Takayasu arteritis
Introduction
Introduction to arteritis Aortitis is a chronic progressive non-specific inflammation of the aorta and its main branches and pulmonary arteries, which causes stenosis or occlusion in different parts. A small number of patients cause arterial dilatation or aneurysms due to inflammation destroying the middle layer of the arterial wall. The clinical manifestations vary depending on the location of the lesion. basic knowledge The proportion of sickness: 0.0031% Susceptible people: no specific people Mode of infection: non-infectious Complications: angina pectoris myocardial infarction
Cause
Cause of aortic inflammation
(1) Causes of the disease
The cause is still unclear, there have been syphilis, arteriosclerosis, tuberculosis, thromboangiitis obliterans (Buerge disease), congenital anomalies, giant cell arteritis, connective tissue disease, rheumatism, rheumatoid disease, endocrine abnormalities, metabolism Abnormalities are related to factors such as autoimmunity.
(two) pathogenesis
The pathogenesis of arteritis has the following doctrine:
1. Autoimmune theory:
At present, it is generally believed that the disease may be caused by the in vivo immune process after infection by streptococcus, tuberculosis, virus or rickettsia, and its performance characteristics:
1 There are 7 kinds of globulins in serum protein electrophoresis, and a1 and 2 globulins are increased;
3 "C" reactive protein, anti-chain "O" and anti-mucopolysaccharidase abnormalities;
4 collagen disease and the disease are combined;
5 aortic arch syndrome is similar to rheumatic rheumatoid aortitis;
6 hormone therapy has obvious curative effect, but these characteristics are not reliable evidence of immunology of this disease. The titer and antibody price of serum anti-aortic antibody are significantly higher than other diseases. The aortic antigen is located in the media and adventitia of the aorta. Serum immunoglobulin showed IgG, IgA and IgM increased, and the latter two were characterized by autopsy. Some autopsy found active tuberculosis in some patients, including tuberculosis of the periorbital lymph nodes. Shimizt et al believe that this may be due to this. The lesion directly affects the aorta or an allergic reaction to tuberculous lesions. Microscopic examination shows that the arterial wall of the lesion has new granuloma and Laghans giant cells, but it is non-specific inflammation, and no tuberculosis is found. And tuberculosis lesions rarely invade the vascular system. From clinical observations, about 22% of patients with tuberculosis, mainly cervical and mediastinal lymphaden tuberculosis or tuberculosis, treated with various anti-tuberculosis drugs, are ineffective for aortitis, indicating the disease Not directly caused by tuberculosis infection.
2. Endocrine abnormalities:
The disease is more common in young women, so it is thought that it may be related to endocrine factors. Numano et al observed the female nasal arteritis in the follicular and luteal phase 24h urine specimens, found that the excretion of estrogen was significantly higher than that of healthy women, in the rabbit test, long-term The application of estrogen can produce pathological changes similar to aortitis in the aorta and its main branches. Clinically, high doses of estrogen can easily damage the blood vessel wall. For example, patients taking prostate cancer can cause vascular disease and stroke. Increased, long-term use of contraceptives can cause complications of thrombosis, so Numano and other believe that excessive secretion of estrogen and malnutrition factors (tuberculosis) may be the cause of high incidence of this disease.
3. Genetic factors:
In recent years, the relationship between aortitis and heredity has attracted the attention of some scholars. Numano has reported that 10 pairs of close relatives, such as sisters, mothers and daughters, have been found in Japan, especially in twin sisters. For homozygotes, a pair of twin sisters have been found to have arteritis in China, and two pairs of non-biological sisters are clinically consistent with the diagnosis of aortitis, but only 1 of each pair has angiography, and we have 67 cases. HLA analysis of patients with arteritis found that A9, A10, A25, Awl9, A30, B5, B27, 1340, B51, Bw60, DR7, DRw10, DQtw3 appeared frequently and statistically significant, but the antigen was not concentrated enough. HLA analysis of patients with arteritis found that A9, A10, B5, Bw40, Bw51, Bw52 appeared frequently, especially Bw52, and 124 patients were followed up for 20 years. Bw52-positive arteritis was severely inflammatory and required hormones. The dose is large and resistant to hormones; the complications of aortic regurgitation, angina pectoris and heart failure are more serious than those of Bw52 negative, suggesting that HLA antigen gene imbalance has an important role.
