Perioperative Management of Takayasu Arteritis for Cardiac Surgery　― Review and Single-Center Experience ―

Abstract

Takayasu arteritis (TAK) is classified as a large vessel vasculitis and often causes vascular stenosis, occlusion, and aneurysm formation. Although the principal treatment for TAK involves suppressing inflammation with glucocorticoids, the emergence of biological disease-modifying antirheumatic drugs has considerably changed the treatment landscape of TAK in recent years. Several biological disease-modifying antirheumatic drugs, such as tocilizumab (TCZ), have shown promising effects on TAK in clinical studies. Cardiologists and cardiovascular surgeons encounter patients receiving these drugs who require catheterization, endovascular treatment, or cardiovascular surgery. However, in patients treated with glucocorticoids and TCZ, there needs to be greater awareness of more complications than usual after surgery, such as delayed wound healing, systemic infection, and surgical site infection. In addition, in patients receiving TCZ, inflammatory markers, such as C-reactive protein, may not increase when complications arise from infection. Unfortunately, there are no guidelines or solid evidence that have clearly defined the optimal perioperative treatment strategy for patients with TAK who require cardiovascular surgery. This article reviews the evidence and our recent experience supporting the perioperative use of TCZ, and proposes a protocol that can reduce complications in patients with TAK undergoing invasive cardiovascular treatment.

Takayasu arteritis (TAK), which often affects young women, is a rare disease characterized by the inflammation of large blood vessels, resulting in vascular stenosis, occlusion, and aneurysm formation.^1–6 Since 2000, the age at diagnosis of TAK has become younger because of advances in imaging tools, such as computed tomography (CT) angiography, magnetic resonance imaging and ¹⁸F-fluorodeoxyglucose positron emission tomography (FDG-PET).² Glucocorticoids (GCs) and immunosuppressant doses have increased, but the proportion of patients requiring surgical treatment has remained the same at 22%.² Therefore, the opportunities for cardiovascular surgery in young patients with TAK may have increased. TAK often causes aortic dilatation/aneurysm and stenosis/occlusion of the coronary arteries. Therefore, aortic replacement/repair, aortic valve replacement, coronary artery bypass graft (CABG) surgery, and endovascular treatment are often required in patients with TAK.^7–13

GCs are the principal treatment for TAK.^14,15 However, the emergence of biological disease-modifying antirheumatic drugs (bDMARDs), represented by tocilizumab (TCZ), has markedly changed the treatment landscape of TAK.^16–21 The 2017 Japanese Circulation Society (JCS) guidelines for the management of vasculitis syndrome indicated TCZ as a Class I treatment recommendation for TAK, whereas the use of a tumor necrosis factor inhibitor was a Class IIa recommendation.¹⁴

Perioperative TAK management in patients who have cardiovascular surgery and receive TCZ can be challenging because of concerns about an increased likelihood of surgical complications, such as systemic infection, delayed wound healing, and surgical site infection (SSI), due to the administration of GCs and immunosuppressants. Furthermore, if immunosuppressant drugs are discontinued before surgery, clinicians must be aware of the potential for TAK relapse after surgery. This dilemma concerns many clinicians involved with the perioperative management of patients with TAK. At present, there are no guidelines or solid evidence that clearly define the optimal timing of perioperative discontinuation of TCZ for patients with TAK who require cardiovascular surgery. In this article, we describe perioperative management for patients with TAK who require cardiovascular surgery, focusing on GCs and TCZ. Our aim is to help cardiologists and cardiovascular surgeons, who are occasionally involved in treating patients with TAK, to better understand this disease and perioperative treatment.

TCZ

TCZ is a recombinant humanized anti-interleukin-6 receptor monoclonal antibody. Patients with TAK usually self-administer 162 mg TCZ subcutaneously once a week. Current and future promising immunosuppressive therapies for TAK are listed in Table 1.²² In the 2017 JCS guidelines, only TCZ and tumor necrosis factor inhibitor are recommended as treatments for TAK; other bDMARDs are not described in the guidelines.¹⁴ Among the bDMARDs, the evidence for treating TAK is accumulating, especially for TCZ, and the results of several large-scale clinical studies investigating the efficacy of TCZ in TAK have been published.^23–26 Furthermore, randomized controlled trials have suggested TCZ treatment enables the dose of GC to be reduced.^17,27 Other trials have reported on the long-term safety and efficacy outcomes for TCZ in patients with TAK refractory to other conventional treatments.^28,29

Table 1.

Current and Future Promising Immunosuppressive Therapies for TAK

Immunosuppressant	JCS recommendation	Clinical evidence
Tocilizumab	Class I	RCT17,28
TNF inhibitors	Class II a	RCT52
JAK inhibitors	Not listed	Prospective study53,54
Secukinumab	Not listed	Prospective study55
Rituximab	Not listed	Case reports56

JAK, Janus kinase; JCS, Japanese Circulation Society; RCT, randomized controlled trial; TAK, Takayasu arteritis; TNF, tumor necrosis factor.

