The long-term success of cardiovascular surgery in Takayasu arteritis: 48 years of experience in Mexico, beyond forefront techniques

Introduction

Background

Vasculitis is a clinical pathological process in which inflammation causes damage to blood vessels (1,2).

The Takayasu arteritis (TA) has a global prevalence of 1% to 2% per million inhabitants (3). The diagnosis is more frequent in young women. In Mexico, a gender ratio of 6.9 to 1 is reported in favor of women and the more frequent diagnosis is made before 30 years of age (4). The main cause of death is of cardiovascular origin including ischemic cardiomyopathy and valvular disease. The cardiovascular cause is 7.6 times more frequent than in the general population and there may be a delay in the diagnosis (5,6). The therapeutic management varies and there have been great technological advances, which have proven efficient in their performance both in their isolated application form and hybrid management (surgery-use of stents) (7). The largest series still do not reach follow-up periods longer than 20 years (8).

A meta-analysis showed better long-term outcome when using cardiac surgery (9). Although endovascular management has also been used, its main challenge is that the long-term results of this procedure are still unknown (10). Moreover, the persistent inflammatory condition that is often present after its performance, could result in restenosis.

Rationale and knowledge gap

There are still two unresolved concepts regarding endovascular management; The first issue is the lack of precise control over arterial inflammation. Although there are clinical and imaging criteria, the measurement is not precise. This necessitates achieving genuine control over inflammatory activity before any surgical or interventional procedure. The second issue is the absence of comparisons between long-term surgery evaluations and interventions in this context.

Objective

The main objective of this study was to determine the long-term impact of surgical management of TA through the evaluation of survival and evolution of patients undergoing corrective surgery for occlusive or aneurysmal lesions. We present this article in accordance with the STROBE reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-24-709/rc).

Methods

This was a retrospective and descriptive, cohort study between 1969 and 2017 in the National Institute of Cardiology Ignacio Chavez. A review of the clinical records of patients that met more than three classification criteria to TA of the American College of Rheumatology (ACR) 1990 (11) and the new 2022 ACR/European Alliance of Associations for Rheumatology classification criteria for TA (11,12) (Figure S1).

The selection and recruitment process for the population with TA based on the study’s design is depicted in an algorithm (Figure 1). Inclusion criteria encompassed individuals requiring a surgical procedure between 1969 and 2017, without restrictions based on sex or age. Patients intervened in other institutions were excluded.

Figure 1 Drawing that shows an algorithm, the type of design and the methodology carried out to obtain the selected cases of TA included in this study. (I) The cases with diagnosis of TA that had undergone surgery in the period studied were located in the surgical archives and the clinical archive of the hospital. (II) The criteria with which they were classified by the rheumatologists who evaluated them at the time of the surgical event were analyzed and those that met ≥3 ACR criteria were selected, which were used at that time. (III) All cases were thoroughly reviewed by M.E.S., rheumatologist, to evaluate whether they met the previous and current classification criteria in TA. (IV) Of the total number of patients found with a diagnosis of TA. Only those who had all the data to be classified and who were certain of the clinical, surgical and laboratory data sought were included, and only 44 were included. (V) The classification of the type of surgery was proposed with these terms by the group of surgeons. (VI) To give a report with the greatest approximation of the long-term results in the care of these patients. TA, Takayasu arteritis; FDG, fluorodeoxyglucose; ACR, American College of Rheumatology.

The patients who underwent surgery were presented to a heart team and that selection was made up of expert specialists, rheumatologists, vascular interventionists and vascular and cardiothoracic surgeons. The patient data was collected from the clinical history, obtained from the institutional records where they were extracted. Demographic variables, follow-up time, type of surgery and information on the type of procedures and complications was obtained.

The surgical event was classified into five groups: (I) organ-preservation surgery (mainly renal autograft); (II) bypass (revascularization of affected organs or segments with Woven Dacron graft); (III) replacement (replacement of affected aortic segment with a Woven Dacron graft); (IV) cardiac surgery (direct procedures in heart); (V) exclusion [resection of an affected organ (nephrectomy)] (Figure 2).

