Pustaka Ilmiah Universitas Padjadjaran

Abstrak

Chronic Limb Ischemia and Heart Failure in a Patient with Takayasu’s Arteritis

Background. Takayasu’s Arteritis (TAK) is a rare chronic inflammatory large vessel disease which frequently involves the aorta and/or its major branches. Progressive stenosis, occlusion and or dilatation on the vessels might result various complications such as stroke, myocardial infarction, heart failure, claudication, aortic aneurism, renal failure and pulmonary artery disease. The epidemiology of TAK is different in every country per year; USA has 2.6 cases/million, Japan 1/3000, while in Indonesia only a few were reported. METHODS. This observational studies in Takayasu’s Arteritis found one case report per year in Dr. Hasan Sadikin Hospital. A 30-years old female, Indonesian nationality, Sundanese ethnic, without risk factor of peripheral artery disease. She had symptoms and signs of progressive claudication, pulseless extremity, dyspnea on effort, asymmetrical arm blood pressure, gangrene, and parese. Examination modalities were. a) MSCT angio-graphic of inferior extremity showed right posterior tibialis artery with reconstruction in the right ankle joint, and one-third occlusion of half left posterior tibialis until left dorsalis pedia artery; b) USG Doppler of legs showed no flow right dorsalis pedia artery and minimal flow left dorsalis artery, and c) Echocardiography showed impaired systolic LV function (EF 37%) with akinetic of anteroseptal wall, hypokinetic of anterior & anterolateral walls. Based on the findings, she was diagnosed as Chronic Limb Ischemia Fontaine Stage III-IV, heart failure, sequelae of stroke infarct and hypertension. Therefore, amputation and anastomosis bypass graft/reconstruction of right femoralis artery to right posterior tibialis artery with saphena magna vein were done. The results of anatomic pathological femoralis artery were inflammation of tunica intima tissue followed by infiltration of fibrotic cells and calcification. The patient was treated with methotrexate, methylprednisolon, cilostazol, warfarin, bisoprolol, captopril, and amlodipine. RESULTS. It is very difficult to diagnose TAK, currently angiography is the gold standard. Costs and facility limitations were difficulties in diagnosing TAK in this patient. Early diagnosis in this patient was based on Sharma and ACR TAK criterias. Furthermore, she had amputated and anastomosis bypass graft/reconstruction, and anatomic pathological results confirmed it was TAK Type 3 Nasu criteria. Although the upper extremity / coronary angiography and carotid ultrasound were not examined, but based on signs, symptoms and echocardiography might show abnormalities of the vessels such as aorta and or branches of coronary artery, carotid artery, subclavian artery, arteries and arteries brachiocephalica renalis. The complications she had were heart failure, claudication, stroke, hypertension, and asymmetrical different blood pressure. In spite, she had claudication in the lower extremities, this is a unique sign in TAK diagnosis. Chronic limb ischemia until gangrene in the lower extremities is rare. In some cases of claudication TAK more commonly occur in upper extremity than in lower extremity and rarely cause gangrene.is CONCLUSION :TAK is a rare vasculities disease. TAK diagnosis is very difficult and needs many criterias as confirmation, one of which is through biopsy. Our case showed anatomical pathology Type 3 by Nasu TAK criteria. The unique condition in this case was chronic limb ischemia until gangrene on lower extremity, which is a rare TAK case in the world. Good management of TAK patients includes adherent treatment, prevention against progression of TAK disease, and appropriate treatment will reduce mortality, morbidity, disability, recurrence and poor complications. Comperehensive management of various multidisciplinary will result a good prognosis.