Perioperative Management of Patients With Rheumatoid Arthritis Undergoing Elective Total Hip and Knee Arthroplasty

TCZ has been commercially available for use in the treatment of TAK since 2017, but has been available in Japan for the treatment of patients with rheumatoid arthritis (RA) since 2008. Although most surgeries for patients with RA are orthopedic surgeries, which differ from cardiovascular surgeries in patients with TAK, the perioperative management of patients with RA can provide guidance for the perioperative management of patients with TAK treated with TCZ.³⁰ Specifically, perioperative withdrawal of TCZ and its resumption can be considered for patients with RA. According to the 2022 American College of Rheumatology guidelines, patients on once-weekly subcutaneous TCZ injections for RA should have treatment withdrawn 2 weeks before elective total hip and knee arthroplasty.^31,32 In the absence of wound healing problems, SSI, and systemic infection, TCZ can be resumed a minimum of 2 weeks after surgery.

Inflammation and Surgical Complications of TAK

In a previous retrospective multicenter study, Saadoun et al. analyzed the outcomes of 166 vascular procedures to manage arterial complications in patients with TAK.³³ In that study, a multivariate analysis revealed that biological inflammation at the time of revascularization was independently associated with the occurrence of arterial complications after the vascular procedure.³³ Other studies have also reported that active disease of TAK markedly increases the risk of postoperative complications and results in poor outcomes after surgery.^34,35

The long-term outcomes of coronary artery revascularization for patients with TAK have also been reported, with CABG and percutaneous coronary intervention having a poor prognosis for revascularization during the active vs. stable stage of TAK.³⁶ Another study reported that initial disease activity was a predictor of long-term cardiovascular outcomes in patients with TAK and severe coronary stenosis.³⁷ Therefore, cardiovascular surgery for patients with TAK should be performed after suppressing inflammation as much as possible if the patient’s condition allows.

GCs and Surgical Complications

An association between the dosage of GCs and wound healing has been reported.³⁸ The rate of wound complications may be increased 2- to 5-fold in patients taking chronic GCs for at least 30 days before surgery compared with those not taking GCs. In addition, complication rates may vary depending on the dose and duration of GC use, comorbidities, and type of surgery. Another study reported that the use of GCs was a risk factor for SSI, with increased doses increasing the risk.³⁹ Finally, the use of GCs has been reported to increase the hazard ratio for postoperative death within 1 year after orthopedic surgery.⁴⁰

Delayed Wound Healing and Relapse During the Perioperative Phase Under TCZ Treatment

Delayed wound healing under TCZ administration has been reported. For example, Momohara et al. reported that delayed wound healing was observed after surgery in 20 of 161 RA patients who were receiving intravenous TCZ once every 4 weeks.⁴¹ Delayed wound healing was more likely to occur after spinal surgery, but there was no significant difference in the GC dose administered.⁴¹ The time from final TCZ infusion to the surgical procedure did not differ significantly between patients with and without delayed wound healing.⁴¹ Multivariate analysis revealed that the use of prednisolone (PSL), a foot operation, and spinal surgery were factors associated with delayed wound healing.⁴¹ In a recent meta-analysis, the use of bDMARDs was a risk factor for SSI, but not for delayed wound healing and postoperative death after orthopedic surgery in patients with RA.³⁹ These results suggest that the use of GCs and complex surgery are closely associated with delayed wound healing.

A relapse of inflammatory disease due to discontinuing TCZ is another concern. Momohara et al. reported that 36 of 161 patients experienced a relapses of RA symptoms after surgery.⁴¹ Compared with the non-relapse group, the relapse group was more likely to have a history of tumor necrosis factor inhibitor administration and a longer duration from final TCZ infusion to surgery.⁴¹ These results suggest that TCZ withdrawal for a longer period of time preoperatively may cause postoperative relapse.

We previously reported on a patient who experienced postoperative TAK relapse after a long preoperative TCZ withdrawal period.⁴² Briefly, our patient was a 23-year-old woman who was diagnosed with TAK. CT angiography showed severe stenosis in the ostia of the left main coronary artery. PSL was initiated at 45 mg (1 mg/kg/day). During the PSL tapering process, TCZ was administered every week because of an increase in C-reactive protein concentrations, which were thought to indicate an asymptomatic relapse of TAK. Thereafter, the dose of PSL was reduced to 10 mg, and TCZ was suspended for 5 weeks. Minimally invasive cardiac surgery (MICS)-CABG was performed because the incidence of wound infections and septic complications was expected to be lower with a thoracotomy than with a median sternotomy.^43–45 In this case, because the preoperative withdrawal period was 5 weeks, TCZ had to be resumed 1 week after surgery owing to a relapse of TAK before wound healing was complete.⁴² After restarting TCZ, left pleural effusion increased. A thoracentesis culture was negative; therefore, the pleural effusion was thought to be due to delayed wound healing associated with the left intercostal incision by MICS-CABG. The healing process was slower than normal, and the pleural effusion took 4 weeks after surgery to disappear. In this case, wound healing was thought to be delayed because of the early resumption of TCZ.⁴² These findings suggest that TCZ should be restarted after the completion of wound healing.