Figure 2 Drawing showing the five different types of surgery. (A) Organ preservation. We include procedures that modify the natural evolution of the disease about the rescued organs. At the renal level, there are autotransplantation and renal revascularization. (B) Bypass (revascularization of affected organs or segments with Woven Dacron graft bypass at the cerebral level, revascularization of the supra-aortic trunks, in intestinal function, revascularization of the mesenteric artery). (C) Replacement (replacement of affected aortic segment with a Woven Dacron graft). (D) Cardiac surgery (direct procedures in heart). (E) Exclusion [resection of an affected organ (nephrectomy)].

Inflammatory activity was evaluated according to the Dabague-Reyes criteria, in which a score greater than or equal to 5 was considered as active inflammation (13). The laboratory data included into criteria are complete blood count, erythrocyte sedimentation rate (ESR), fibrinogen (Fb), and C-reactive protein (CRP).

The arterial lesion was classified according to Hata et al. (14) (Figure 3).

Figure 3 We show the new classification. Type I involves primarily the branches from the aortic arch. Type IIa involves the ascending aorta, aortic arch and its branches. Type IIb involves the ascending aorta, aortic arch with its branches and thoracic descending aorta. Type III involves the thoracic descending aorta, abdominal aorta and/or renal arteries. This type could be meaningful when considering the spread of vascular lesions. Type IV affects only the abdominal aorta and/or renal arteries. Type V affects the combined features of both types of IIb and IV. Furthermore, the involvement of coronary or pulmonary artery should be indicated as C (+) or P (+), respectively.

Statistical analysis

Variables with a loss of the sample data of more than 20% were excluded. The categorical variables were described by percentages and prevalence, and the comparison was done using the Chi-squared or Fisher’s exact test. Statistical significance was considered with an error <0.05 and a power of 0.84. Numerical variables with parametric distribution were described using measures of central tendency. The inferential comparison was performed using the Student’s t-test, and the survival analysis was performed using Kaplan-Meier.

Ethical statement

The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013) (15). The National Institute of Cardiology Research Committee Board approved this retrospective study in January 5, 2020 (No. 19-1140), and the requirement for patient consent to use clinical data was waived due to the retrospective study design.

Trial registration

ClinicalTrials.gov Identifier ID NCT03654222 retrospectively registered the studies involving human participants.

Results

A total of 66 patients were evaluated, and 25 (38%) were eliminated because their medical records did not provide enough evidence. A total of 41 patients were finally analyzed. Thirty-one (76%) were women, and 10 (24%) were men. The age at diagnosis was 29±10 years.

Table 1 describes the demographic characteristics of the patients and their initial symptoms at the moment of diagnosis. The female gender prevailed with a ratio of 3.1:1. Among these patients, 88% were under 40 years old, with only five individuals (12%) surpassing this age threshold.

According to the 1990 classification criteria, the percentages of cases that were younger than 40 years were 36 (88%), claudication of extremities [16 (39%)], murmurs [32 (78%)], the difference in systolic arterial pressure between an arm and another 35 (85%). Also, according to a new criterion, the patients had angina [16 (39%)], arterial lesions in one territory [19 (46.3%)], in two [16 (39%)], in three [6 (15%)] and abdominal aorta involvement of renal or mesenteric involvement [18 (44%)].

Table S1 shows the type of arterial injury the patients and the type of surgery performed.

Of the 41 patients, a total of 7 (17%) had a diagnosis of coronary artery disease, of which 3 (17.6%) underwent surgical coronary revascularization with saphenous vein grafts, 16 (39%) had coronary valve disease, of which 14 (87.5%) underwent surgical management, 8 (57%) underwent aortic valve replacement. In 4 (28.5%), a double valve replacement was performed (3 mitral-aortic and 1 mitral-tricuspid), and in 2 (14%), a mitral valve replacement was performed; an aneurysm was found in 5 (12%), and a Bentall and DeBono procedure was performed. In summary, cardiac surgery was performed in 15 (37%), organ preservation in 12 (29%), bypass in 7 (17%), exclusion in 5 (12%), replacement in 1 (2%), and other surgeries in 1 (2%).

A total of 15 (37%) patients had reports of inflammatory activity at the moment of surgery; in 11 (27%), inflammatory activity could not be evaluated at the moment of hospitalization. The average score had a median of 2.5 (min–max: 0–3) in patients who did not show inflammatory activity and of 5 (min–max: 4–6.5) in patients who had activity. The highest inflammatory activity was found in patients who underwent exclusion procedures. Percentage of the type of cardiac surgery and the frequencies of inflammatory activity are reported (Table 2, Figure 4).

