085. THE ANTEROMEDIAL ULTRASOUND EXAMINATION OF THE LARGE SUPRAAORTIC VESSELS IDENTIFIES HIGHER RATES OF LARGE VESSEL INVOLVEMENT THAN PREVIOUS REPORTED IN PATIENTS WITH GIANT CELL ARTERITIS

Abstract Background/Aims Giant cell arteritis with large vessel vasculitis (LV-GCA) represents a distinct, less researched sub-category of giant cell arteritis (GCA). In comparison to cranial GCA, the patient’s diagnostic pathway is less well described and it is thought that LV-GCA is underdiagnosed, including in patients with polymyalgia rheumatica and cranial-GCA. Advances in imaging (e.g. PET-CT) and treatment (tocilizumab), have provided additional options in the diagnosis and management of LV-GCA. The aim was to describe the contemporary clinical journey for patients diagnosed with LV-GCA. Methods The electronic patient health record system in NHS Lothian (TrakCare) was used to collect relevant data. Patients with imaging-confirmed large vessel vasculitis, diagnosed with GCA after 1 January 2017 were included. Follow-up was until August 2020. Results Eighteen patients with LV-GCA were included. The mean age was 65 years and 66.7% were female. Two patients had known cranial-GCA but 89% of patients were diagnosed exclusively with large vessel involvement. The most common symptoms were malaise (55%), weight loss (55%), polymyalgia rheumatica (55%) and limb claudication (44%). Pyrexia of unknown origin was a feature in only 17% of patients. Two patients were asymptomatic and were investigated on the basis of raised inflammatory markers. Mean CRP at baseline was 99mg/L and ESR 85mm/hour. The mean time from symptom-onset to diagnosis was 6.8 months (range 1 to 15 months). Sixteen patients (89%) were reviewed by at least one other secondary care specialist. One third of patients were referred from General Medicine followed by Vascular Surgery (16%) and General Practice (16%). 7/18 patients were inpatients at the time of referral. 56% of patients required two modalities of imaging to confirm large vessel involvement. The most commonly used imaging techniques (in descending order) were CT-Chest/Abdomen/Pelvis, CT-angiogram, PET-CT and Vascular Ultrasound. 50% of patients underwent follow-up imaging, most commonly MR- or CT-angiography. Mean follow-up was for 1.6 years. The mean prednisolone dose at 3 months (n = 18) was 24mg daily and 8mg at 12 months (n = 12). 28% of patients relapsed during the follow-up period at 4, 5, 8, 9 and 24 months post-diagnosis. 7/18 patients were commenced on methotrexate for steroid-side effects or for relapse. 8/18 received subcutaneous tocilizumab in combination with methotrexate in two cases. Three patients were started on azathioprine but only one continued. Conclusion In modern-day clinical practice, patients with LV-GCA experience a longer time to diagnosis than those with cranial symptoms. Patients with LV-GCA can experience an array of constitutional symptoms. Frequently, more than one imaging modality is required to confirm LV-GCA and the majority of patients will have seen other hospital specialists or have been admitted to hospital before diagnosis. Methotrexate and tocilizumab are the most frequently-used and effective steroid-adjunct in this single-centre cohort. Disclosure O. Cronin: None. N.D. McKay: Consultancies; Gilead. Other; Has received support for conference attendance from Pfizer and Gilead, Has received educational support from UCB, Gilead, Celgene, Biogen, Sanofi, Abbvie, Novartis, Pfizer. H. Preston: None. H. Harris: None. B. Hauser: None.

Download Full-text

Large-vessel Involvement and Varicella Zoster Virus Vasculopathy in Giant Cell Arteritis–related Stroke: Something to Keep an Eye On

The Journal of Rheumatology ◽

10.3899/jrheum.170317 ◽

2017 ◽

Vol 44 (10) ◽

pp. 1566-1566 ◽

Cited By ~ 1

Author(s):

GIANFRANCO VITIELLO ◽

DANIELE CAMMELLI

Keyword(s):

Varicella Zoster Virus ◽

Giant Cell Arteritis ◽

Giant Cell ◽

Large Vessel ◽

Varicella Zoster ◽

Vessel Involvement

Download Full-text

JAK Inhibitor Effectiveness in Giant-Cell Arteritis With Large-Vessel Involvement Assessed by 18F-FDG PET-CT