Consecutive Cardiovascular Surgical Cases of TAK at the National Cerebral and Cardiovascular Center

Table 2 presents data for 8 consecutive patients with TAK who were prescribed TCZ and who underwent cardiovascular surgery at the National Cerebral and Cardiovascular Center between December 2019 and August 2023. The patients’ clinical information was collected after approval had been obtained from the research ethics committees of the National Cerebral and Cardiovascular Center (R21076-2). Informed consent was obtained in the form of opt-out on the National Cerebral and Cardiovascular Center website. Postoperative complications were observed in 3 of 8 patients; Patients 1–3 experienced postoperative complications, Patients 4–8 did not. None of the patients had elevated white blood cell counts or inflammatory markers (e.g., C-reactive protein concentrations and erythrocyte sedimentation rate). The mean PSL dose at the time of surgery was 8.7 mg/day. The mean time from the final administration of TCZ to surgery was 17.5 days, and the mean time from surgery to the resumption of TCZ was 17.0 days.

Table 2.

Clinical Information for 8 Consecutive Patients With TAK Who Were Prescribed TCZ and Underwent Cardiovascular Surgery at the NCVC

Patient no.	Age (years)	Sex	Duration of TAK (years)	Disease for surgery	Surgical procedure	Past surgical procedure	WBC (/μL)	CRP (mg/dL)	ESR (mm/h)	Fibrinogen (mg/dL)
1	29	F	3	TAA	TAR+Des Ao replacement, rt CCA reconstruction	–	8,730	0.04	3	180
2	29	F	2	Severe AR, TAA, lt CCA aneurysm	Bentall, TAR+CET, lt CCA reconstruction	–	3,290	0.01	7	169
3	57	M	6	LCA pseudoaneurysm	LCA reconstruction	Bentall	2,420	0.01	NA	120
4	78	F	40	SMI	MICS-CABG	–	8,590	0.02	5	305
5	26	F	6	TAA	TAR+CET	–	6,690	0.01	2	164
6	38	F	11	AAE	Bentall	–	6,750	0.01	3	195
7	60	F	32	TAA	TEVAR	AAA (Y-grafting), TEVAR	4050	0.01	3	147
8	53	F	27	Prosthetic valve dysfunction	Re-Bentall	AVR	5,440	0.03	4	195
Patient no.	PSL (mg)	Immunosuppressant	Time from final TCZ administration to operation (days)	Time from surgery to TCZ resumption (days)	FDG uptake	Complications (excluding delayed wound healing and relapse of TAK)			Delayed wound healing	Relapse
1	16	MTX, AZA	14	9	+	Chest re-exploration for hemostasis			–	–
2	13	MTX	19	14	+	Chest re-exploration for hemostasis			+	–
3	2	MTX	8	29	NA	STEMI, bacteremia			+	–
4	10	–	39	15	+	–			–	–
5	12.5	CYA	19	17	–	–			–	–
6	6	–	18	17	–	–			–	–
7	5	–	18	14	NA	–			–	–
8	5	–	5	21	–	–			–	–

Patients 1–3 experienced complications, Patients 4–8 did not. AAA, abdominal aortic aneurysm; AAE, annulo-aortic ectasia; AR, aortic regurgitation; AVR, aortic valve replacement; AZA, azathioprine; CABG, coronary artery bypass grafting; CCA, common carotid artery; CET, conventional elephant trunk; CRP, C-reactive protein; CYA, cyclosporine A; Des Ao, descending aorta; ESR, erythrocyte sedimentation rate; FDG, ¹⁸F-fluorodeoxyglucose; LCA, left coronary artery; lt, left; MICS, minimally invasive cardiac surgery; MTX, methotrexate; NA, not available; NCVC, National Cerebral and Cardiovascular Center; rt, right; SMI, silent myocardial ischemia; STEMI, ST-elevation myocardial infarction; TAA, thoracic aortic aneurysm; TAK, Takayasu arteritis; TAR, total arch replacement; TCZ, tocilizumab; TEVAR, thoracic endovascular aortic repair; WBC, white blood cell.

Patient 1 had extremely refractory TAK. Despite the administration of GCs and TCZ, the thoracic aortic aneurysm expanded. Then, immunosuppressant combination therapy with azathioprine and methotrexate (MTX) was administered. Even so, the diameter of the ascending aorta expanded to 58 mm×62 mm (Figure 1A) when the patient was referred to our hospital for evaluation of surgical indications. Although FDG-PET showed heterogeneous FDG accumulation in the ascending aorta that became clear in delayed scans (Figure 1B), the degree of accumulation had weakened compared with FDG accumulation prior to initiation of immunosuppressant combination therapy. Because there was a risk that the thoracic aortic aneurysm would rupture while TAK inflammation was being brought under control, surgery was performed. The day after surgery, the patient required chest re-exploration for hemostasis. However, it has been 4 years since Patient 1 was discharged, and the TAK inflammation has been controlled without the need for further surgery.

