|Year : 2022 | Volume
| Issue : 1 | Page : 34-36
Giant carotid aneurysm in takayasu arteritis
Debasis Acharya, Debasish Das, Jogendra Singh, Subhas Pramanik
Department of Cardiology, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
|Date of Submission||26-Feb-2021|
|Date of Decision||19-Apr-2021|
|Date of Acceptance||20-Apr-2021|
|Date of Web Publication||08-Feb-2022|
Dr. Debasis Acharya
Department of Cardiology, All India Institute of Medical Sciences, Bhubaneswar - 751 019, Odisha
Source of Support: None, Conflict of Interest: None
Takayasu arteritis is an arteritis of unknown etiology, resulting in stenosis or dilatation of the aorta and its major branches. .We report a rare case of a giant right common carotid artery aneurysm on the one side in a 29-year-old young male with refractory hypertension with severely stenotic, diffusely diseased, corkscrew appearance of the contralateral carotid artery, which has not been described in the literature so far. Our case is a unique demonstration of nature's paradox in vascular behavior in Takayasu arteritis in the right and left carotid arteries in an index patient; one having a giant aneurysm and the other one being severely stenotic, diffusely diseased with corkscrew appearance.
Keywords: Aneurysm, arteritis, carotid
|How to cite this article:|
Acharya D, Das D, Singh J, Pramanik S. Giant carotid aneurysm in takayasu arteritis. J Indian coll cardiol 2022;12:34-6
| Introduction|| |
Extracranial carotid aneurysm is a rare disease. The common causes are atherosclerosis, trauma, and previous surgery, followed by infection, previous neck irradiation, and fibromuscular dysplasia.,,, There are also few reported causes such as Marfan syndrome, Bechet's disease, and Takayasu arteritis. A paucity of literature evidence exists about the development of carotid aneurysm in Takayasu arteritis in young age. The reported incidence of aneurysmal lesions in Takayasu arteritis varies from 4.9% to 31.9%.,, The most common site of aneurysm is the aorta, followed by the subclavian, brachiocephalic, and common carotid artery, and the incidence of intracranial carotid aneurysm varies from 1.8% to 3.9%., We report a rare case of Takayasu arteritis presenting with refractory hypertension with simultaneous presence of giant carotid aneurysm on the right side measuring 17 mm with severely stenotic diffusely diseased corkscrew appearance of the left common carotid in an index patient, which has not been reported in the literature so far. Our case is a unique demonstration of different vascular pathophysiology and behavior of carotid arteries in Takayasu arteritis.
| Case Report|| |
A 29-year-old young male presented with refractory hypertension with blood pressure of 220/110 mmHg in the right arm with the absent left radial pulse, feeble left carotid pulse, and palpable abdominal aorta pulsation. Serum chemistry revealed deranged serum creatinine of 1.6 mg/dL with normal lipid profile and erythrocyte sedimentation rate of 80 mm/h. Ultrasonography of the abdomen revealed suprarenal abdominal aorta aneurysm and diminished corticomedullary differentiation of both kidneys with normal bilateral renal Doppler flow, and renal biopsy revealed focal segmental glomerulosclerosis. Carotid Doppler revealed diffuse thickening and narrowing of the left common carotid with dilatation of the right carotid artery. The patient could not afford for positron emission tomography–computed tomography to delineate the paradoxical bilateral carotid lesions. We subjected the patient to transfemoral aortic arch angiogram to profile and possible left carotid intervention in the background of vascular Doppler information of the stenotic left carotid artery. We used minimal low osmolar contrast (Visipaque) with 1:1 dilution with pre and postcatheterization adequate hydration to prevent contrast-induced nephrotoxicity. Aortic arch angiogram revealed giant right carotid aneurysm with a diameter of 17 mm and diffusely diseased and thinned out corkscrew appearance of the left common carotid and complete occlusion of the left subclavian artery [Figure 1]. There was an aneurysm of suprarenal abdominal aorta and bilateral renal arteries were normal in caliber [Figure 2]. Our case is a unique demonstration in paradoxical vascular behavior of carotid arteries in Takayasu arteritis; one having giant aneurysm and the other one being severely stenotic, diffusely diseased with corkscrew appearance. Simultaneous presence of positive and negative vascular remodeling in carotid arteries in an index patient with Takayasu arteritis has not been described in the literature so far; same arteries behaved striking differently during the evolution of the same disease process. In view of asymptomatic nature of the patient without any history of arm claudication, left subclavian angioplasty was not considered and left carotid artery was also not intervened in view of long-segment diffuse disease in very young age. The patient was put on oral steroid therapy and multiple renal-friendly antihypertensives with advice for regular follow-up.
|Figure 1: Giant right carotid aneurysm with paradoxical critical stenosis and corkscrew paradoxical critical stenosis and corkscrew|
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|Figure 2: Suprarenal abdominal aorta aneurysm with normal renal arteries|
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| Discussion|| |
We present a rare case of simultaneous presence of such a large carotid aneurysm on the one side 17 mm in size with severely stenotic diffusely diseased corkscrew appearance of contralateral carotid in an index patient, which has not been reported in the literature so far. Our case is a unique demonstration of different vascular pathophysiology and behavior in carotid arteries in Takayasu arteritis. All the cases of carotid artery aneurysm in Takayasu arteritis have been described only in the right carotid artery; no case of left carotid artery aneurysm has been described in the literature so far. Predilection for the involvement of right carotid artery in Takayasu arteritis is not known; local hemodynamic factor may be playing a role behind aneurysmal dilation of only right common carotid artery in Takayasu arteritis. Histopathology of carotid artery aneurysm reveals destruction of medial elastic tissue and fibrosis of media and adventitia. Nasu classified the histopathological pictures of arterial lesions in Takayasu arteritis into three types: granulomatous inflammation, diffuse productive inflammation, and fibrosis. Paradoxically, no giant cells are seen in those giant aneurysms; most of the lesions belong to fibrotic type. Carotid aneurysms in Takayasu arteritis have a risk of rupture, even in the noninflammatory stage. Surgical treatment is recommended for almost all extracranial carotid aneurysms in Takayasu arteritis. No clear relationship exists between the activity of systemic inflammation or steroid administration and the incidence of early postoperative complications or anastomotic aneurysm formation in the late period, and an early operation with the patient under steroid coverage should not be avoided even in the acute inflammatory stage. Tabata et al. reported rupture of two cases of right carotid aneurysm more than 20 mm in diameter. Our carotid aneurysm had a diameter of 17 mm for which we advised regular follow-up to serially monitor the diameter of carotid artery aneurysm.
| Conclusion|| |
Our case is a unique demonstration in paradoxical vascular behavior of carotid arteries in Takayasu arteritis; one having giant aneurysm and the other one being severely stenotic, diffusely diseased with corkscrew appearance. Simultaneous presence of positive and negative vascular remodeling in carotid arteries in an index patient with Takayasu arteritis has not been described in the literature so far; same arteries behaved striking differently in the same disease process. Topography also plays a role in phenotypic expression in evolution of vascular pathophysiology in Takayasu arteritis. Exclusive aneurysmal dilation of the right carotid artery may be due to direct transmission of central aortic pressure to innominate artery. Our case is a beautiful demonstration of nature's paradox observed in the right and left carotid arteries in the evolution of the pathobiology of Takayasu arteritis.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]