Abstract
Objective
Type V Takayasu arteritis (TAK) is the most extensive form of this large-vessel vasculitis, frequently necessitating complex surgical management due to its multiterritory arterial involvement. This study aims to evaluate the clinical efficacy and safety of 1-stage supra-aortic and aortovisceral artery (SAVA) bypass in patients with Numano type V TAK.
Methods
We retrospectively reviewed all patients diagnosed with type V TAK undergoing simultaneous SAVA bypass at 6 tertiary centers in China between February 2017 and April 2024. These patients were selected from a multicenter surgical database of 264 patients with TAK. Demographics and characteristics were collected. The primary end point was mortality within 30 days after surgery; secondary end points included graft patency, major surgery-related complications, and overall survival. All patients were prospectively followed, and outcomes were analyzed.
Results
A total of 12 patients, with 115 SAVA segments affected by TAK, underwent reconstruction of 42 arteries. These reconstructions utilized 14 autologous great saphenous vein grafts and 28 prosthetic grafts with a mean operative time of 514 ± 101 minutes. The 30-day survival rate was 100%. During a mean follow-up duration of 47.4 ± 28.5 months, 4 cases of graft restenosis were detected, of which 1 was successfully resolved via surgical thrombectomy and 3 were managed conservatively. No late mortality or major complications was observed. Postoperatively, systolic blood pressure decreased significantly, and patients achieved sustained symptom relief with improved health-related quality of life.
Conclusions
With appropriate perioperative management and surgical planning, the simultaneous reconstruction of SAVA in type V TAK can be performed safely and effectively.
Key Words: Takayasu arteritis, Numano type V, supra-aortic reconstruction, aortovisceral artery bypass, simultaneous multivessel surgery
Graphical Abstract
Simultaneous supra-aortic and aortovisceral artery bypass for type V Takayasu arteritis.
Central Message.
Simultaneous supra-aortic and aortovisceral bypass for severe Takayasu arteritis is feasible. This largest-ever series shows the single-stage surgery is safe with excellent long-term outcomes.
Perspective.
Managing type V TAK requires balancing surgical risks. Staged repairs risk hemodynamic instability, whereas single-stage surgery is complex. Our findings demonstrate that a simultaneous reconstruction is not only feasible but safe, offering a definitive treatment. This work provides a new benchmark for managing the most severe form of TAK, prioritizing patient safety and long-term results.
Takayasu arteritis (TAK) is a rare, chronic granulomatous vasculitis of unknown etiology predominantly affecting large arteries, particularly the aorta and its main branches.1, 2, 3 Although the global incidence is estimated at approximately 1 to 3 cases per million per year, the prevalence is notably higher in East Asian populations, reaching approximately 40 cases per million in Japan.4,5 Characterized by persistent vessel wall inflammation, TAK can lead to structural alterations such as thickening, fibrosis, stenosis, or complete occlusion, often resulting in severe ischemic complications, including stroke, myocardial infarction, renal failure, and limb ischemia.6,7 Clinically, TAK is classified into 5 angiographic patterns, ranging from isolated lesions in the ascending aorta or supra-aortic branches to extensive panaortic involvement.8 Of these, type V TAK, the most prevalent subtype, is characterized by simultaneous involvement of both the supra-aortic and abdominal aorta and/or renal arteries.9,10 This extensive pattern is associated with multiple vascular lesions, recurrent stenosis, and a high risk of major ischemic complications.9
Although corticosteroids and immunosuppressive agents remain the standard initial therapy, up to 70% of patients with refractory or advanced disease ultimately require surgical or endovascular intervention to restore arterial perfusion.11 For those with severe complications—such as aortic regurgitation, refractory hypertension, or cerebral hypoperfusion—surgical revascularization can significantly improve long-term survival, raising 15-year survival rates from 43% with medical management to 67.5%.12 Nevertheless, the diffuse nature of arterial involvement, the technical demands of multivessel reconstruction, and the elevated risks of perioperative complications and restenosis render the surgical management of type V TAK highly challenging and controversial.
Existing studies are limited by small sample sizes, heterogeneity, and short follow-up, with few focusing specifically on patients with type V disease.9,12,13 Consequently, optimal operative strategies and real-world risk-benefit profiles for this subgroup remain poorly defined. In our institutional experience, we have found that careful patient selection, surgical expertise, strict perioperative hemodynamic management, and tailored perioperative immunosuppression allow for the safe performance of simultaneous supra-aortic and aortovisceral artery (SAVA) bypass procedures in type V TAK.
In this report, we present the largest consecutive multicenter series to date evaluating the outcomes of simultaneous SAVA bypass in patients with type V TAK, providing a systematic analysis of perioperative and intermediate-term results. Our aim is to offer evidence-based guidance for the surgical management of this complex and high-risk patient population.
Methods
Patients
This multicenter observational study involved 264 patients with TAK who underwent surgical intervention for worsening symptoms despite medical therapy at our institution in China between February 2017 and April 2024.14 All patients were diagnosed according to the 1990 American College of Rheumatology or the 2022 American College of Rheumatology/European League Against Rheumatism classification criteria.6,15
From this cohort, 12 patients who received simultaneous reconstruction of the supra-aortic branches, and descending aorta (or visceral arteries) were included for final analysis. Indications for surgery were angiographically confirmed severe stenosis (>70%) or occlusion of SAVA, significant symptomatic deterioration or impaired quality of life despite anti-inflammatory therapy, technical feasibility of bypass, preserved cerebral and peripheral vascular adaptation, and adequate overall fitness for major surgery.16, 17, 18, 19 Exclusion criteria included significant comorbidities precluding surgery. The study was approved by the Beijing Hospital Ethics Committee (approval No. 2024BJYYEC-KY068; approved April 11, 2024). Given the retrospective nature of the study, the requirement for informed consent was waived.