Figure 1.

Chest computed tomography and ¹⁸F-fluorodeoxyglucose (FDG) positron emission tomography images of Patient 1. (A) The ascending aorta expanded to 58 mm×62 mm. (B) Heterogeneous FDG accumulation in the aorta.

Patient 2 also had refractory TAK. Despite treatment with GCs and MTX, TAK activity was not under control. TCZ administration improved FDG-PET uptake, but it was still evident (Figure 2A) at the time when Patient 2 was referred to our hospital. Moreover, the ascending aortic aneurysm had expanded to 57 mm×53 mm (Figure 2B), and the patient developed severe aortic regurgitation (Figure 2C) and heart failure symptoms, so surgery was performed. The day after surgery, Patient 2 required chest re-exploration for hemostasis. The postoperative course was uneventful. Three years have passed since the surgery, and there has been no recurrence of TAK and no symptoms of heart failure.

Figure 2.

¹⁸F-Fluorodeoxyglucose positron emission tomography (FDG-PET) images, chest computed tomography, and echocardiography images of Patient 2. (A) FDG-PET uptake remained in the aorta. (B) The ascending aortic aneurysm expanded to 57 mm×53 mm. (C) Echocardiography showing severe aortic regurgitation.

Patient 4 is a newly diagnosed TAK patient. Coronary angiography revealed complete occlusion of the right coronary artery and 90% stenosis of the left anterior descending artery (Figure 3A,B). Although immediate CABG was considered, GCs and TCZ were administered based on evidence that it is better to suppress inflammation before surgery. After 4 months treatment with GCs and TCZ, FDG-PET uptake was still observed but was showing signs of improvement (Figure 3C,D). MICS-CABG was performed without any related complications.

Figure 3.

Coronary angiography and ¹⁸F-fluorodeoxyglucose positron emission tomography (FDG-PET) images of Patient 4. (A) There is 100% occlusion the right coronary artery (right anterior oblique view). Good collateral flow is observed from the conus branch to the posterolateral branch. (B) There is a severe (90%) stenosis in the proximal of the left coronary artery (cranial view). (C) A strong FDG-PET signal is observed in the aorta before medical therapy. (D) After initiating treatment with glucocorticoids and tocilizumab, FDG-PET uptake is still observed but is showing signs of improvement.

At present, it is difficult to accurately define remission of TAK.⁴⁶ In previous studies, FDG-PET had the potential to monitor disease activity in TAK.^47–51 Of our 3 patients with postoperative complications (Patients 1–3; Table 2), 1 did not undergo preoperative FDG-PET and the other 2 showed FDG-PET uptake in the aorta and its major branch arteries. Of our 5 patients without postoperative complications (Patients 4–8; Table 2), 1 did not undergo preoperative FDG-PET and only 1 of the others showed FDG-PET uptake. These results suggest that complications are more likely to occur in patients whose preoperative TAK activity is not sufficiently controlled. In addition, the 3 patients with complications were characterized by the concomitant use of immunosuppressants (e.g., MTX) other than TCZ and a short disease duration. Patients 1 and 2 had rapidly enlarging aortic aneurysms, and Patient 3 was undergoing reoperation for a coronary artery aneurysm after a Bentall procedure. The complications in these patients were thought to be due to the extreme difficulty in controlling inflammation even with the use of MTX and TCZ. Delayed wound healing was observed in 2 patients with complications, but was not observed in any patients without complications. In addition, there did not appear to be any noticeable difference in the time of preoperative discontinuation or the number of days before restarting TCZ between patients with and without complications. A relapse of TAK was not observed in any of the patients.

Summary

In summary, the following patients with TAK are more likely to experience postoperative complications:

• those who undergo surgery without adequate suppression of TAK inflammation

• those who receive high doses of GCs before surgery, causing delayed wound healing and SSI

• those who do not discontinue TCZ, which causes SSI

• those with a long TCZ withdrawal period before surgery, causing postoperative relapse of TAK

• those who restart TCZ before wounds have healed, resulting in delayed wound healing.

Therefore, to reduce perioperative complications, clinicians should perform the following procedures before cardiac surgery in patients with TAK:

• administer TCZ in the early stage of the disease and reduce the GC dose as much as possible

• perform FDG-PET before surgery to confirm the absence of active inflammation

• suspend TCZ 2–3 weeks before cardiovascular surgery and resume TCZ after wounds have healed

• consider MICS to reduce the extent of surgical wounds and the risk of infection.