Figure 4 Frequency of type of surgery and the cases with or without inflammatory activity. (A) The frequency in percentages of type of surgeries that were performed in this study; (B) the percentage of cases that entered the surgical procedure with inflammatory activity according to the type of surgery in patients with Takayasu arteritis.

Most of the deaths were not associated with the surgical event. Only two deaths showed a relation with surgery; one was due to rupture of the posterior ventricular atrial groove while the mitral valve was change and the other was secondary to mesenteric thrombosis in a patient who later went to surgery for a right renal autograft and underwent a laparotomy 14 days after. Mortality due to surgery corresponded to 4.8%. Mortality due to some other event corresponded to 24%. In both cases, the complication occurred on days 28 and 15 of the hospitalization and was the cause of death (Table 3).

Mortality in the group of patients undergoing cardiac surgery was the highest. The survival according to the type of surgery and follow-up are shown in Figure 5.

Figure 5 The survival according to the type of surgery and follow-up. (A) The probability of survival of TA in relation to the surgical procedure, which in the long term is very high since it is greater than 90% in all types of surgery and this is maintained over the years. The two deaths were each from organ preservation surgery and cardiac surgery. (B) Survival rate according to the type of surgery and its relationship with causes of mortality not due to surgery are shown in this analysis by Kaplan-Meier. The survival rate of patients with TA undergoing surgery for another type of non-cardiac surgery was 100%; those who underwent organ preservation surgery were 80% at 24 years, those who were included for cardiac surgery, and those whose bypass was performed were both 75% at 24 years. TA, Takayasu arteritis.

Regarding the mortality associated with the surgical event and the long-term survival rate, we observed that 90% of patients who underwent cardiac surgery survived 15 years. In comparison, the organ-preservation surgery had a survival rate of 90% at 35 years. Patients who underwent bypass, replacement, exclusion, and other surgeries had a survival rate of 100% after a 45-year follow-up (Figure 5).

Patients undergoing cardiac surgery complications were studied at two different stages: during the hospital stay and after five years of follow-up. A total survival rate of 15 years was reached in less than 50% of the cases. The average survival rate in patients who underwent bypass surgery was 25 years in 70% of the cases. The rate of survival in the patients who had undergone organ-preservation surgery was 30 years in 90% of the cases (Figure 4).

There was only one case of replacement surgery in which the thoracic aorta was replaced using a thoraco-abdominal approach. The patient later had pneumonia and died of septic shock a week later.

In comparison of patients with and without activity at the time of surgery, we found no difference in mortality from all causes or those due to surgery. The surgical data of the patients are shown in Table S1.

Discussion

The general characteristics found in the Mexican population differ slightly from those reported worldwide. The relationship between genders in this study was of 3.1:1 in favor of females while this ratio is usually reported to be of 6:1. This reported ratio might be biased since only patients requiring surgery were included and therefore, it does not represent the entire population. Other reports in Mexican patients, a ratio of 5.8–6.9 to 1 in favor of women (2,9,10), has been found, closely resembling that found worldwide.

In Mexico, the prevalence of type V arterial lesions is high, which represents that the surgical intervention performed is complex since the involvement found in these patients is throughout the aorta and is often associated with pulmonary damage to the coronary and valvular arteries (16,17). The incidence of cardiovascular alterations is similar to what was found in Korean patients, which have been reported to be the cause of increased mortality in patients with TA (18,19). The complex incidence of arterial and cardiovascular injury and the presence of inflammatory activity are factors that have frequently been associated with a higher mortality rate in previous studies (20). Survival of patients with TA in Mexico has been reported to be of up to 60% after 35 years of follow-up (21).

Even when it is seen that the surgery has been performed in the presence of inflammatory activity, since sometimes it is necessary to intervene urgently before waiting for appropriate therapeutic control of the inflammation.

Rosa Neto et al. (22) reported 146 patients with TA undergoing a vascular procedure, with a follow-up of 23 years. The survival rate was 87%; in patients treated by intervention and surgery, they reported that inflammatory activity at the time of intervention was associated with elevated mortality.