Data Collection and Definitions
Demographic, clinical, and surgical data were collected prospectively and cross-checked by 2 independent investigators. Disease activity was assessed using the 2018 EULAR Consensus Definition.19 Angiographic findings were classified using the Hata classification, as established at the 1994 Tokyo International TAK Conference (Table E1).20 Perioperative and follow-up data included complications, graft patency, and health-related quality of life as measured by the EuroQol-5 Dimension (EQ-5D) questionnaire.
Treatment
The surgical decisions were made by a multidisciplinary team—comprising vascular surgery, interventional radiology, rheumatology, neurology, nephrology, and anesthesiology—in consultation with the patients and/or their families to align with their preferences.21 Surgical intervention was preferentially performed during the remission state of TAK; in patients with active disease, surgery was considered only after comprehensive multidisciplinary evaluation. Perioperative glucocorticoids were individualized to ensure adequate immunosuppression.14 Preoperative assessment included ultrasonography of the great saphenous vein (GSV) for graft suitability. Prosthetic grafts were primarily used for large-diameter reconstructions (eg, aorta) or when autologous vein was unavailable or unsuitable. The revascularization strategy was developed by a multidisciplinary team, prioritizing healthy vessel segments, defined as those free from macroscopic wall thickening, edema, or calcification, for anastomosis. Supra-aortic branch inflow was typically from the ascending aorta, common carotid, or subclavian artery; aortovisceral artery inflow options included the abdominal aorta, ascending aorta-abdominal aorta bypass graft, or the arc of Riolan. All potential inflow and target vessels were carefully evaluated with computed tomography angiography (CTA) and/or digital subtraction angiography for caliber, patency, and wall quality. To minimize arterial clamping time, branch anastomoses of bypass grafts were completed ex vivo before implantation.
Strict blood pressure management was maintained perioperatively, targeting a systolic blood pressure of 140 to 160 mm Hg. Angiography and segmental pressure measurements of SAVA were obtained and compared with peripheral pressures. Intraoperatively, continuous invasive blood pressure monitoring was performed, and detailed records included operative duration, clamping time, and blood loss estimates.
Postoperative Management and Follow-up
Postoperatively, patients were managed in the surgical intensive care unit for 1 to 3 days. Pharmacological management was individualized and included glucocorticoids, immunosuppressants, antihypertension agents, and antiplatelet or anticoagulant therapies as indicated. Surgical success was defined by the alleviation of ischemic symptoms and a reduction in blood pressure, without the occurrence of major complications.
Graft surveillance was conducted by CTA or ultrasound every 3 to 6 months postdischarge. Outcomes data were obtained from clinical records or telephone interviews, with data censored at last follow-up (January 2025) or death. Secondary end points included major complications, defined as graft or stent thrombosis, cardiovascular or cerebrovascular events, or anastomotic aneurysm. Restenosis was considered as luminal narrowing >70%.
Statistical Analysis
Continuous variables were expressed as mean ± SD or median (interquartile range), with group comparisons performed using t test or Mann-Whitney U test. Categorical data were compared with χ2 or Fisher exact test. Kaplan-Meier analysis was used to assess cumulative patency and survival. Analyses were performed with R version 4.4.0 (R Foundation for Statistical Computing), with significance set at P < .05.
Results
Patient Characteristics
This study included 12 female patients with a mean age of 30.2 ± 11.8 years and a mean age of disease onset of 23.2 ± 9.3 years. Three patients (25%) were classified as childhood-onset TAK, defined as disease onset at or before age 16 years. All patients had confirmed type V TAK and were referred for surgical intervention due to refractory or progressive vascular disease despite medical therapy. The mean duration from disease onset to surgical intervention was 7.0 ± 6.0 years. At the time of surgery, 4 patients (33.3%) were assessed as having active diseases per 2018 EULAR recommendations. The mean preoperative erythrocyte sedimentation rate and C-reactive protein were 13.2 ± 12.9 mm/hour and 5.3 ± 10.67 mg/dL, respectively. Only 1 patient showed marked elevation in inflammatory markers, whereas the remaining 11 patients (92%) had values within normal limits.
The most common presenting symptoms were pulselessness (100%) and hypertension (75%), the latter potentially underreported due to frequent upper limb arterial occlusion influencing measurement. Cerebral ischemic symptoms—including dizziness, transient monocular blindness, syncope, and visual impairment—were present in 10 patients (83.3%), whereas limb ischemic symptoms such as absent or asymmetric pulses of limb, and intermittent claudication occurred in 8 patients (66.7%) (Table 1).
Table 1.
Clinical symptoms and features of 12 patients with Takayasu arteritis
| Feature | Result |
|---|---|
| Fever | 0 (0) |
| Fatigue | 4 (33.3) |
| Headache | 2 (16.7) |
| Dizziness | 8 (66.7) |
| TIA | 3 (25.0) |
| Stroke | 1 (8.3) |
| Vision impairment | 2 (16.7) |
| Angina | 1 (8.3) |
| Arterial claudication | 4 (33.3) |
| Pulselessness | 12 (100.0) |
| Pulse asymmetry | 6 (50.0) |
| Hypertension | 9 (75.0) |
Values are presented as n (%). TIA, Transient ischemic attack.