Based on our experience, we propose a treatment protocol during the perioperative period as shown in Figure 4. Please note that this proposal is a suggestion only for cardiovascular surgery, and there is no consensus regarding the TCZ withdrawal period for minimally invasive catheter procedures such as percutaneous coronary intervention, percutaneous transluminal renal angioplasty, and endovascular treatment. Patients with TAK undergoing cardiovascular surgery should be administered TCZ and the dose of GCs should be reduced as fast as possible. After confirming the induction of TAK remission in patients, TCZ should be discontinued 2–3 weeks before surgery. After confirming postoperative wound healing, TCZ should be resumed 2–3 weeks after surgery. We believe this protocol will be able to reduce postoperative complications and TAK relapse associated with the discontinuation of TCZ.

Figure 4.

Proposed treatment protocol for Takayasu arteritis (TAK). In patients with TAK undergoing cardiovascular surgery, the dose of glucocorticoids (GCs) should be reduced as much as possible. The use of tocilizumab (TCZ) should be suspended for 2–3 weeks before surgery. After cardiovascular surgery, wound healing should be confirmed and TCZ should be resumed 2–3 weeks after surgery.

Acknowledgments

The authors thank Ellen Knapp, PhD, from Edanz (https://jp.edanz.com/ac) for editing a draft of this manuscript.

Sources of Funding

This work was supported by grants from the Ministry of Health, Labour and Welfare, Japan (23FC1019).

Disclosures

Y.N. has received lecture fees and research grants from Chugai, and research grants from AbbVie. The other authors have no conflict of interests to disclose.

IRB Information

Approval to collect patient information was obtained from the research ethics committees of the National Cerebral and Cardiovascular Center (R21076-2).

