Brkljacic, B

Cammelli, D

Castellani, S.

De Gregorio, Maria Grazia

Matucci Cerinic, M

Vitiello, G

English

Florence Research

Three dimensional vascular ultrasound imaging in mediumand large vessel vasculitis: our experiencePoster No.: C-0894Congress: ECR 2019Type: Scientific ExhibitAuthors: M. G. De Gregorio1, D. Cammelli1, G. Vitiello1, B. Brkljacic2, M.Matucci Cerinic1, S. Castellani1; 1Florence/IT, 2Zagreb/HRKeywords: Arteries / Aorta, Vascular, Ultrasound-Colour Doppler, Diagnosticprocedure, InflammationDOI: 10.26044/ecr2019/C-0894Any information contained in this pdf file is automatically generated from digital materialsubmitted to EPOS by third parties in the form of scientific presentations. Referencesto any names, marks, products, or services of third parties or hypertext links to third-party sites or information are provided solely as a convenience to you and do not inany way constitute or imply ECR's endorsement, sponsorship or recommendation of thethird party, information, product or service. ECR is not responsible for the content ofthese pages and does not make any representations regarding the content or accuracyof material in this file.As per copyright regulations, any unauthorised use of the material or parts thereof aswell as commercial reproduction or multiple distribution by any traditional or electronicallybased reproduction/publication method ist strictly prohibited.You agree to defend, indemnify, and hold ECR harmless from and against any and allclaims, damages, costs, and expenses, including attorneys' fees, arising from or relatedto your use of these pages.Please note: Links to movies, ppt slideshows and any other multimedia files are notavailable in the pdf version of presentations.www.myESR.orgPage 1 of 12Aims and objectivesGiant cell arteritis (GCA) is the most frequent systemic vasculitis in middle-age andelderly caucasian populations. Besides temporal arteries, the disease can mainly involvethe subclavian and axillary arteries and the aortic arch. The diagnosis of GCA may bedifficult due to clinical heterogeneity. The diagnostic hallmark of GCA is the presence ofinflammation in the vessel wall that can be effectively and reliably detected nowadays bythe noninvasive technique of Color Doppler ultrasonography (CDUS), as proved by manyclinical studies (1) . To the best of our knowledge no data exist about three dimensional(3D) vascular ultrasound imaging in patients affected by GCA. We sought to assess theextension of inflammatory involvement of temporal, subclavian and axillary arteries by3D vascular ultrasound imaging in patients with confirmed or suspected GCA and toevaluate the relations between inflammation markers abnormalities, clinical symptomsand 3D findings.Page 2 of 12Methods and materialsSince January 2018 patients with confirmed or suspected GCA diagnosis were studiedwith Siemens Paragon Sequoia, 9L4 4-9 MHz and Logiq9 4.5-16 MHz probes. GCAdiagnosis was made by rheumatologists according to clinical and laboratory parameters(2-3) after instrumental confirmation by CDUS and/or PET examination (4). We set a# 1mm diagnostic cut-off value for circumferential, hypoechogenic perivascular halo ofthe temporal arteries and a # 1.5 mm hypoechogenic wall thickening for the axillary andsubclavian arteries (5-6). Clinical and laboratory data were collected. Discrete data aresummarized as frequencies while continuous as mean ± SD. #2 test or Fisher exacttest when appropriate were used for comparison of categorical variables. Analyses wereperformed using the software package SPSS 19.Page 3 of 12ResultsTwenty two patients were studied. Mean age was 70.4±12 years, 68% were women(Figure 1). Among patients with confirmed GCA diagnosis, 54% had temporal arteritis,while 27% had only subclavian and axillary involvement; among the remaining patients(19%), referred to our centre for high clinical suspicion of GCA, one was affectedby systemic lupus erythematosus (SLE), two had polymyalgia rheumatica and onerheumatoid arthritis. Most patients (94%) were on steroid treatment: 12% were onsteroids and tocilizumab and 18% on steroids plus methotrexate. At the time of 3Dvascular examination, 90% of patients complained at least one symptom: 