A total of 115 arterial lesions of SAVA were identified, with stenosis and/or occlusion constituting the predominant lesion types (Table 2). Supra-aortic vessels accounted for 62 lesions. All patients had left common carotid and left subclavian artery lesions, and 83.3% had bilateral common carotid involvement. Visceral artery involvement was present in all patients, most often affecting the renal arteries (91.7% overall; left renal artery 66.7%, right 58.3%).
Table 2.
Distribution of arterial involvement in 12 patients with Takayasu arteritis
| Involved artery/system | Result |
|---|---|
| Aorta involved | 12 (100) |
| Ascending aorta | 5 (41.7) |
| Arch | 2 (16.7) |
| Descending thoracic aorta | 6 (50) |
| Suprarenal abdominal aorta | 8 (66.7) |
| Infrarenal abdominal aorta | 6 (50) |
| Supra-arch involved | 12 (100) |
| Brachiocephalic artery | 6 (50) |
| Right common carotid artery | 10 (83.3) |
| Right vertebral artery | 6 (50) |
| Right subclavian artery | 6 (50) |
| Left common carotid artery | 12 (100) |
| Left vertebral artery | 10 (83.3) |
| Left subclavian artery | 12 (100) |
| Visceral arteries involved | 12 (100) |
| Celiac trunk | 2 (16.7) |
| Superior mesenteric artery | 4 (33.3) |
| Left renal artery | 8 (66.7) |
| Right renal artery | 7 (58.3) |
| Inferior mesenteric artery | 1 (8.3) |
| Left common femoral artery | 2 (16.7) |
| Right common femoral artery | 2 (16.7) |
| Other | 6 (50) |
| Intracerebral artery | 4 (33.3) |
| Pulmonary artery | 2 (16.7) |
| Coronary artery | 1 (8.3) |
Perioperative Medication Management
As detailed in Table 3, all patients received preoperative oral corticosteroids, typically prednisone 20 mg/day (range 10-60 mg), except 1 who received methylprednisolone. Nine (75%) were also treated with conventional synthetic disease-modifying antirheumatic drugs, and 1 received tofacitinib for concurrent ankylosing spondylitis.
Table 3.
Disease activity, medication management, and 30-day postoperative complications in 12 patients with Takayasu arteritis
| Case no. | Preoperative disease activity∗ | Routine immunosuppressive therapy | Perioperative corticosteroids Pre-/postoperative |
Perioperative antithrombotic drugs Pre-/postoperative |
30-d Postoperative complication |
|---|---|---|---|---|---|
| 1 | Inactive | Prednisolone 10 mg once a day by mouth +AZA 50 mg once a day by mouth |
Pre: Methylprednisolone 40 mg once a day by intravenous route Post: Methylprednisolone 40 mg once a day by intravenous route for 1 d |
Pre: None Post: LMWH→warfarin |
None |
| 2 | Inactive | Prednisolone 15 mg once a day by mouth +CTX 100 mg once a day by mouth |
Pre: Methylprednisolone 40 mg once a day by intravenous route Post: Methylprednisolone 40 mg once a day by intravenous route for 1 d |
Pre: Aspirin Post: LMWH→aspirin + rivaroxaban |
Multiple organ failure |
| 3 | Inactive | Prednisolone 20 mg once a day by mouth +MTX 20 mg once a week by mouth +LEF 10 mg once a day by mouth |
Pre: Hydrocortisone150 mg once a day by intravenous route Post: Hydrocortisone 50 mg once a day by intravenous route for 1 d |
Pre: Aspirin Post: LMWH→aspirin + rivaroxaban |
None |
| 4 | Inactive | Prednisolone 15 mg once a day by mouth +CTX 50 mg every night by mouth |
Pre: Methylprednisolone 40 mg once a day by intravenous route Post: Methylprednisolone 40 mg once a day by intravenous route for 1 d |
Pre: None Post: LMWH→aspirin + rivaroxaban |
None |
| 5 | Inactive | Prednisolone 10 mg once a day by mouth +tofacitinib 10 mg once a day by mouth |
Pre: Methylprednisolone 40 mg once a day by intravenous route Post: Hydrocortisone 100 mg once a day by intravenous route for 2 d |
Pre: None Post: LMWH→aspirin + rivaroxaban |
Active bleeding |
| 6 | Inactive | Prednisolone 40 mg once a day by mouth +CTX 100 mg once a day by mouth |
Pre: Hydrocortisone 300 mg once a day by intravenous route Post: Hydrocortisone 200 mg once a day by intravenous route for 2 d |
Pre: Aspirin + clopidogrel Post: LMWH→aspirin + clopidogrel |
None |
| 7 | Active | Prednisolone 10 mg once a day +MTX 10 mg once a day by mouth +CTX 100 mg every other day by mouth |
Pre: Methylprednisolone 40 mg once a day by intravenous route Post: Methylprednisolone 40 mg once a day by intravenous route for 3 d |
Pre: Aspirin Post: LMWH→warfarin |
None |
| 8 | Active | Methylprednisolone 20 mg once a day by mouth +MMF 0.5 g twice a day by mouth |