References

• 1.   Kerr GS, Hallahan CW, Giordano J, Leavitt RY, Fauci AS, Rottem M, et al. Takayasu arteritis. Ann Intern Med 1994; 120: 919–929, doi:10.7326/0003-4819-120-11-199406010-00004.
• 2.   Ohigashi H, Haraguchi G, Konishi M, Tezuka D, Kamiishi T, Ishihara T, et al. Improved prognosis of Takayasu arteritis over the past decade: Comprehensive analysis of 106 patients. Circ J 2012; 76: 1004–1011, doi:10.1253/circj.CJ-11-1108.
• 3.   Watanabe Y, Miyata T, Tanemoto K. Current clinical features of new patients with Takayasu arteritis observed from cross-country research in Japan: Age and sex specificity. Circulation 2015; 132: 1701–1709, doi:10.1161/circulationaha.114.012547.
• 4.   Shimizu Y, Murohara T. Takayasu arteritis in terms of disease duration and sex differences. Circ J 2024; 88: 295–296, doi:10.1253/circj.CJ-23-0900.
• 5.   Konda N, Sakai R, Saeki K, Matsubara Y, Nakamura Y, Miyamae T, et al. Nationwide clinical and epidemiological study of large-vessel vasculitis in Japan in 2017. Mod Rheumatol 2023; 34: 167–174, doi:10.1093/mr/road019.
• 6.   Yoshifuji H, Nakaoka Y, Uchida HA, Sugihara T, Watanabe Y, Funakoshi S, et al. Organ damage and quality of life in Takayasu arteritis: Evidence from a national registry analysis. Circ J 2024; 88: 285–294, doi:10.1253/circj.CJ-23-0656.
• 7.   Diao Y, Yan S, Premaratne S, Chen Y, Tian X, Chen Z, et al. Surgery and endovascular management in patients with Takayasu’s arteritis: A ten-year retrospective study. Ann Vasc Surg 2020; 63: 34–44, doi:10.1016/j.avsg.2019.07.009.
• 8.   Joseph G, Thomson VS, Attumalil TV, Mathen PG, Anandaraj AM, George OK, et al. Outcomes of percutaneous intervention in patients with Takayasu arteritis. J Am Coll Cardiol 2023; 81: 49–64, doi:10.1016/j.jacc.2022.10.024.
• 9.   Ergi DG, Schaff HV, Pochettino A, Hurst PD, Greason KL, Daly RC, et al. Outcomes of aortic surgery in patients with Takayasu arteritis. J Thorac Cardiovasc Surg 2024, doi:10.1016/j.jtcvs.2024.01.041.
• 10.   Sun N, Pandey AK, Manchikanti S, Gupta A, Rajeev A, Muniswamy S, et al. Outcome of open repair of thoracoabdominal aortic aneurysm in Takayasu arteritis: A retrospective analysis. Ann Vasc Surg 2024; 103: 99–108, doi:10.1016/j.avsg.2023.12.074.
• 11.   Matsuura K, Ogino H, Matsuda H, Minatoya K, Sasaki H, Yagihara T, et al. Surgical outcome of aortic arch repair for patients with Takayasu arteritis. Ann Thorac Surg 2006; 81: 178–182, doi:10.1016/j.athoracsur.2005.06.043.
• 12.   Ogino H, Matsuda H, Minatoya K, Sasaki H, Tanaka H, Matsumura Y, et al. Overview of late outcome of medical and surgical treatment for Takayasu arteritis. Circulation 2008; 118: 2738–2747, doi:10.1161/circulationaha.107.759589.
• 13.   Espitia O, Bruneval P, Assaraf M, Pouchot J, Liozon E, de Boysson H, et al. Long-term outcome and prognosis of noninfectious thoracic aortitis. J Am Coll Cardiol 2023; 82: 1053–1064, doi:10.1016/j.jacc.2023.06.031.
• 14.   Isobe M, Amano K, Arimura Y, Ishizu A, Ito S, Kaname S, et al. JCS 2017 guideline on management of vasculitis syndrome: Digest version. Circ J 2020; 84: 299–359, doi:10.1253/circj.CJ-19-0773.
• 15.   Uchida HA, Nakaoka Y, Sugihara T, Yoshifuji H, Maejima Y, Watanabe Y, et al. Clinical characteristics and treatment outcomes of patients with newly diagnosed Takayasu arteritis in Japan during the first 2 years of treatment: A nationwide retrospective cohort study. Circ J 2024, doi:10.1253/circj.CJ-24-0178.
• 16.   Nakaoka Y, Higuchi K, Arita Y, Otsuki M, Yamamoto K, Hashimoto-Kataoka T, et al. Tocilizumab for the treatment of patients with refractory Takayasu arteritis. Int Heart J 2013; 54: 405–411, doi:10.1536/ihj.54.405.
• 17.   Nakaoka Y, Isobe M, Takei S, Tanaka Y, Ishii T, Yokota S, et al. Efficacy and safety of tocilizumab in patients with refractory Takayasu arteritis: Results from a randomised, double-blind, placebo-controlled, phase 3 trial in Japan (the TAKT study). Ann Rheum Dis 2018; 77: 348–354, doi:10.1136/annrheumdis-2017-211878.
• 18.   Misra DP, Rathore U, Patro P, Agarwal V, Sharma A. Disease-modifying anti-rheumatic drugs for the management of Takayasu arteritis: A systematic review and meta-analysis. Clin Rheumatol 2021; 40: 4391–4416, doi:10.1007/s10067-021-05743-2.
• 19.   Regola F, Uzzo M, Toniati P, Trezzi B, Sinico RA, Franceschini F. Novel therapies in Takayasu arteritis. Front Med 2021; 8: 814075, doi:10.3389/fmed.2021.814075.
• 20.   Matsumoto K, Suzuki K, Takeshita M, Takeuchi T, Kaneko Y. Changes in the molecular profiles of large-vessel vasculitis treated with biological disease-modifying anti-rheumatic drugs and Janus kinase inhibitors. Front Immunol 2023; 14: 1197342, doi:10.3389/fimmu.2023.1197342.