Recent studies have found that Chinese Han arteritis patients are significantly associated with HLA-13R4 and DR7 alleles. The nucleotide variation of the upstream regulatory region of the DR7 allele may be related to its pathogenesis and disease, and it is found that DR4(+) or DR7 ( +) Patients with lesions and arterial stenosis were more severe than those with DR4(-) or DR7(-). Kitamura reported HLA-1352(+) vs. 1352(-), aortic regurgitation, ischemic heart Disease, lung infarction, etc. were significantly higher, and the incidence of renal artery stenosis, B39 (+) was significantly higher than 1339 (-).
Arteritis mainly involves the elastic arteries, such as the aorta and its main branches, pulmonary artery and coronary artery. This disease also often involves the muscular arteries. About 84% of the patients have 2 to 13 arteries, including the brachiocephalic artery. The left subclavian artery, the renal artery, the abdominal aorta and the superior mesenteric artery are the most common sites, the abdominal aorta is associated with renal artery involvement in about 80%, and the simple renal artery involvement is 20%, unilateral and bilateral involvement. Similarly, the celiac artery and the radial artery; pulmonary artery involvement accounted for about 50%; coronary artery involvement was not uncommon in recent years.
4. The pathological changes are summarized as follows:
(1) Morphological changes: This disease begins from the middle layer of the arteries and the outer membrane to the full-thickness of the arterial wall of the intima, showing diffuse intimal fibrous tissue hyperplasia, showing extensive and irregular hyperplasia and hardening, and the lumen has Different degrees of stenosis or occlusion, often combined with thrombosis, the lesion is more severe at the entrance of the aortic branch, the disease is often multiple, the normal tissue area is often seen between the two affected areas, showing a jumping lesion (skip lesion As the lesion progresses, the normal tissue area gradually decreases. In elderly patients, there is often atherosclerosis. In recent years, it has been found that the incidence of arterial dilatation lesions caused by this disease is higher than before, because the lesion progresses rapidly. The elastic fibers and smooth muscle fibers of the arterial wall are severely damaged or broken, while the fibrosis is delayed and insufficient, and the arterial wall is thinned. Under the influence of local hemodynamics, the artery is dilated or aneurysm is formed, which is more common in the thoracic and abdominal aorta. And the right brachiocephalic artery, more common in men, Hotchi had found in 47 autopsy in 47 cases (57.3%) with arterial dilatation, aneurysm and arterial dissection, of which arterial dilation 26 (31.7%), aneurysm in 11 cases (13.4%), aneurysm with arterial dilatation in 6 cases (7.3%), arterial dissection in 4 cases (4.9)%, pulmonary artery lesions and aorta were basically the same, the main lesions in the middle and outer Membrane, intimal fibrous thickening is a secondary reaction of the medial and adventitial inflammation, almost obstructive lesions can be seen in the branches around the pulmonary artery, and the bronchial artery forms a collateral anastomosis. After bilateral elastic and muscular arteries are involved. Pulmonary hypertension can be suggested.
(2) Histological changes: Nasu divides the pathology of aortitis into three types, namely granulomatous type, diffuse inflammatory type, and fibrotic type, of which fibrosis type is dominant, and there is a gradual increase trend, even in fibrosis type. In the middle, near the old lesions, new active lesions can be seen. It is difficult to determine the initial inflammation of the disease during autopsy. According to the study, there are three different manifestations of inflammation, namely acute exudation, chronic non-specific inflammation and granuloma. The affected area is gradually enlarged, and the middle layer of the artery is often scattered, and there may be inflammation granulation tissue and coagulative necrosis. The middle and outer membranes of the nourishing blood vessels in the outer membrane are obviously thickened, causing stenosis or occlusion of the lumen; Lymphocytes and plasma cells were infiltrated in all layers, and epithelioid cells and Langham giant cells were also seen in the middle layer. Electron microscopy showed that the smooth muscle cells of the arterial wall were slender, mostly filled with myofilaments, and few organelles; Destruction, decomposition and disappearance of myofilament, swelling of mitochondria and endoplasmic reticulum, vacuolization, resulting in emptying and disintegration of cells; irregular nuclei, peripheral agglutination of chromatin, rare fibroblasts, collagen fibrils Rich, partially dissolved, less reticular fibers, elastic fibers have a uniform distribution, silky fibers of low electron density matrix, as well as of loose longitudinal traveling.