Pre: Methylprednisolone 40 mg once a day by intravenous route Post: Methylprednisolone 40 mg once a day by intravenous route for 3 d |
Pre: None Post: LMWH→aspirin + rivaroxaban |
Wound infection |
| 9 | Active | Prednisolone 10 mg once a day by mouth | Pre: Methylprednisolone 60 mg once a day by intravenous route Post: Methylprednisolone 40 mg once a day by intravenous route for 3 d |
Pre: None Post: LMWH→aspirin + clopidogrel |
None |
| 10 | Inactive | Prednisolone 10 mg once a day by mouth +MMF 1 g twice a day by mouth |
Pre: Hydrocortisone 200 mg once a day by intravenous route Post: Methylprednisolone 40 mg once a day by intravenous route for 2 d |
Pre: Aspirin Post: LMWH→aspirin + clopidogrel |
Wound infection |
| 11 | Inactive | Prednisolone 10 mg once a day by mouth +LEF 20 mg once a day by mouth + HCQ 200 mg once a day by mouth |
Pre: Hydrocortisone 200 mg once a day by intravenous route Post: Methylprednisolone 40 mg once a day by intravenous route for 1 d |
Pre: None Post: LMWH→aspirin + rivaroxaban |
None |
| 12 | Active | Prednisolone 10 mg once a day by mouth | Pre: Methylprednisolone 40 mg once a day by intravenous route Post: Methylprednisolone 40 mg once a day by intravenous route for 3 d |
Pre: Aspirin Post: LMWH→aspirin + rivaroxaban |
None |
AZA, Azathioprine; LMWH, low molecular weight heparin; CTX, cyclophosphamide; MTX, methotrexate; LEF, leflunomide; MMF, mycophenolate mofetil; HCQ, hydroxychloroquine.
Disease activity was assessed using the 2018 European League Against Rheumatism consensus definition.19
In accordance with the perioperative immunoprotection strategy, all patients were transitioned from oral to intravenous corticosteroids during the perioperative period to optimize immunomodulation and minimize surgical and inflammatory stress. Specifically, 9 received methylprednisolone (mean 49 ± 15 mg/day), and 3 received hydrocortisones (mean 217 ± 76 mg/day). This protocol aimed to stabilize disease activity and reduce the risk of disease flare or other immune-related complications during the high-risk perioperative period.
Antiplatelet therapy was maintained for patients with prior vascular interventions: two patients continued long-term dual antiplatelet therapy after prior angioplasty, and 6 patients received aspirin preoperatively. Antihypertension agents were prescribed in 75% to optimize blood pressure control before surgery. Details of perioperative medication management are summarized in Table 3.
Operative Records
A total of 42 arteries were reconstructed among the 115 affected SAVAs, including 10 aortic segments, 14 visceral arteries (10 renal, 2 superior mesenteric, and 2 femoral), and 18 supra-aortic vessels. Forty-two bypass grafts were utilized, consisting of 14 GSVs and 28 artificial blood vessels. Additionally, 1 patient underwent vertebral artery transposition for vertebral artery reconstruction, and 1 patient received concomitant coronary artery bypass grafting (CABG). Sequential grafting was performed in 8 out of 12 patients (67%) (Table 4). Representative postoperative 3-dimensional CTA images demonstrating these complex reconstructions are shown in Figure 1.
Table 4.
Clinical features, arterial involvement, revascularization procedures, and follow-up patency in 12 patients with Takayasu arteritis
| Case no. | Age (y)/sex | Symptoms | Arterial involvement |
Revascularized arteries |
Follow-up patency | |||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Supra-arch | Visceral | Aorta | Other | Location | Reconstructed | Original | Terminal | Bridge type | ||||
| 1 | 19/Female | Hypertension; pulselessness; pulse asymmetry | LCCA, LSA, BCA, RCCA | RRA, CT, LCFA, RCFA | DTA, Suprarenal Abd | Aorta | DTA | AA | Infrarenal Abd | ABV | Yes | |
| Supra-Arch | LCCA | ABV(AA) | LCCA | GSV | Yes | |||||||
| Visceral | RRA | ABV(AA) | RRA | GSV | Yes | |||||||
| 2 | 48/F | Hypertension; dizziness, blurred vision; pulselessness, pulse asymmetry; angina; fatigue | LCCA, LSA, LVA | LRA, RRA | Arch, DA | Coronary | Aorta | Abd | AA | Abd | ABV | Lost to follow-up |
| Supra-Arch | LICA | ABV(AA) | LICA | GSV | ||||||||
| Visceral | – | |||||||||||
| Coronary | Combined | |||||||||||
| 3 | 17/Female | Hypertension; dizziness, TIA, pulselessness; fatigue; pulse asymmetry | LCCA, LSA, LVA, RCCA | LRA, RRA, SMA | AA | – | Aorta | Abd | AA | Abd | ABV | Yes |