• 21.   Abe Y, Fujii T, Miyawaki Y, Sugihara T, Uchida HA, Maejima Y, et al. The real-world clinical decisions of physicians in the management of Takayasu arteritis and giant cell arteritis in Japan: A cross-sectional web-questionnaire survey. Mod Rheumatol 2024, doi:10.1093/mr/roae034.
• 22.   Arita Y, Ishibashi T, Nakaoka Y. Current immunosuppressive treatment for Takayasu arteritis. Circ J 2024; 88: 1605–1609, doi:10.1253/circj.CJ-23-0780.
• 23.   Mekinian A, Resche-Rigon M, Comarmond C, Soriano A, Constans J, Alric L, et al. Efficacy of tocilizumab in Takayasu arteritis: Multicenter retrospective study of 46 patients. J Autoimmun 2018; 91: 55–60, doi:10.1016/j.jaut.2018.04.002.
• 24.   Mekinian A, Saadoun D, Vicaut E, Thietart S, Lioger B, Jego P, et al. Tocilizumab in treatment-naïve patients with Takayasu arteritis: TOCITAKA French prospective multicenter open-labeled trial. Arthritis Res Ther 2020; 22: 218, doi:10.1186/s13075-020-02311-y.
• 25.   Alibaz-Oner F, Kaymaz-Tahra S, Bayındır Ö, Yazici A, Ince B, Kalkan K, et al. Biologic treatments in Takayasu’s arteritis: A comparative study of tumor necrosis factor inhibitors and tocilizumab. Semin Arthritis Rheum 2021; 51: 1224–1229, doi:10.1016/j.semarthrit.2021.09.010.
• 26.   Harigai M, Miyamae T, Hashimoto H, Yoshida A, Yamashita K, Nakaoka Y. A multicentre, large-scale, observational study of tocilizumab in patients with Takayasu arteritis in Japan: The ACTEMRA^® (ACT)-Bridge study. Mod Rheumatol 2023; 33: 998–1006, doi:10.1093/mr/roac099.
• 27.   Nakaoka Y, Isobe M, Tanaka Y, Ishii T, Ooka S, Niiro H, et al. Long-term efficacy and safety of tocilizumab in refractory Takayasu arteritis: Final results of the randomized controlled phase 3 TAKT study. Rheumatology (Oxford) 2020; 59: 2427–2434, doi:10.1093/rheumatology/kez630.
• 28.   Nakaoka Y, Yanagawa M, Hata A, Yamashita K, Okada N, Yamakido S, et al. Vascular imaging of patients with refractory Takayasu arteritis treated with tocilizumab: Post hoc analysis of a randomized controlled trial. Rheumatology (Oxford) 2022; 61: 2360–2368, doi:10.1093/rheumatology/keab684.
• 29.   Yoshida S, Suzuki E, Matsumoto H, Yokose K, Fujita Y, Temmoku J, et al. Effectiveness of combination tocilizumab and glucocorticoids as an induction therapy in patients with Takayasu arteritis: An observational study. Mod Rheumatol 2023; 33: 360–366, doi:10.1093/mr/roac033.
• 30.   George MD, Baker JF. Perioperative management of immunosuppression in patients with rheumatoid arthritis. Curr Opinion Rheumatol 2019; 31: 300–306, doi:10.1097/bor.0000000000000589.
• 31.   Goodman SM, Springer BD, Chen AF, Davis M, Fernandez DR, Figgie M, et al. 2022 American College of Rheumatology/American Association of Hip and Knee Surgeons guideline for the perioperative management of antirheumatic medication in patients with rheumatic diseases undergoing elective total hip or total knee arthroplasty. Arthritis Care Res 2022; 74: 1399–1408, doi:10.1002/acr.24893.
• 32.   Goodman SM, Bykerk VP, DiCarlo E, Cummings RW, Donlin LT, Orange DE, et al. Flares in patients with rheumatoid arthritis after total hip and total knee arthroplasty: Rates, characteristics, and risk factors. J Rheumatol 2018; 45: 604–611, doi:10.3899/jrheum.170366.
• 33.   Saadoun D, Lambert M, Mirault T, Resche-Rigon M, Koskas F, Cluzel P, et al. Retrospective analysis of surgery versus endovascular intervention in Takayasu arteritis: A multicenter experience. Circulation 2012; 125: 813–819, doi:10.1161/circulationaha.111.058032.
• 34.   Zheng T, Zhu S, Ou JF, Fang WG, Qiao ZY, Qi RD, et al. Treatment with corticosteroid and/or immunosuppressive agents before surgery can effectively improve the surgical outcome in patients with Takayasu’s arteritis. J Invest Surg 2019; 32: 220–227, doi:10.1080/08941939.2017.1408718.
• 35.   Matsuura K, Ogino H, Kobayashi J, Ishibashi-Ueda H, Matsuda H, Minatoya K, et al. Surgical treatment of aortic regurgitation due to Takayasu arteritis: Long-term morbidity and mortality. Circulation 2005; 112: 3707–3712, doi:10.1161/circulationaha.105.535724.
• 36.   Wang X, Dang A, Lv N, Cheng N, Cheng X, Yang Y, et al. Long-term outcomes of coronary artery bypass grafting versus percutaneous coronary intervention for Takayasu arteritis patients with coronary artery involvement. Semin Arthritis Rheum 2017; 47: 247–252, doi:10.1016/j.semarthrit.2017.03.009.
• 37.   Wang H, Zhang Y, Shen Z, Fang L, Liu Z, Zhang S. Comparing the effects of different management strategies on long-term outcomes for significant coronary stenosis in patients with Takayasu arteritis. Int J Cardiol 2020; 306: 1–7, doi:10.1016/j.ijcard.2020.02.051.
• 38.   Wang AS, Armstrong EJ, Armstrong AW. Corticosteroids and wound healing: Clinical considerations in the perioperative period. Am J Surg 2013; 206: 410–417, doi:10.1016/j.amjsurg.2012.11.018.