In this study, we found that the overall survival rate in patients treated by surgery at 45 years was 95% and the long-term causes of death were not related to surgery. However, it is relevant to mention that the patients who died had documented inflammatory activity before the surgical event.

The results obtained between complications and early mortality before 30 days have been clearly described in the first series and published reports, such as Saadoun et al. (23), Mwipatayi et al. (24) and Kaku et al. (25) which reported only one premature death in 20 operated patients. Before surgery, all patients received high doses of prednisolone. Schmidt et al. (26) reported an early mortality rate of 3% and Miyata et al. (27) reported 12 premature deaths after surgical procedure,

Although there is variability in the findings, it can be summarized that early complications in most series are low and very similar to what we found.

This study mentions cases that began in the 70s and the two patients who died from causes related to the surgical event had undergone surgery, one in 1987 who received mitral valve replacement and the patient died due to rupture of the posterior ventricular atrial groove and the another in 1991, a patient who received a right kidney auto transplant performed days later and presented mesenteric thrombosis. Li (28) reported 12 deaths in a Chinese series of 810 TA patients, of whom three died after surgery, and only 2 of the deaths were related to the surgical event. Chiche (29) reported 68 renal autotransplantation surgeries, out of which 26 corresponded to TA patients, and described a 90% survival at 150 months follow-up. This finally summarizes that early complications have a low incidence in most series reports of patients with TA.

Concerning the type of surgeries that were treated at this institution we found that cardiac surgery was the most prevalent intervention, and it had the highest mortality rate. In one patient, death was associated with surgery, and in 4, it was not related to the surgical procedure. The survival rate after 5 years was 90%. Death after 15 years was associated with surgery in 50% of cases. In the remaining patients, death was due to non-surgical causes.

Organ preservation surgery was the second most common type of surgery. Two deaths were reported; one was associated with the surgical event and had documented inflammatory activity, and the other was due to pulmonary edema. In this group of patients, there was a better survival rate (90%) after 30 years.

Bypass surgery was the third most common procedure in 7 cases, and 4 had inflammatory activity. Survival rate in this group was 100%.

Exclusion surgery was performed in 5 cases and 4 of them had inflammatory activity, one of those who died was not due to surgery. The survival rate in this group was 100% at 45 years. Survival rate was 80% in patients who had a 25-year follow-up; mortality was not associated with a surgical event.

Although new technologies have been implemented for the medical treatment of TA patients, the surgical procedure including cardiovascular surgery is still very important for symptom control and the treatment of complex obstructions. Nowadays, endovascular, or open surgical intervention is performed; however, comparisons of the yields of open and endovascular methods have been poorly studied. Furthermore, a hybrid combination in TA has been proposed to treat some types of vascular lesions. A meta-analysis demonstrated that there is a lower risk of stenosis with the open surgical intervention than with the endovascular intervention (30).

Complications such as cerebrovascular accidents are more frequent in TA patients that undergo open surgery in comparison to those who undergo endovascular intervention. However, differences related to the location of the lesion and the cerebrovascular accident have been found in open surgeries; this type of complications is more frequently found when supra-aortic branches are involved than when renal arteries are affected (30).

The variability of arterial lesions is related to stenosis and occlusion. Aneurysms are present in very few cases, and their prevalence was low, very similar to what was found in the Chinese and Portuguese populations (31,32).

Although the use of endovascular treatment is increasing, long-term follow-up and implementation of additional strategies to treat restenosis remain challenging (33). Histopathological studies have shown subclinical inflammatory activity that cannot be evaluated in patients with TA through clinical or laboratory findings, so there is no consensus to confirm its presence; the activity could be present in up to 40% of patients even if it has not been informed by clinical or imaging parameters (22,34). Furthermore, recent scores to evaluate it are not perfect.

Our results show many patients with a long-term evolution of the surgical procedures in its different approaches and demonstrate a low mortality rate related to the procedure. The prevalence of death from other causes is similar to that found in other series of patients.

Limitations of the study

In retrospective studies, it is difficult to evaluate whether immunosuppressor drugs were employed and to determine the combination of strategies employed in each patient. Therefore, it was difficult to evaluate the presence and type of inflammatory activity and whether anti-inflammatory drugs had been used, which could have impacted the success of the treatment.