(3) Pathological classification: According to the location of the affected blood vessels, aortitis can be divided into 4 types:
1 head type, involving the aortic arch and its main branches;
2 chest and abdomen aorta type, mainly involving the descending aorta and / or abdominal aorta;
3 renal artery type, involving the renal artery alone;
4 mixed type, the lesion involves both the above two groups of blood vessels; 5 pulmonary artery type, the lesion mainly involves the pulmonary artery.
Pathophysiology
The main physiological changes of aortitis are: distal ischemia of the lesion and proximal hypertension of the lesion, partial or complete occlusion of the artery, which impedes the supply of blood flow in the distal part, resulting in ischemic symptoms, depending on the location and extent of the obstruction. Different effects.
Prevention
Arteritis prevention
To prevent possible incentives, the room should not be too cold and humid, the temperature should be appropriate, prevent infection, strengthen exercise, enhance physical fitness, improve autoimmune function, regular life, strengthen nutrition, not cold drink and over-eating fat, Do not eat spicy food and avoid alcohol and tobacco.
Complication
Arteritis complications Complications angina pectoris myocardial infarction
According to the analysis of 530 cases of arteritis, about 15% of patients had complications, 90% of them had only one type of complication, 10% of patients had 2 complications, and the most complications occurred within 5 years after onset (70%) Among the 76 complications in 76 cases: 27 cases of cerebral thrombosis, 18 cases of heart failure, 11 cases of aortic regurgitation, 9 cases of blindness, 6 cases of angina pectoris, 5 cases of myocardial infarction, kidney 4 cases of functional failure, 3 cases of cerebral hemorrhage, 1 case of aortic dissection, 1 case of nasal septal perforation, Japan reported that most patients with heart failure combined with aortic regurgitation; heart failure can also be caused by severe hypertension Without aortic regurgitation, heart failure was controlled in most patients after drug treatment. A small number of patients showed elevated central arterial pressure, causing heart enlargement and heart failure, but the two upper limbs were pulse-free and should be diagnosed. Note that individual patients develop coronary steal syndrome, the most harmful of which is cerebral ischemia and persistent hypertension, which is the most important cause of deterioration or even death.
Symptom
Symptoms of aortic inflammation Common symptoms of bowel recurrence Carotid pulsation weakened or disappeared angiography abnormal nasal septum perforation convulsions nausea
A few weeks before the onset of local symptoms or signs, a small number of patients may have general malaise, fatigue, fever, loss of appetite, nausea, sweating, weight loss and irregular menstruation. When local symptoms or signs appear, systemic symptoms will Gradually reduce or disappear, most patients do not have the above symptoms.
According to the lesions can be divided into four types: brachiocephalic artery type (aortic arch syndrome); thoracic and abdominal aortic type; mixed type; pulmonary artery type.