| Supra-Arch | LICA | ABV(AA) | LICA | ABV | Yes | |||||||
| RICA | ABV(AA) | RICA | ABV | Yes | ||||||||
| Visceral | SMA | ABV(AA) | SMA | GSV | Yes | |||||||
| LRA | ABV(AA) | LRA | GSV | Yes | ||||||||
| RRA | ABV(AA) | RRA | GSV | Yes | ||||||||
| 4 | 42/Female | Hypertension; pulselessness; pulse asymmetry | LCCA, LVA, LSA | LRA, RRA, SMA | DA | – | Aorta | Abd | AA | Abd | ABV | Yes |
| Supra-Arch | LCCA | ABV(AA) | LCCA | ABV | Yes | |||||||
| Visceral | – | |||||||||||
| 5 | 28/Female | Hypertension; headache; claudication; pulselessness; palpitation | LCCA, LSA, LVA, RCCA, RSA | RRA, SMA, CT, LCFA, RCFA | AA, Abd | Intracerebral, pulmonary | Aorta | Abd | AA | Abd | ABV | Yes |
| Supra-Arch | RVA | RVA transposition | Yes | |||||||||
| Visceral | LCFA | ABV(AA) | LCFA | ABV | Yes | |||||||
| RCFA | ABV(AA) | RCFA | ABV | Yes | ||||||||
| 6 | 28/Female | Hypertension; dizziness, headache, blurred vision, vision loss, TIA; pulselessness | BCA, LCCA, LVA, LSA, RCCA, RSA, RVA | LRA, RRA | AA | Intracerebral | Aorta | – | ||||
| Supra-Arch | RCCA | Infrarenal Abd | RCCA | ABV | No | |||||||
| Visceral | LRA | ABV(Abd) | LRA | GSV | Yes | |||||||
| RRA | ABV(Abd) | RRA | GSV | Yes | ||||||||
| 7 | 41/Female | Dizziness, pulselessness, TIA; palpitation | LCCA, LVA, LSA, BCA, RCCA, RCA, RSA | LRA, RRA | Abd | – | Aorta | Abd | Suprarenal Abd | Infrarenal Abd | ABV | Yes |
| Supra-Arch | LCCA | ABV(Abd) | LCCA | ABV | Yes | |||||||
| LICA | ABV(Abd) | LICA | ABV | Yes (Revision) | ||||||||
| Visceral | – | |||||||||||
| 8 | 29/Female | Hypertension; dizziness; pulselessness; cardiac insufficiency | LCCA, LVA, LSA, RCCA | LRA, RRA | Abd, DTA | – | Aorta | Abd | AA | Abd | ABV | Yes |
| Supra-Arch | LICA | ABV(AA) | LICA | GSV | Yes | |||||||
| RICA | ABV(AA) | RICA | ABV | Yes | ||||||||
| Visceral | LRA | Abd | LRA | GSV | Yes | |||||||
| 9 | 44/Female | Hypertension; dizziness, pulselessness, pulse asymmetry, claudication; fatigue | LSA | LRA | AA, DA | Pulmonary | Aorta | DTA, Suprarenal Abd | AA | Infrarenal Abd | ABV | Yes |
| Supra-Arch | LSA | ABV(AA) | LAA | ABV | Yes | |||||||
| Visceral | SMA | ABV(AA) | SMA | ABV | Yes | |||||||
| LRA | ABV(AA) | LRA | GSV | Yes | ||||||||
| RRA | ABV(AA) | RRA | GSV | Yes | ||||||||
| 10 | 15/Female | Dizziness, claudication, pulselessness | LCCA, LVA, LSA, BCA, RCCA | LRA | DTA | Intracerebral | Aorta | DTA | AA | Infrarenal Abd | ABV | Yes |
| Supra-Arch | LCCA | ABV(AA) | LCCA | ABV | Yes | |||||||
| RCCA | ABV(AA) | RCCA | ABV | Yes | ||||||||
| RSA | ABV(AA) | RSA | ABV | Yes | ||||||||
| Visceral | LRA | Abd | LRA | GSV | No | |||||||
| 11 | 16/Female | Stroke; pulselessness, pulse asymmetry, claudication | LCCA, LSA, BCA, RCCA, RSA | LRA | Ab | Aorta | Abd | Suprarenal Abd | Infrarenal Abd | ABV | Yes | |
| Supra-Arch | LCCA | ABV(Abd) | LCCA | ABV | No | |||||||
| LSA | ABV(Abd) | LSA | ABV | Yes | ||||||||
| Visceral | – | |||||||||||
| 12 | 35/Female | Hypertension; dizziness, pulselessness; fatigue | LCCA, LVA, LSA, BCA, RCCA, RSA | RRA | AA | Intracerebral | Aorta | – | ||||
| Supra-Arch | RCCA | Infrarenal Abd | RCCA | ABV | Yes | |||||||
| Visceral | RRA | CT | RRA | GSV | Yes | |||||||
TIA, Transient ischaemic attack; LCCA, left common carotid artery; LSA, left subclavian artery; BCA, brachiocephalic artery; RCCA, Right common carotid artery; RRA, right renal artery; CT, celiac trunk; DTA, descending thoracic aorta; AA, abdominal aorta; Abd, abdominal; LVA, left vertebral artery; LRA, left renal artery; SMA, superior mesenteric artery; LCFA, left common femoral artery; RCFA, right common femoral artery; GSV, great saphenous vein graft; ABV, artificial blood vessel graft.
Figure 1.
Postoperative computed tomography angiography scan showing multisite arterial reconstruction in 2 patients with Takayasu's arteritis. Case 1 (top row): A, Ascending aorta–abdominal aorta prosthetic bypass and left carotid artery prosthetic bypass. B, Prosthetic graft limb to left renal artery bypass. C, Riolan's arch to right renal artery bypass. Case 2 (bottom row): D, Ascending aorta–abdominal aorta prosthetic bypass. E, Prosthetic graft limb to right subclavian artery and bilateral carotid arteries. F, Autologous great saphenous vein bypass from abdominal aorta to left renal artery.
