com
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Table 1. Balloon sizing for different cardiovascular interventions.
Interventions Balloon Profile Studies
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Reference diameter = height in cm/10 +10
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Coronary artery
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