1. Brachiocephalic artery type (aortic arch syndrome)
(1) Symptoms: Carotid artery and vertebral artery stenosis and occlusion can cause different degrees of ischemia in the brain, dizziness, dizziness, headache, memory loss, black spots on one or both sides of vision, vision loss, visual field reduction Even blindness, chewing muscle weakness and masticatory muscle pain in the muscles, fewer patients with nasal septum perforation due to ischemia, upper jaw and ear shell ulcers, tooth loss and facial muscle atrophy, severe cerebral ischemia may have repeated syncope, convulsions , aphasia, hemiplegia or coma, especially when the head is up, cerebral ischemic symptoms are more likely to occur, a small number of patients due to local blood pressure and low oxygen partial pressure or carotid artery and surrounding tissue adhesion, carotid sinus is more sensitive, when the head is sharp When changing position or standing up, carotid sinus syncope can occur. Upper limb ischemia can cause unilateral or bilateral upper limb weakness, cold, soreness, numbness and even muscle atrophy. A few patients may have subclavian artery stealing syndrome ( Subclavian steal syndrome), when the lateral subclavian artery or the innominate artery stenosis is more than 50% or occluded, the pressure of the ipsilateral vertebral artery can be reduced by 1.33 kPa (10 mmHg) or more. The blood of the vertebral artery is reversed into the vertebral artery and the subclavian artery on the stenosis or occlusion side, and when the upper limb is active, the blood flow can be increased by 50% to 100%, causing siphoning at the distal end of the stenosis or occlusion site. Increased brain ischemia, and transient dizziness or syncope.
(2) Signs: Carotid artery, radial artery, and iliac artery pulsation weakened or disappeared. The systolic pressure difference between the upper limbs was greater than 1.33 kPa (10 mmHg). About half of the patients could hear more than two grades of systolic vascular murmur in the neck or upper part of the collarbone. A few are accompanied by tremors, but the degree of miscellaneous sound and stenosis is not completely proportional. The arteries with mild stenosis or complete occlusion are not obvious. If collateral circulation is formed, the blood flow is enlarged and curved. Continuous vascular murmurs can be produced when the collateral is circulated.
2. Thoracic and abdominal aortic type
(1) Symptoms: Patients with high blood pressure may have headache, dizziness, palpitation, weakness due to lower limb ischemia, cold, soreness, fatigue and intermittent claudication. Patients with pulmonary stenosis may have palpitation and shortness of breath. A small number of patients have angina or myocardial infarction, which is caused by stenosis or occlusion caused by coronary artery involvement.
(2) Signs:
1 hypertension: hypertension is an important clinical manifestation of this disease, especially the increase of diastolic blood pressure, the more severe the renal artery stenosis, the higher the diastolic blood pressure, the mechanism may be severe stenosis of the thoracic descending aorta, making the heart Excretion of blood flow to the upper extremities caused by regional hypertension and/or renal vascular hypertension caused by renal artery stenosis; systolic hypertension caused by aortic regurgitation, etc., in simple renal vascular hypertension Using the same cuff to measure the lower limb systolic blood pressure is 2.66 ~ 5.32kPa (20 ~ 40mmHg) higher than the upper limb; simple chest lowering aortic stenosis, the upper limb blood pressure is high, lower limb blood pressure is low or can not be measured; if the above two combinations exist At the same time, the blood pressure levels of the upper and lower limbs are more different, and hypertension increases the cardiac afterload, which causes left ventricular hypertrophy, enlargement and heart failure. As a result of aortitis involving the ascending aorta, the aortic ring is dilated, with or without Separation of the junction; and can invade the aortic valve insufficiency caused by fibrosis and hyperplasia of the valve, clinical attention should be paid to the differential diagnosis of rheumatic heart disease.