Regarding the origin of the grafts, 8 cases (67%) utilized the ascending aorta as the inflow site, 2 cases used the abdominal aorta, 1 case used the infrarenal abdominal aorta, and 1 case used both the infrarenal abdominal aorta and the celiac trunk. The distal anastomosis sites included the normal abdominal aorta, the internal carotid artery, or the subclavian artery, selected according to the anatomical requirements of each patient.
All surgeries were technically successful (100%). The mean operative time was 514 ± 101 minutes. The average vascular occlusion time was 34.0 ± 15.5 minutes, with a mean intraoperative blood loss of 1021 ± 816 mL. The average blood transfusion volumes were 211 ± 308 mL autologous blood, 603 ± 501 mL packed red blood cells, and 450 ± 332 mL fresh frozen plasma. Postoperatively, all patients were admitted to the intensive care unit for intensive monitoring of vital signs, with a mean intensive care unit stay of 3.1 ± 2.7 days, and the mean length of hospital stay was 31 ± 13 days.
Postoperative Blood Pressure Control
Blood pressure was closely monitored in all patients following surgery. Preoperative blood pressure averaged 154.8 ± 48.6/69.7 ± 15.3 mm Hg, whereas blood pressure on the first postoperative day was 125.8 ± 30.6/61.9 ± 13.6 mm Hg. Systolic blood pressure decreased significantly postoperatively (P = .025), indicating effective control of systolic hypertension (Figure 2, A and B).
Figure 2.
Changes in blood pressure and quality of life before and after surgical intervention. A, Boxplots show individual and grouped systolic blood pressure measurements before (Pre) (blue) and following (Post) (red) treatment. B, Boxplots show diastolic blood pressure measurements before and following treatment. Paired lines indicate matched pre- and postintervention values for each patient. Systolic blood pressure significantly decreased after surgery (P = .025), whereas the reduction in diastolic blood pressure was not statistically significant (P = .19). Boxplots show significant increases in EuroQol-5 Dimension (EQ-5D) index scores (C) and EuroQol-Visual Analogue Scale (EQ-VAS) scores (D) at follow-up compared with preoperative values (P < .05). Paired lines represent individual patient changes, indicating enhanced health-related quality of life after surgery.
Perioperative Complications
The 30-day postoperative complication rate was 33.3% (4 out of 12) with no mortality. Two patients developed wound infections, both of whom resolved with antibiotic therapy and wound care. One experienced active bleeding requiring chest tube drainage. Another patient who underwent concomitant CABG developed progressive hypotension and subsequently multiorgan dysfunction syndrome. Despite treatment in the coronary care unit, this patient's condition remained critical, and she was discharged to a local palliative care facility in a state of persistent organ failure. This patient was subsequently lost to follow-up and represents the 1 patient not included in the long-term follow-up and quality of life analyses (Table 3).
Intermediate Follow-up
Eleven patients (91.7%) completed follow-up, with a mean duration of 47.4 ± 28.5 months. One patient developed thrombosis of an abdominal aorta-to-left common carotid artificial graft at 7 months postoperatively, which was successfully managed with surgical thrombectomy. Among these 11 patients, 8 (72.7%) experienced no graft-related adverse events. Of 37 bypass grafts evaluated, 2 developed stenosis (both in supra-aortic arteries) and 1 occlusion occurred in a renal artery after prior ipsilateral renal dysfunction (Table 4). All affected grafts were artificial blood vessels, resulting in a vascular event rate of 8.1%. Kaplan-Meier analysis showed no significant difference in vascular event incidence among graft locations (P = .064) (Figure 3). All patients maintained sustained symptom relief without recurrence throughout follow-up, and no major complications (hemorrhage, stroke, transient ischemic attack, infection, or mortality) were observed.
Figure 3.
Kaplan-Meier analysis of vascular event-free survival by graft location. Survival curves show the probability of freedom from vascular events for aortic (blue), supra-aortic (red), and visceral artery (green) reconstructions. The y-axis represents survival percentage (%), and the x-axis represents time in years. No significant difference in event rates was observed among graft locations (P = .57). Shaded areas represent 95% CI. The table below indicates the number of grafts at risk at each time point.
Quality of Life Analysis
Quality of life was assessed in 11 patients using the EQ-5D questionnaire (1 was lost to follow-up). The EQ-5D score evaluates health status across functional dimensions (range, −1 to 1), whereas the EuroQol-Visual Analogue Scale (EQ-VAS) (range, 0-100) assesses subjective health perception. At the last follow-up, both EQ-5D and EQ-VAS scores were significantly improved compared with preoperative values (P < .05), indicating enhanced health-related quality of life postsurgery (Figure 2, C and D).
Discussion
Indications and Theoretical Rationale
Managing late-stage TAK with extensive arterial involvement is challenging due to its heterogeneity and complex anatomy. Patients with type V TAK frequently present with severe renovascular hypertension or hypertension secondary to aortic coarctation, compounded by multiterritory ischemia involving the supra-aortic, thoracoabdominal, and renal arteries.22 Without timely intervention, the majority of these patients develop refractory hypertension and die from cardiovascular complications before reaching age 35 years.3 Therefore, timely surgical management targeting multiple affected vascular territories is crucial in such cases.