• 39.   Ito H, Murata K, Sobue Y, Kojima T, Nishida K, Matsushita I, et al. Comprehensive risk analysis of postoperative complications in patients with rheumatoid arthritis for the 2020 update of the Japan College of Rheumatology clinical practice guidelines for the management of rheumatoid arthritis. Mod Rheumatol 2022; 32: 296–306, doi:10.1080/14397595.2021.1913824.
• 40.   Cordtz RL, Zobbe K, Højgaard P, Kristensen LE, Overgaard S, Odgaard A, et al. Predictors of revision, prosthetic joint infection and mortality following total hip or total knee arthroplasty in patients with rheumatoid arthritis: A nationwide cohort study using Danish healthcare registers. Ann Rheum Dis 2018; 77: 281–288, doi:10.1136/annrheumdis-2017-212339.
• 41.   Momohara S, Hashimoto J, Tsuboi H, Miyahara H, Nakagawa N, Kaneko A, et al. Analysis of perioperative clinical features and complications after orthopaedic surgery in rheumatoid arthritis patients treated with tocilizumab in a real-world setting: Results from the multicentre TOcilizumab in Perioperative Period (TOPP) study. Mod Rheumatol 2013; 23: 440–449, doi:10.1007/s10165-012-0683-0.
• 42.   Arita Y, Nakaoka Y, Eda Y, Kitabayashi K, Hasegawa S. Perioperative management of Takayasu arteritis for cardiac surgery in a patient treated with tocilizumab. JACC Case Rep 2020; 2: 2363–2367, doi:10.1016/j.jaccas.2020.07.039.
• 43.   Grossi EA, Galloway AC, Ribakove GH, Zakow PK, Derivaux CC, Baumann FG, et al. Impact of minimally invasive valvular heart surgery: A case-control study. Ann Thorac Surg 2001; 71: 807–810, doi:10.1016/s0003-4975(00)02070-1.
• 44.   Schmitto JD, Mokashi SA, Cohn LH. Minimally-invasive valve surgery. J Am Coll Cardiol 2010; 56: 455–462, doi:10.1016/j.jacc.2010.03.053.
• 45.   Bonatti J, Wallner S, Crailsheim I, Grabenwöger M, Winkler B. Minimally invasive and robotic coronary artery bypass grafting: A 25-year review. J Thorac Dis 2021; 13: 1922–1944, doi:10.21037/jtd-20-1535.
• 46.   Bonaca MP, Olin JW. ACC/AHA aortic disease guidelines: What was simple is now complex-moving to multidisciplinary teams, specialized centers. J Am Coll Cardiol 2022; 80: 2353–2355, doi:10.1016/j.jacc.2022.11.007.
• 47.   Tezuka D, Haraguchi G, Ishihara T, Ohigashi H, Inagaki H, Suzuki J, et al. Role of FDG PET-CT in Takayasu arteritis: Sensitive detection of recurrences. JACC Cardiovasc Imaging 2012; 5: 422–429, doi:10.1016/j.jcmg.2012.01.013.
• 48.   Banerjee S, Quinn KA, Gribbons KB, Rosenblum JS, Civelek AC, Novakovich E, et al. Effect of treatment on imaging, clinical, and serologic assessments of disease activity in large-vessel vasculitis. J Rheumatol 2020; 47: 99–107, doi:10.3899/jrheum.181222.
• 49.   Quinn KA, Alessi HD, Ponte C, Rose E, Ahlman MA, Redmond C, et al. Use of ¹⁸F-fluorodeoxyglucose positron emission tomography to standardize clinical trial recruitment in Takayasu’s arteritis. Rheumatology (Oxford) 2022; 61: 4047–4055, doi:10.1093/rheumatology/keac021.
• 50.   Bahrami M, Mohammadi H, Mirgaloyebayat H, Mohajeri Z, Fazeli P, Mojahedi A, et al. The role of ¹⁸F-fluorodeoxyglucose PET/computed tomography in the diagnosis and monitoring of large vessel vasculitides: A review article. Am J Nucl Med Mol Imaging 2023; 13: 127–135.
• 51.   Tahra SK, Özgüven S, Ünal AU, Öner FA, Öneş T, Erdil TY, et al. Assessment of Takayasu arteritis in routine practice with PETVAS, an ¹⁸F-FDG PET quantitative scoring tool. Turk J Med Sci 2022; 52: 313–322, doi:10.55730/1300-0144.5317.
• 52.   Wang J, Kong X, Ma L, Ding Z, Chen H, Chen R, et al. Treatment efficacy and safety of adalimumab versus tocilizumab in patients with active and severe Takayasu arteritis: An open-label study. Rheumatology (Oxford) 2024; 63: 1359–1367, doi:10.1093/rheumatology/kead387.
• 53.   Kong X, Sun Y, Dai X, Wang L, Ji Z, Chen H, et al. Treatment efficacy and safety of tofacitinib versus methotrexate in Takayasu arteritis: A prospective observational study. Ann Rheum Dis 2022; 81: 117–123, doi:10.1136/annrheumdis-2021-220832.
• 54.   Wang J, Dai X, Ma L, Wu S, Jin X, Ji Z, et al. Efficacy and safety of tofacitinib versus leflunomide with glucocorticoids treatment in Takayasu arteritis: A prospective study. Semin Arthritis Rheum 2022; 55: 152018, doi:10.1016/j.semarthrit.2022.152018.
• 55.   Tian X, Li M, Jiang N, Zhao Y, Li J, Zhou Y, et al. Comparative efficacy of secukinumab versus tumor necrosis factor inhibitors for the treatment of Takayasu arteritis. Arthritis Rheumatol 2023; 75: 1415–1423, doi:10.1002/art.42496.
• 56.   Pazzola G, Muratore F, Pipitone N, Crescentini F, Cacoub P, Boiardi L, et al. Rituximab therapy for Takayasu arteritis: A seven patients experience and a review of the literature. Rheumatology (Oxford) 2018; 57: 1151–1155, doi:10.1093/rheumatology/kex249.