Clinical Nuclear Medicine ◽

10.1097/rlu.0000000000003913 ◽

2021 ◽

Vol Publish Ahead of Print ◽

Author(s):

Kevin Prigent ◽

Achille Aouba ◽

Nicolas Aide ◽

Hubert de Boysson

Keyword(s):

Giant Cell Arteritis ◽

Giant Cell ◽

Fdg Pet ◽

Large Vessel ◽

Jak Inhibitor ◽

Pet Ct ◽

18F Fdg ◽

Fdg Pet Ct ◽

Vessel Involvement

Download Full-text

OP24. LARGE VESSEL INVOLVEMENT IN GIANT CELL ARTERITIS: INCIDENCE, PREDICTORS, AND MORTALITY

Rheumatology ◽

10.1093/rheumatology/keh749 ◽

2005 ◽

Vol 44 (suppl_3) ◽

pp. iii10-iii11

Author(s):

E. L. Matteson

Keyword(s):

Giant Cell Arteritis ◽

Giant Cell ◽

Large Vessel ◽

Vessel Involvement

Download Full-text

AB0501 THREE CASES OF VERTEBRAL ARTERITIS IDENTIFIED ON FDG-PET IN PATIENTS WITH SUSPECTED GCA AT UNIVERSITY COLLEGE LONDON HOSPITAL (UCLH)

Annals of the Rheumatic Diseases ◽

10.1136/annrheumdis-2020-eular.410 ◽

2020 ◽

Vol 79 (Suppl 1) ◽

pp. 1549.2-1549

Author(s):

D. Ludwig ◽

M. Naja ◽

S. Voo ◽

V. Morris

Keyword(s):

Giant Cell Arteritis ◽

Giant Cell ◽

Pet Imaging ◽

Fdg Pet ◽

Immunosuppressive Treatment ◽

Temporal Artery ◽

Large Vessel ◽

Diagnostic Tools ◽

History Of ◽

Vessel Involvement

Background:Giant cell arteritis (GCA) may affect both cranial and extra-cranial vessels; where the latter occurs, it can be termed large-vessel GCA (LV-GCA). Large vessel involvement is common: histological evidence has been seen in 80% of autopsies of patients with known GCA, and imaging studies suggest large vessel involvement in over 80%1. LV-GCA is important to diagnose due to the risks of vascular complications such as occlusion and ischaemic stroke. The clinical diagnosis can be challenging, and the American College of Rheumatology (ACR) GCA classification criteria often underperform in cases of LV-GCA1. F-fluorodeoxyglucose positron emission tomography (FDG-PET) has been found to be useful in the detection of extra-cranial involvement to support the diagnosis of LV-GCA.2Objectives:To appreciate the variability in presentation of cases of LV-GCA, and to further characterise a subgroup of patients with vertebral arteritis.To explore the use of FDG-PET imaging in GCA patients in addition to or in place of traditional diagnostic tools (temporal artery ultrasound / biopsy).Methods:Through evaluation of the new GCA fast-track pathway implemented at UCLH, a subgroup of patients diagnosed with vertebral arteritis was identified. The history and presentation of these patients were analysed.Results:Three patients were diagnosed with vertebral arteritis. All three were male, Caucasian and aged over 70. All were investigated for GCA due to a history of severe headache (frontal in one, occipital in one, bi-temporal in one) with associated red flag symptoms. Two had a history of jaw claudication and visual disturbances (unilateral visual loss in one, transient diplopia in the other). Both of these patients had positive temporal artery biopsies. The third patient had no ischaemic symptoms but a strong history of prominent polymyalgic features and a positive temporal artery ultrasound. Inflammatory markers were raised in two, and normal in one, of the patients. Only one had systemic symptoms (weight loss). All three proceeded to FDG-PET scans which showed vertebral arteritis and were commenced on immunosuppressive treatment.Conclusion:The cases discussed illustrate the heterogeneity of the presentation of LV-GCA, and the diagnostic challenge this poses. FDG-PET imaging is useful in confirming extra-cranial involvement and therefore guiding treatment.References:[1]Large-vessel giant cell arteritis: diagnosis, monitoring and management.Matthew J Koster, Eric L Matteson, Kenneth J Warrington.2018, Rheumatology, Vol. 57, pp. 32-42.[2]EULAR recommendations for the use of imaging in large vessel vasculitis in clinical practice.Dejaco C, Ramiro S, Duftner C, et al.2018, Annals of the Rheumatic Diseases, Vol. 77, pp. 636-643.Disclosure of Interests: :None declared

Download Full-text

Giant-Cell Arteritis: Do We Treat Patients with Large-Vessel Involvement Differently?