Given the relatively young age of most TAK patients, long-term durability is a major consideration when selecting surgical approach.11 In patients with complex, multisegment involvement and long life expectancy, open bypass reconstruction demonstrates superior long-term patency compared to alternative approaches, as supported by previous reports.23, 24, 25 Redo surgery carries higher risk and additional burdens.26,27 Thus, when feasible, single-stage open bypass may offer better prospects for these patients.
Pathophysiologically, patients with chronic extracranial vascular occlusion may develop compensatory intracranial vessel dilatation. Isolated cervical branch revascularization, whereas persistent hypertension is associated with cerebral hyperperfusion syndrome, whereas isolated aortic or renal revascularization may precipitate acute cerebral ischemia by abruptly lowering blood pressure.26,28 These observations support synchronous revascularization for patients with widespread arterial involvement to achieve both optimal blood pressure control and adequate cerebral perfusion. Although staged procedures reduce operative trauma per session, they risk perioperative complications from hemodynamic instability. In selected patients, synchronous multivessel revascularization is therefore preferred when operative risk is acceptable.
Surgical Technique
A standard operative strategy for concomitant SAVA reconstruction in TAK is not established. Our center uses a sequential revascularization protocol: supra-aortic branch reconstruction followed by aortic/visceral bypass, with strict avoidance of actively inflamed or diseased vessel segments for anastomosis.
The rationale for this specific surgical sequence—performing supra-aortic branch reconstruction before visceral artery bypass—is grounded in safety and hemodynamic stability. Restoring cerebral perfusion first reduces the risk of perioperative cerebral ischemia in patients with compromised supra-aortic arteries. This approach permits continuous neurological monitoring and protection before the hemodynamic challenges of aorta or visceral artery clamping. Aortovisceral artery reconstruction often requires controlled systemic hypotension to minimize bleeding and protect anastomosis. Because intraoperative blood pressure reduction is generally easier to achieve and control than elevation, securing cerebral perfusion beforehand prevents cerebral hypoperfusion and stroke during hypotensive periods. Consequently, this sequence ensures more stable intraoperative hemodynamics and enhances neurological and end-organ protection.
Regarding graft inflow, the ascending aorta is typically selected for supra-aortic bypass owing to its relative sparing from inflammation; alternatively, the brachiocephalic or subclavian arteries may be used when feasible to avoid thoracotomy. For aortovisceral reconstruction, inflow is selected based on intraoperative findings and preoperative imaging. In our series, the ascending aorta was the most frequent inflow source (75%), followed by the suprarenal or infrarenal abdominal aorta. Our most common approach uses an ascending-to-abdominal aorta prosthetic conduit, from which bypasses to target arteries are constructed using either a separate prosthetic graft or a reversed GSV, depending on the vessel diameter and anatomical position. In selected cases, when preoperative CTA demonstrates a well-developed, tortuous Riolan arterial arcade with adequate caliber, the Riolan arch can serve as an alternative inflow source, facilitating a side-to-side anastomosis with the target vessel. The anatomy is meticulously evaluated intraoperatively to prevent kinking or impaired mesenteric perfusion.
Timing of Surgery
Current consensus guidelines recommend disease quiescence (remission phase) before surgical intervention to reduce perioperative complications associated with active vascular inflammation.17,19,29 However, delayed diagnosis, subclinical progression, and high disease burden occasionally necessitate urgent or semiurgent surgery. Preoperative immunosuppression with corticosteroids and/or conventional synthetic disease-modifying antirheumatic drugs remains a cornerstone for optimal outcomes, as advocated by current literature.30, 31, 32 In our series, intravenous corticosteroids were administered preoperatively regardless of inflammatory marker activity to mitigate the stress response and prevent postoperative flares.14,33
Perioperative Management
Optimal perioperative management requires multidisciplinary collaboration, focusing on blood pressure stabilization, anti-inflammatory and antithrombotic regimens, and intensive monitoring. Intra- and postoperative blood pressure is maintained within 140 to 160 mm Hg systolic to minimize the risk of cerebral and visceral hypoperfusion, as well as hypertensive complications.34 After aortovisceral revascularization, aggressive volume resuscitation and avoidance of severe hypotension are critical, given the risk of hypoperfusion due to acute afterload reduction.
Special consideration is required for patients requiring concomitant cardiac surgery. In our series, the only patient who experienced severe postoperative morbidity (multiorgan dysfunction) underwent simultaneous CABG and SAVA bypass. This suggests that the physiological stress of combining extensive aortic reconstruction with coronary bypass may exceed the reserve of these fragile patients. In such high-risk scenarios, a staged approach, addressing the coronary pathology first, or a hybrid strategy might be preferable to simultaneous open surgery to minimize operative trauma and optimize survival.
Antithrombotic therapy is individualized based on patient risk and surgical factors. Perioperative dual antiplatelet therapy (eg, aspirin and clopidogrel) is recommended for patients with prosthetic grafts, previous endovascular procedures, or higher thrombotic risk, whereas long-term single antiplatelet therapy may be continued at the clinician's discretion.17,35 Long-term combination therapy (eg, rivaroxaban plus aspirin) is considered for selected high-risk cases, although the most effective antithrombotic strategy for this population remains to be defined.36
Long-term Outcomes and Surveillance
Lifelong multidisciplinary follow-up is essential to monitor disease recurrence, graft patency, and major vascular events. High-risk factors for recurrence include short disease duration, prior relapses, cerebrovascular events, renovascular hypertension, aortic aneurysms, arch involvement, extensive disease (>6 vessels), and elevated baseline inflammatory markers.37 Ongoing clinical and imaging surveillance, stringent blood pressure control, and optimization of immunosuppression are essential for long-term management.