2 vascular murmur: about 80% of patients in the upper umbilical can be heard and high-profile systolic or contractile and diastolic dual-phase vascular murmur, regardless of unilateral or bilateral renal artery stenosis, more than half of the abdominal vascular murmur only I ~ II It can be transmitted to the left or right side. The noise is located in the range of 2 to 7 cm on the umbilicus and 2.5 cm on both sides of the umbilicus. The intensity of the noise is not parallel with the degree of renal artery stenosis. According to animal experiments, the abdominal aortic stenosis of the dog is found. Vascular murmurs occur at 60% of the time. When the stenosis is 73%, the murmur is loudest. If it is more than 78%, the murmur is weakened or inaudible. It is generally considered that the abdominal aorta or renal artery stenosis is <60%, and the stenosis is far. , the proximal systolic pressure difference <3.99kPa (30mmHg), no functional significance, that is, does not cause renal vascular hypertension, only when the stenosis is >60%, the stenosis is far, the proximal systolic pressure difference is >3.99kPa ( Renal vascular hypertension occurs when 30mmHg), but there is also a narrow renal artery stenosis and systolic pressure difference is not obvious, which is due to long-term hypertension caused by progressive arcuate artery and interlobular arteriosclerosis, resulting in increased peripheral renal resistance , the nature of the noise to determine the condition of the lesion Meaningful, continuous vascular murmur reflects the pressure difference throughout the cardiac cycle, suggesting that there may be renal artery stenosis, but the arteriovenous fistula should be excluded. The intensity of vascular murmur is affected by various factors, such as elevated blood pressure, increased heart rate, and bowel. The sound is weakened, fasting or thin body is more audible and vascular murmur, otherwise it is difficult to hear. When the disease is suspected, it should be auscultated repeatedly under different conditions, but abdominal vascular murmur is not a specific sign of renal artery stenosis, a few primary Sexual hypertension or those over the age of 50 may also smell mild vascular murmurs in the upper abdomen. If you do not smell vascular murmurs, you can not exclude renal artery stenosis, especially fibromuscular dysplasia (FMD) due to its lesions. Often limited to the middle segment of the renal artery or its branches, the upper abdomen is generally difficult to hear murmurs, 27 cases of FMD patients were examined in Fuwai Hospital, and 7 cases of abdominal vascular murmurs were found, so it should be combined with relevant examinations, comprehensive analysis to determine, about 50% The patients with arteritis can smell vascular murmurs in the neck, because the right side is sometimes confused with the jugular murmur, so the left side is more pathological than the right vascular murmur. diagnosis.
3 upper and lower extremity systolic pressure difference normal people in the arterial direct pressure measurement of the upper limb and lower limb blood pressure equal, when using a fixed width cuff (adult 12cm) sphygmomanometer, the lower extremity arterial systolic blood pressure level is 2.66 ~ 5.32 higher than the upper limb kPa (20 ~ 40mmHg), because the systolic pressure is proportional to the thickness of the limb, and inversely proportional to the width of the cuff. If the lower extremity of the aorticitis patient uses a widened cuff, the systolic pressure difference of the upper limb is <2.66kPa (20mmHg), which reflects The aortic system has a stenosis.
3. Mixed type
With the above two types of characteristics, it is a multiple lesion, and most patients have a serious condition.
4. Pulmonary artery type
It is not uncommon for this disease to be associated with pulmonary artery involvement, accounting for about 50%. All three types can be associated with pulmonary artery involvement, but there is no significant difference between pulmonary arterial involvement in each type, and no pulmonary artery involvement has been found. However, pulmonary arterial involvement in foreign countries has been reported as the first clinical manifestation of aortitis. Pulmonary hypertension is mostly a late complication, accounting for about 1/4, mostly mild or moderate, while severe is rare, clinically palpitations, shortness of breath More, but the symptoms are milder, the pulmonary valve area can be heard and the systolic murmur and the second sound of the pulmonary valve, the heavier side of the pulmonary stenosis is weakened, and should be associated with other pulmonary vascular diseases, such as pulmonary thromboembolism or Identification of primary pulmonary hypertension.
Wu Donghai and others have analyzed the clinical manifestations and related examinations of 700 cases of arteritis, and proposed the diagnostic criteria for arteritis:
1. The age of onset is generally below 40 years old.
2. The subclavian artery, mainly the left subclavian artery stenosis or occlusion, weak or no pulse, low blood pressure or undetectable, the systolic pressure difference between the two upper limbs is greater than 1.33 kPa (10 mmHg), and the secondary or upper blood vessels are heard on the clavicle. Noise.
3. Carotid stenosis or obstruction, arterial pulsation weakened or disappeared, the neck smelled secondary or above vascular murmurs, or there was no pulse disease fundus changes.
4. Chest, abdominal aortic stenosis, upper abdomen or back smell secondary vascular murmur; with the same cuff, lower limbs lower than the upper limb blood pressure 2.66 kPa (20mmHg) or more.