The American Journal of Medicine ◽

10.1016/j.amjmed.2017.03.054 ◽

2017 ◽

Vol 130 (8) ◽

pp. 992-995 ◽

Cited By ~ 15

Author(s):

Hubert de Boysson ◽

Eric Liozon ◽

Marc Lambert ◽

Anael Dumont ◽

Jonathan Boutemy ◽

...

Keyword(s):

Giant Cell Arteritis ◽

Giant Cell ◽

Large Vessel ◽

Vessel Involvement

Download Full-text

Large-vessel involvement in giant cell arteritis

Current Opinion in Rheumatology ◽

10.1097/01.bor.0000197996.04709.4e ◽

2006 ◽

Vol 18 (1) ◽

pp. 10-17 ◽

Cited By ~ 120

Author(s):

Tim Bongartz ◽

Eric L Matteson

Keyword(s):

Giant Cell Arteritis ◽

Giant Cell ◽

Large Vessel ◽

Vessel Involvement

Download Full-text

OP0180 DIAGNOSTIC VALIDITY OF ULTRASOUND INCLUDING EXTRA-CRANIAL ARTERIES IN GIANT CELL ARTERITIS

Annals of the Rheumatic Diseases ◽

10.1136/annrheumdis-2020-eular.5036 ◽

2020 ◽

Vol 79 (Suppl 1) ◽

pp. 112.2-112

Author(s):

I. Monjo ◽

E. Fernández ◽

D. Peiteado ◽

A. Balsa ◽

E. De Miguel

Keyword(s):

