Ann Thorac Surg 2008;85:1504-1505. doi:10.1016/j.athoracsur.2007.10.072
© 2008 The Society of Thoracic Surgeons
Correspondence
Vascular Surgery in Behcet’s Disease
Dilek Erer, MD,
Erkan Iriz, MD,
Veli Yildirim Imren, MD,
Gursel Levent Oktar, MD
Department of Cardiovascular Surgery, Gazi University Medical Faculty, Dede Korkut Sokak, No: 6/9, Çankaya, Ankara 06640, Turkey
(Email: dilekerer{at}yahoo.com).
To the Editor:
We read with great interest the article by Umehara and colleagues [1], in which they present successful treatment of a ruptured thoracoabdominal aneurysm in a patient with Behcet’s disease. They have performed an extensive operation with very good results. However, we believe certain points in the article should be emphasized.
Behcet’s disease is an autoimmune multi-systemic disorder based on vasculitis. Vascular surgical procedures should be the last resort. Instead, medical management should be aimed, unless surgery is definitely required, because any intervention may lead to further complications such as new occlusions, aneurysms, or pseudoaneurysms [1–3]. When definitely required, operations should preferably be performed when the disease is under strict control with immunosuppressives. In case of an emergency, such as a rupture, the remission status of the patient should be re-evaluated. External (such as active uveitis, aphthae, and genital ulcers) and internal manifestations (such as cardiovascular complications) of the disease are strongly related with exacerbation of the disease. Prior to intervention, it has been shown that bolus dose of immunosuppressives (eg, prednisolone) may decrease perioperative and postoperative vascular complications [2].
It is understood from the article that the disease of the patient is not well controlled with 8 mg/day prednisolone. Another point is that based on the computerized tomography images, we could not be sure of the exact location of the rupture, and the aneurysms seemed to be located at the infrarenal abdominal aorta. We see an aortic dissection inferior to the renal level with hematoma formation around the aorta in Figure 1A (see Reference 1). Because of the tortuous appearance of the aorta in Figure 1B (see Reference 1), only the retroperitoneal hematoma is identifiable. Moreover, in Figure 1C (see Reference 1), we see aneurysms on both sides of the infrarenal aorta. Thus, the necessity for such a major procedure (thoracoabdominal aortic replacement with the use of cardiopulmonary bypass and separate reconstruction of each of the visceral arteries) in the presence of an active vasculitis may be speculated. Information on the duration of the operation would be a helpful addition. Although a 10-month follow-up was uneventful, the patient still faces the lifelong risk of stenosis and pseudoaneurysm because of interventions to the four visceral arteries and femoral artery, as well as proximal and distal anastomoses. Was just the replacement of the ruptured segment without interfering with the visceral arteries or only the renal arteries not possible? Would an endovascular treatment option be more appropriate? In addition, it would be helpful if the authors could provide more information on the medical precautions taken before, during, and after the surgery for a successful outcome by means of additional immunosuppressives and heparin.
 |
References
|
|---|
- Umehara N, Saito S, Ishii H, Aomi S, Kurosawa H. Rupture of thoracoabdominal aortic aneurysm associated with Behcet’s disease Ann Thorac Surg 2007;84:1394-1396.[Abstract/Free Full Text]
- Ugurlucan M, Sayin OA, Surmen B, et al. Complication of Behcet’s disease: spontaneous aortic pseudoaneurysm J Card Surg 2006;21:589-591.[Medline]
- Alpagut U, Ugurlucan M, Dayioglu E. Major arterial involvement and review of Behcet’s disease Ann Vasc Surg 2007;21:232-239.[Medline]
Top
References