5. Renal artery stenosis, high blood pressure, short course of disease, secondary vascular murmurs in the upper abdomen.
6. The lesion involves pulmonary artery stenosis, or coronary stenosis, or aortic regurgitation.
7. The blood is fast, and there is tenderness in the arteries.
Among the above 7 items, in addition to the first item, and at least 2 of the other 6 items, especially the second item is the most common, which can be qualitatively diagnosed as arteritis. For some suspicious patients, digital subtraction angiography is required. Or three-dimensional ultra-high-speed CT or MRI to confirm the diagnosis. If the arterial involvement (part, extent, degree) is specifically determined, digital subtraction angiography is required.
Classification criteria for arteritis developed by the American College of Rheumatology in 1990:
1 The age of onset is under 40 years old;
2 intermittent trips;
3 upper arm artery pacing is weakened;
4 The systolic pressure difference between the two upper limbs is greater than 1.33 kPa (10 mmHg);
5 There is a vascular murmur in the junction of the subclavian artery and the aorta;
6 angiographic abnormalities, 3 of the 6 items can be diagnosed, in addition, Chapel Hill (1994) meeting to define the classification criteria for arteritis: granulomatous arteritis involving the aorta and its branches, The average patient is younger than 50 years old.
8. Diagnostic criteria for arteritis (1990 ACR standard):
(1) The age of onset is 40 years old, and the age or symptoms associated with aortitis are less than 40 years old.
(2) Intermittent claudication of limbs: Muscle fatigue and discomfort occur in one or more limbs during activities, especially in the upper limbs.
(3) Attenuation of the brachial artery pulsation: the pulsation of one or both arm arteries is weakened.
(4) The contraction pressure difference between the two upper arms is >10 mmHg (1.33 kPa).
(5) vascular murmur: vascular murmur in the subclavian artery and aortic area, unilateral or bilateral subclavian artery or abdominal aorta can smell murmur.
(6) Abnormal angiography: primary aortic branch or proximal and proximal aorta stenosis or atresia, lesions are often focal or segmental, these are not caused by aortic sclerosis, fibrous tissue and muscular dysplasia or similar Caused.
At least 3 of the above 6 can be diagnosed.
Examine
Examination of arteritis
1. Erythrocyte sedimentation rate increases
ESR is an important indicator reflecting the disease activity of this disease. About 43% of the patients, including those within 10 years of onset, most of the ESR increases. Those older than 10 years tend to be stable, and most of the ESR is normal.
2. "C" reactive protein
Its clinical significance is the same as erythrocyte sedimentation rate, and the positive rate is similar to erythrocyte sedimentation rate, which is an indicator of the disease activity of this disease.
3. Anti-streptolysin "O"
The increase in these antibodies only indicates that the patient has had a hemolytic streptococcal infection in the recent past, and about half of the patients have a positive or suspected positive reaction.
Blood picture
A small number of patients can see an increase in white blood cells, which is also a response to inflammatory activity, but there is no significant change in neutrophils. About one-third of patients have anemia, often mild anemia, which is a long-term disease activity or an increase in female hormones on hematopoietic function. Caused.
5. Serum protein electrophoresis
Often, 1, 2 and gamma globulin increase, and albumin decreases.
6. Serum anti-aortic antibody assay
This method has certain value for the diagnosis of arteritis. The serum anti-aortic antibody titer is 1:32 positive, 1:16 is negative, the positive rate of aortitis patients can reach 91.5%, and the titer is 1:64. Those accounted for 65% and false negatives accounted for 8.5%.
7. Chest X-ray examination
(1) Cardiac changes: About 1/3 of patients have different degrees of cardiac enlargement, mostly mild left ventricular enlargement, and less severe enlargement, mainly due to increased post-load caused by hypertension; secondly due to aortic valve closure Incomplete or coronary lesions caused by myocardial damage.
(2) changes in the thoracic aorta: often bulging, bulging, dilatation, and even tumor-like dilatation of the ascending aorta or arch descending, may be the effect of hypertension or the performance of aortitis, related to the type and extent of the lesion, The descending aorta, especially the thinning adduction and pulsation in the middle and lower segments, is an important indication for the wide stenosis of the thoracic descending aorta.