Conclusions

In the advanced stage of TA, arterial occlusive damage affects organ irrigation and functionality changing the prognosis depending on the organ involved. There are diverse types of surgical and interventional approaches to treat the complexity of each patient in TA. In relation to the type of pre-surgical management, no inflammatory activity is suggested for any approach. In cardiothoracic surgery, the choice of the method by experts leads to a good long-term prognosis. Interventional treatment successfully resolves arterial occlusive aspects; however, the experience is short-term. The findings obtained in a single center provide internal validity, but cannot be generalized. The low incidence of this vasculitis leads us to propose the need for international multicenter studies adjusting for possible biases.

Acknowledgments

The authors would like to thank all the patients in this study.

Funding: None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://jtd.amegroups.com/article/view/10.21037/jtd-24-709/rc

Data Sharing Statement: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-24-709/dss

Peer Review File: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-24-709/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-24-709/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). The National Institute of Cardiology Research Committee Board approved this retrospective study in January 5, 2020 (No. 19-1140), and the requirement for patient consent to use clinical data was waived due to the retrospective study design.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. La Barbera L, Rizzo C, Camarda F, et al. The Contribution of Innate Immunity in Large-Vessel Vasculitis: Detangling New Pathomechanisms beyond the Onset of Vascular Inflammation. Cells 2024;13:271. [Crossref] [PubMed]
2. Fang C, Du L, Gao S, et al. Association between premature vascular smooth muscle cells senescence and vascular inflammation in Takayasu's arteritis. Ann Rheum Dis 2024;83:1522-35. [Crossref] [PubMed]
3. Serra R, Butrico L, Fugetto F, et al. Updates in Pathophysiology, Diagnosis and Management of Takayasu Arteritis. Ann Vasc Surg 2016;35:210-25. [Crossref] [PubMed]
4. Soto ME, Espinola N, Flores-Suarez LF, et al. Takayasu arteritis: clinical features in 110 Mexican Mestizo patients and cardiovascular impact on survival and prognosis. Clin Exp Rheumatol 2008;26:S9-15. [PubMed]
5. Nazareth R, Mason JC. Takayasu arteritis: severe consequences of delayed diagnosis. QJM 2011;104:797-800. [Crossref] [PubMed]
6. Li T, Du J, Gao N, et al. Numano type V Takayasu arteritis patients are more prone to have coronary artery involvement. Clin Rheumatol 2020;39:3439-47. [Crossref] [PubMed]
7. Peng M, Ji W, Jiang X, et al. Selective stent placement versus balloon angioplasty for renovascular hypertension caused by Takayasu arteritis: Two-year results. Int J Cardiol 2016;205:117-23. [Crossref] [PubMed]
8. Gülcü A, Gezer NS, Akar S, et al. Long-Term Follow-Up of Endovascular Repair in the Management of Arterial Stenosis Caused by Takayasu's Arteritis. Ann Vasc Surg 2017;42:93-100. [Crossref] [PubMed]
9. Qureshi MA, Martin Z, Greenberg RK. Endovascular management of patients with Takayasu arteritis: stents versus stent grafts. Semin Vasc Surg 2011;24:44-52. [Crossref] [PubMed]
10. Mason JC. Takayasu arteritis: surgical interventions. Curr Opin Rheumatol 2015;27:45-52. [Crossref] [PubMed]
11. Arend WP, Michel BA, Bloch DA, et al. The American College of Rheumatology 1990 criteria for the classification of Takayasu arteritis. Arthritis Rheum 1990;33:1129-34. [Crossref] [PubMed]
12. Grayson PC, Ponte C, Suppiah R, et al. 2022 American College of Rheumatology/EULAR classification criteria for Takayasu arteritis. Ann Rheum Dis 2022;81:1654-60. [Crossref] [PubMed]