Our experience demonstrates that open bypass using uninvolved arterial segments (especially the ascending aorta for supra-aortic branches) provides favorable perioperative and long-term results, with no major neurological complications observed in this series. As endovascular techniques evolve, their role in selecting patients with complex TAK may expand, but current evidence supports open surgery as the gold standard for durable repair in suitable candidates.
Limitations
This study is limited by its retrospective design, small sample size, and lack of a comparison group. The relative rarity of this surgery and paucity of published data on simultaneous SAVA revascularization for type V TAK limit external comparisons. Additionally, our cohort was exclusively women, which reflects the epidemiology of the disease but limits the generalizability of our findings to male patients. Larger multicenter studies are warranted to confirm these findings and to define optimal patient selection, surgical techniques, and adjunctive medical therapies.
Conclusions
Simultaneous reconstruction of SAVA in patients with extensive TAK is feasible and safe in experienced centers, with satisfactory perioperative and long-term outcomes. Optimal results require individualized operative planning, multidisciplinary collaboration, rigorous perioperative immunomodulation, and vigilant long-term follow-up.
Conflict of Interest Statement
The TAKS database was supported by Unendingcraft Technology Co Ltd. The authors reported no conflicts of interest.
The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for. which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.
Acknowledgments
The authors thank all included patients and their families.
Vascular Improvement Platform: Takayasu's Arteritis Surgical Database (VIP-TAKS) Study Collaborators include Peng Li, MMa, Yong Lan, MDa, Shuping Tan, MMa, Chengran Lu, MDa, Yuqing Miao, MDa, Xiaoyan Zhang, PhDa, Jiayin Luo, MBa, Hui Yang, MBa, Honglin Dong, MDb, Sheng Yan, MDb, Yifei Li, MMb, Tao Yang, MDc, Jianjun Shi, MMd, Qiang Zhang, MMd, Mingchao Ding, MMe, Hongcheng Ren, PhDe, Zhen Chen, MDf, Xinping Tian, MDg, and Jing Li, MDg. Affiliations: (a) Department of Vascular Surgery, Beijing Hospital, National Center of Gerontology; Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, P.R. China; (b) Department of Vascular Surgery, Second Hospital of Shanxi Medical University, Taiyuan, Shanxi, P.R. China; (c) Department of Vascular Surgery, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Third Hospital of Shanxi Medical University, Tongji Shanxi Hospital, Taiyuan, P.R. China; (d) Department of Cardiovascular Surgery, Taiyuan Central Hospital of Shanxi Medical University, Taiyuan, Shanxi, P.R. China; (e) Department of Interventional Vascular, Aerospace Center Hospital, Beijing, P.R. China; (f) Department of Rheumatology, Shengli Clinical Medical College of Fujian Medical University, Fujian Provincial Hospital, Fuzhou University Affiliated Provincial Hospital, Fuzhou, Fujian, P.R. China; (g) Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, P.R. China.
Footnotes
Supported by National High-Level Hospital Clinical Research Funding (No. BJ-2024-142, BJ-2024-187, BJ-2025-242, BJ-2024-247, BJ-2018-089), Clinical and Translational Medicine Research Project of the Chinese Academy of Medical Sciences (No. 2023-I2M-C&T-B-115), and CAMS Innovation Engineering Project (No. 2025-I2M-TS-18).
Drs Li, Zhao, and Wang contributed equally to this article as first authors.
Clinical Trial Registry Number: ChiCTR2500097249.
IRB/ERB Number and Date of Approval: 2024BJYYEC-KY068; April 11, 2024.
Informed Consent Statement: Written informed consent was waived.
Contributor Information
Zhiyuan Wu, Email: wuzhiyuan5025@bjhmoh.cn.
Yongpeng Diao, Email: sunheartdyp@163.com.
Yongjun Li, Email: liyongjun4679@bjhmoh.cn.
Vascular Improvement Platform: Takayasu's Arteritis Surgical Database (VIP-TAKS) Study Collaborators:
Peng Li, Yong Lan, Shuping Tan, Chengran Lu, Yuqing Miao, Xiaoyan Zhang, Jiayin Luo, Hui Yang, Honglin Dong, Sheng Yan, Yifei Li, Tao Yang, Jianjun Shi, Qiang Zhang, Mingchao Ding, Hongcheng Ren, Zhen Chen, Xinping Tian, and Jing Li
Appendix E1
Table E1.
Angiographic classification of the affected arteries20
| Type | Definition |
|---|---|
| Type I | Branches of the aortic arch |
| Type IIa | Ascending aorta and aortic arch and its branches |
| Type IIb | Ascending aorta, aortic arch and its branches, and thoracic descending aorta |
| Type III | Thoracic descending aorta, abdominal aorta, or renal arteries |
| Type IV | Abdominal aorta or renal arteries |
| Type V | Combined features of types IIb and IV |
| C+ | Coronary artery involvement |
| P+ | Pulmonary artery involvement |
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