8. ECG examination
About half of the patients have left ventricular hypertrophy, left ventricular strain or high voltage, a few manifestations of coronary insufficiency or myocardial infarction changes, pulmonary hypertension caused by pulmonary stenosis can be expressed as right ventricular hypertrophy, left ventricular afterload increased may partially cover the electrocardiogram Characteristics of right ventricular hypertrophy.
9. Fundus examination
A disease-free fundus is a specific change of the disease, the incidence rate is about 14%, can be divided into three phases: the first phase (vasodilation), optic disc redness, arteriovenous dilation, congestion, venous lumen Uneven, capillary angiogenesis, small hemorrhage, small hemangioma, normal iris vitreous; stage 2 (anastomotic phase), dilated pupils, disappeared response, iris atrophy, retinal arteriovenous anastomosis, peripheral blood vessels disappeared; Complications), manifested as cataract, retinal hemorrhage and exfoliation.
10. Pulmonary function test
Pulmonary function changes are associated with pulmonary stenosis and impaired pulmonary blood flow. Ventilatory function declines with bilateral pulmonary blood flow damage, while diffuse dysfunction is rare, and lung compliance is reduced due to long-term pulmonary blood flow damage. Or pulmonary hypertension caused by changes in cardiopulmonary function.
11. Blood flow chart check
It can check the blood flow of the head and limbs, and can simultaneously determine the diameter of the arterial lumen, which is valuable for diagnosis and understanding of changes in the condition or follow-up observation after surgery.
12.B type ultrasound examination
The aorta and its main branches can be examined for stenosis or occlusion (carotid artery, subclavian artery, renal artery, etc.), and its distal branch can also be probed.
13. Radionuclide inspection
99mTc-DTPA renal photography and captopril challenge test, when the renal artery stenosis, due to renal ischemia caused by increased renin system activity, angiotensin II glomerular glomerular arteriolar contraction, glomerulus Increased filtration pressure, compensatory to maintain proper glomerular filtration rate, taking 25mg of captopril, 1 hour after renal examination, if there is renal artery stenosis, because anthraquinone eliminates angiotensin II The contraction of the small arterioles, so the glomerular filtration rate is lower than before the medication, in order to determine the renal artery stenosis, the positive rate of this method is 96.3%, specificity of 82.7%, more sensitive than simple kidney photography Sex (51.8%) was significantly higher, while specificity was not different.
14. CT examination
Angiography (including DsA) is still the main method for the diagnosis of arteritis. It mainly shows changes in the arterial lumen, but it can not observe the changes of the wall. Its CT can observe the changes of the arterial wall and the early diagnosis of arteritis. The lesion activity has great value, and the wall thickening and calcification can be seen. CT scan is enhanced. It is found that the wall wall enhancement and annular low-density shadow are the active period of the lesion, and the angiography is normal, but there may be abnormal wall wall. Early diagnosis of aortitis, especially three-dimensional reconstruction, can stereoscopically show the aorta and its main branch lesions, showing optimal vascular malformation and complex vascular structures at overlapping sites.
15. Nuclear Magnetic Resonance (MRI) examination
This method is a non-invasive examination, with multi-position, multi-faceted imaging capabilities, the use of MRI spin echo and gradient echo rapid imaging sequence, can detect aortic luminal and wall morphology and aortic hemodynamic changes The aortic valve insufficiency can be determined. This method can show the morphological changes of the intact aorta and its main branches.
16. Angiography
(1) Digital subtraction angiography (DSA): It is a digital image processing system that is injected intravenously with 76% diatrizoate for contrast. It is a better screening method, which is easy to operate and has a small patient burden. The contrast resolution is high, and the lesions in the low-contrast area can also be displayed. Considering that arteritis is the most common cause of renovascular hypertension, the brachial artery, thoracic, abdominal aorta, renal artery, and brachial artery should be treated during angiography. Pulmonary artery examination, generally can replace renal angiography, is also suitable for outpatients, but the renal artery branch lesions are unclear, if necessary, selective renal angiography is still needed.