13. Lupi-Herrera E, Sánchez-Torres G, Marcushamer J, et al. Takayasu's arteritis. Clinical study of 107 cases. American Heart Journal 1977;93:94-103. [Crossref] [PubMed]
14. Hata A, Noda M, Moriwaki R, et al. Angiographic findings of Takayasu arteritis: new classification. Int J Cardiol 1996;54:S155-63. [Crossref] [PubMed]
15. World Medical Association Declaration of Helsinki. ethical principles for medical research involving human subjects. JAMA 2013;310:2191-4. [Crossref] [PubMed]
16. Joh JH, Kim DK, Park KH, et al. Surgical management of Takayasu's arteritis. J Korean Med Sci 2006;21:20-4. [Crossref] [PubMed]
17. Ziadi J, Ben Hammamia M, Sobhi M, et al. Revascularization of supra-aortic trunks in Takayasu's arteritis. J Med Vasc 2019;44:260-5. [Crossref] [PubMed]
18. Jang SY, Park TK, Kim DK. Survival and causes of death for Takayasu's arteritis in Korea: A retrospective population-based study. Int J Rheum Dis 2021;24:69-73. [Crossref] [PubMed]
19. Saritas F, Donmez S, Direskeneli H, et al. The epidemiology of Takayasu arteritis: a hospital-based study from northwestern part of Turkey. Rheumatol Int 2016;36:911-6. [Crossref] [PubMed]
20. Ogino H, Matsuda H, Minatoya K, et al. Overview of late outcome of medical and surgical treatment for Takayasu arteritis. Circulation 2008;118:2738-47. [Crossref] [PubMed]
21. Dabague J, Reyes PA. Takayasu arteritis in Mexico: a 38-year clinical perspective through literature review. Int J Cardiol 1996;54:S103-9. [Crossref] [PubMed]
22. Rosa Neto NS, Shinjo SK, Levy-Neto M, et al. Vascular surgery: the main risk factor for mortality in 146 Takayasu arteritis patients. Rheumatol Int 2017;37:1065-73. [Crossref] [PubMed]
23. Saadoun D, Lambert M, Mirault T, et al. Retrospective analysis of surgery versus endovascular intervention in Takayasu arteritis: a multicenter experience. Circulation 2012;125:813-9. [Crossref] [PubMed]
24. Mwipatayi BP, Jeffery PC, Beningfield SJ, et al. Takayasu arteritis: clinical features and management: report of 272 cases. ANZ J Surg 2005;75:110-7. [Crossref] [PubMed]
25. Kaku Y, Aomi S, Tomioka H, et al. Surgery for aortic regurgitation and aortic root dilatation in Takayasu arteritis. Asian Cardiovasc Thorac Ann 2015;23:901-6. [Crossref] [PubMed]
26. Schmidt J, Kermani TA, Bacani AK, et al. Diagnostic features, treatment, and outcomes of Takayasu arteritis in a US cohort of 126 patients. Mayo Clin Proc 2013;88:822-30. [Crossref] [PubMed]
27. Miyata T, Sato O, Koyama H, et al. Long-term survival after surgical treatment of patients with Takayasu's arteritis. Circulation 2003;108:1474-80. [Crossref] [PubMed]
28. Li J, Zhu M, Li M, et al. Cause of death in Chinese Takayasu arteritis patients. Medicine (Baltimore) 2016;95:e4069. [Crossref] [PubMed]
29. Chiche L, Kieffer E, Sabatier J, et al. Renal autotransplantation for vascular disease: late outcome according to etiology. J Vasc Surg 2003;37:353-61. [Crossref] [PubMed]
30. Jung JH, Lee YH, Song GG, et al. Endovascular Versus Open Surgical Intervention in Patients with Takayasu's Arteritis: A Meta-analysis. Eur J Vasc Endovasc Surg 2018;55:888-99. [Crossref] [PubMed]
31. Yang KQ, Meng X, Zhang Y, et al. Aortic Aneurysm in Takayasu Arteritis. Am J Med Sci 2017;354:539-47. [Crossref] [PubMed]
32. de Saboia Mont'Alverne AR, de Paula LE, Shinjo SK. Características da arterite de Takayasu no início da doença e de acordo com o gênero. Arq Bras Cardiol 2013;101:359-63.
33. Lee TH, Chen IM, Chen WY, et al. Early endovascular experience for treatments of Takayasu's arteritis. J Chin Med Assoc 2013;76:83-7. [Crossref] [PubMed]
34. Kerr GS, Hallahan CW, Giordano J, et al. Takayasu Arteritis [Internet]. Available online: http://annals.org/