Positive Predictive Value ◽

Giant Cell Arteritis ◽

Giant Cell ◽

Negative Predictive Value ◽

Predictive Value ◽

Ultrasound Examination ◽

Axillary Artery ◽

Imaging Modality ◽

Large Vessel ◽

Research Support

Background:Giant cell arteritis (GCA) is a chronic vasculitis of the medium and large arteries. The involvement of large vessel (LV) either isolated or associated with cranial artery is frequent, so it is necessary to use imaging techniques for diagnosis, because the biopsy in these cases is not useful. European League Against Rheumatism (EULAR) recommends an early imaging test in patients with suspected GCA, and ultrasound of temporal±axillary arteries is recommended as the first imaging modality in patients with suspected predominantly cranial GCA (1).Objectives:To assess the validity of Colour Doppler ultrasound (CDUS) of temporal superficial arteries (TA) and LV (axillary, subclavian and carotid) in the diagnosis of GCA, using as gold standard the patient’s definitive clinical diagnosis. Analyse if routine ultrasound examination of LV improves the diagnostic accuracy.Methods:This was an observational, descriptive and analytical study of 198 consecutive patients with GCA suspicion. A baseline CDUS of the TA and LV was performed. Ultrasound diagnosis was made according to the OMERACT (Outcome Measures in Rheumatology) definitions of halo sign and was established as a limit of average intimal thickness ≥ 0.34 mm for superficial temporal arteries and ≥ 1 mm for axillary, subclavian and carotid arteries. Statistical analysis was performed using SPSS version 25.Results:Eighty-seven patients (43.9%) were CDUS compatible with GCA, and 111 patients (56.1%) had a negative CDUS. Among the patients with positive CDUS three different patterns were detected: 45 patients (51.7%) had an exclusive cranial involvement, 31 (35.6%) had a mixed pattern with involvement of both TA and LV and 11 (12.6%) had an exclusive LV involvement. The validity (sensitivity and specificity) and security (positive predictive value and negative predictive value) of diagnostic are shown in table.When we analyse patients with LV involvement, 87.8% have axillary artery involvement, 77.4% subclavian involvement and 34.4% carotids involvement. If we only explored the axillary arteries, 12.2% of patients with LV involvement would not be diagnosed. However, if we explored axillary and subclavian arteries, 100% of patients with LV involvement would be diagnosed.Conclusion:Half of the patients with GCA have LV involvement and up to 12.8% exclusively LV affectation in our series. Adding CDUS exploration of LV arteries to TA increases both sensitivity and diagnostic specificity. The minimum ultrasound examination of LV should include both axillary and subclavian arteries.References:[1]Dejaco C, Ramiro S, Duftner C, et al. EULAR recommendations for the use of imaging in large vessel vasculitis in clinical practice. Ann Rheum Dis. 2018;77(5):636–3SensitivitySpecificityPositive predictive valueNegative predictive valueCDUS TA and LV97,7%97,3%96,6%98,2%CDUS TA83,9%97,3%96,1%88,5%Disclosure of Interests:Irene Monjo: None declared, Elisa Fernández: None declared, Diana Peiteado: None declared, Alejandro Balsa Grant/research support from: BMS, Roche, Consultant of: AbbVie, Gilead, Lilly, Pfizer, UCB, Sanofi, Sandoz, Speakers bureau: AbbVie, Lilly, Sanofi, Novartis, Pfizer, UCB, Roche, Nordic, Sandoz, Eugenio de Miguel Grant/research support from: Yes (Abbvie, Novartis, Pfizer), Consultant of: Yes (Abbvie, Novartis, Pfizer), Paid instructor for: yes (AbbVie, Novartis, Pfizer, MSD, BMS, UCB, Roche, Grunental, Janssen, Sanofi), Speakers bureau: yes (AbbVie, Novartis, Pfizer, MSD, BMS, UCB, Roche, Grunental, Janssen, Sanofi)

Download Full-text

Giant cells in temporal artery biopsies are associated with a reduced risk of large vessel involvement in patients with giant cell arteritis : a retrospective cohort study

10.21203/rs.3.rs-103583/v1 ◽

2020 ◽

Author(s):

Nazanin Naderi ◽

Aladdin Mohammad ◽

Karin Wadström ◽

Minna Willim ◽

Jan-Åke Nilsson ◽

...

Keyword(s):

Giant Cell Arteritis ◽

Giant Cell ◽

Cox Regression ◽

Systemic Disease ◽

Temporal Artery ◽

Giant Cells ◽

Large Vessel ◽

Vascular Involvement ◽

Reduced Risk ◽

Vessel Involvement

Abstract Background: Giant cell arteritis (GCA) is a systemic disease with extensive vascular involvement. There is limited and conflicting information on the relation between patient characteristics at diagnosis and future disease phenotypes. We aimed to investigate predictors of time dependent large vessel involvement (LVI) in a population-based cohort of patients with GCA. Methods: GCA patients with positive temporal artery biopsies (TAB) between 1997and 2010 were identified through a regional pathology register. A structured review of histopathology reports and relevant imaging studies was performed. Cases with LVI through July 2016 were identified. Patients were followed to first LVI, death, migration from the area or July 29, 2016. Event free survival by clinical and histopathologic features was estimated using the Kaplan-Meier method. Potential predictors of LVI were examined using Cox regression models.Results: A total of 274 patients were included. The mean age at GCA diagnosis was 75.7 years. Fifty-one patients (19 %) had documented LVI during the follow-up, corresponding to an incidence rate of 2.4/100 person-years. The median time from GCA diagnosis to the diagnosis of LVI was 4.5 years (interquartile range 0.6-7.4). Thirty-four patients had aortic involvement (67% of those with LVI; 12% of all GCA cases). Survival free of LVI was longer in patients with giant cells in the TAB (75th percentile 14.0 vs 6.7 years; p=0.014). In age-adjusted analysis, the presence of giant cells in the TAB was associated with reduced risk of LVI (hazard ratio 0.48; 95 % confidence interval 0.27-0.86). Conclusions: The negative association with giant cells in the TAB suggests that patients with LVI constitute a subset of GCA with particular disease mechanisms. This underlines the heterogeneity of GCA, which should be further explored in prospective studies.

Download Full-text