(2) Selective angiography: the location, extent, extent, distal branch, collateral circulation, and thoracic and abdominal aorta of the renal artery stenosis can be observed.
(3) Coronary angiography: In recent years, the disease has attracted people's attention. Lupi et al reported that the incidence of coronary artery involvement was 9% to 10%. Two patients with young arteritis were found in Fuwai Hospital. Arterial angiography confirmed coronary proximal stenosis, coronary artery bridging was performed, and postoperative biopsy was diagnosed as coronary arteritis.
Japan's Matsubard et al performed coronary angiography analysis in 21 patients with arteritis. According to the pathological features of coronary artery, there were three types: type I is coronary ostia and its proximal stenosis or occlusion. This type is most common; type II is Diffuse type, the lesion can affect the epicardial branch, or involving several segments, the so-called skip lesion; type III is a coronary aneurysm, the latter two types are rare, due to ascending aortic lesions affecting the coronary artery The membrane produces proliferative inflammation, and the smooth muscle of the middle layer contracts to cause coronary artery stenosis or occlusion.
Diagnosis
Diagnosis and diagnosis of arteritis
Arteritis refers to the chronic progressive non-specific inflammation of the aorta and its main branches and pulmonary or coronary arteries, causing stenosis or occlusion of different parts. A small number of arterial dilatation may also occur to form an aneurysm, which occurs in young women. Before the age of 40, it was found that one or both limbs, especially the left upper limb, had no pulse or weak pulse. The systolic pressure difference between the two sides was greater than 1.33 kPa (10 mmHg). The neck or abdomen or back could smell vascular murmurs. Its clinical manifestations are also different, activities often show increased erythrocyte sedimentation rate, C-reactive protein positive, fever, local arterial pain, etc., so the diagnosis must be differentiated from the following various diseases.
1. Renal artery fibromuscular dysplasia (FMD)
The disease occurs in young women. Most of the lesions involve the distal end of the renal artery and its branches. It can be bead-like changes. The right renal artery is more common, the aorta is rarely affected, and the upper abdomen rarely hears vascular murmurs. Clinical manifestations of aortitis.
2. Atherosclerosis
Most of the ages are over 50 years old, more common in men, shorter medical history, no clinical manifestations of aortitis activity, angiography common sputum, femoral artery and abdominal aortic atherosclerotic lesions, but this disease rarely involves the abdominal aorta The main branch, the renal artery involvement in China is less common, accounting for about 5% of renal vascular hypertension.
3. Congenital aortic coarctation
This disease and aortitis associated with thoracic descending aortic stenosis caused by high blood pressure sometimes confused, the former is more common in men, vascular murmur position is higher, limited to the anterior region and shoulder and back, the abdomen can not hear the noise, the body has no inflammatory activity, Thoracic aorta angiography showed a narrowing of the specific site, the infant type was located in the aortic isthmus, and the adult type formed a limited stenosis at the junction of the arterial catheter.
4. Thrombotic vasculitis (Buerge's disease)
Chronic occlusive inflammation of the peripheral blood vessels, mainly involving the small arteries and veins of the extremities, lower extremities are more common, occur in young men, have a history of smoking, manifest limb ischemia, severe pain, intermittent claudication, weakened dorsal artery pulsation or Disappeared, migratory superficial arteritis, severe musculoskeletal ulcer or necrosis, and the identification of aortitis is generally not difficult, but the formation of thrombosis of this disease can affect the abdominal aorta and renal artery, causing renal vascular high Blood pressure, combined with clinical comprehensive analysis, if necessary, angiography to identify.
5. Nodular polyarteritis
Nodular polyarteritis has fever, rapid erythrocyte sedimentation rate and vasculitis, but mainly occurs in the visceral arterioles, which is different from arteritis.
6. Thoracic outlet syndrome
The iliac artery pulsation is weakened, and the pulsation can be changed with the movement of the head and neck and the upper limbs; the upper limb vein often has a retention phenomenon, the brachial plexus is compressed to cause neuralgia, and the neck X-ray film shows the cervical rib deformity.