60% headache,17% fatigue, 20% fever, 42% polymyalgia, 5% visual loss, 45% jaw claudication (Figure3). In most patients the inflammation markers were abnormal: erythrocyte sedimentationrate (ESR) was increased in 64%, C reactive protein (CRP) in 66% and fibrinogenin 72%. The halo sign was found in 62% of temporal arteries while a hypoechogenicarterial wall thickening was demonstrated in 54% of axillary arteries and in 78% ofsubclavian arteries. In only 6% of patients the halo sign involved only the main temporalarteries. A multiple vessel inflammatory involvement was found in 36% of patients. Inall cases the 3D US examination confirmed the presence of inflammatory signs in bothcranial (temporal arteries) and extracranial (subclavian and axillary) vessels and it clearlydefined its inhomogenous and often spotty appearance (Figures 4-6), thus allowing, ineach arterial segment, a direct overall quantification of the inflammatory process. Jawclaudication was the only symptom significantly associated with the detection of temporalarteries halo sign (p=0.043). At the time of vascular examination the presence of at leastone symptom was significantly related with halo sign of temporal arteries (p=0.042).Among the inflammatory markers only ESR and fibrinogen elevations were significantlyassociated with the finding of halo sign of temporal arteries (p=0.015 and p=0.038,respectively) but not with the detection of hypoechogenic wall thickening of subclavianor axillary arteries (Figure 2).Page 4 of 12Images for this section:Fig. 1: Table 1 describes the general patients characteristics.© Department of Medical and Surgical Critical Care, Florence University of Medicine -Florence/ITPage 5 of 12Fig. 2: Table 2. Clinical and laboratory findings associated with temporal arteries halosign.© Department of Medical and Surgical Critical Care, Florence University of Medicine -Florence/ITFig. 3: Figure 3 describes the clinical symptoms of the study populationPage 6 of 12© Department of Medical and Surgical Critical Care, Florence University of Medicine -Florence/ITFig. 4: Figure 4 - 3D extended view of the hypoechogenic halo surrounding the maintemporal artery (A) and its parietal branch (B).© Department of Medical and Surgical Critical Care, Florence University of Medicine -Florence/ITPage 7 of 12Fig. 5: Figure 5 - Extended hypoechogenic inflammatory wall thickening of the left (A)and right (B) subclavian arteries at 3D ultrasound examination.© Department of Medical and Surgical Critical Care, Florence University of Medicine -Florence/ITPage 8 of 12Fig. 6: Figure 6 - Extended hypoechogenic inflammatory wall thickening of the left (A)and right (B) axillary arteries at 3D ultrasound examination.© Department of Medical and Surgical Critical Care, Florence University of Medicine -Florence/ITPage 9 of 12ConclusionThree dimensional vascular ultrasound imaging can demonstrate even spottyabnormalities along the entire vessel thus allowing a full extent detection and preciseestimate of the inflammatory process; these findings are especially useful for follow-up purposes. Further studies will be nedeed to test reproducibility and interobservervariability.Page 10 of 12Personal informationSergio Castellani - Department of Medical and Surgical Critical Care , Florence Universityof Medicinescaste.sergio@gmail.comPage 11 of 12References1. Chrysidis S, Duftner C, Dejaco C et al. Definitions and reliability assessmentof elementary ultrasound lesions in giant cell arteritis: a study from theOMERACT Large Vessel Vasculitis Ultrasound Working Group. RMD Open.2018;4(1):e000598.2. Fries JF, Hunder GG, Bloch DA. et al. The American College ofRheumatology 1990 criteria for the classification of vasculitis. Summary.Arthritis Rheum 1990;33:1135-6.3. Jennette JC, Falk RJ, Bacon PA et al. 2012 revised International ChapelHill Consensus Conference Nomenclature of Vasculitides. Arthritis Rheum2013 ;65(1):1-11.4. Dejaco C, Ramiro S, Duftner C et al. EULAR recommendations for the useof imaging in large vessel vasculitis in clinical practice. Ann Rheum Dis.2018;77(5):636-643.5. Salvarani C, Silingardi M, Ghirarduzzi A et al. Is duplex ultrasonographyuseful for the diagnosis of giant-cell arteritis? Ann Intern Med.2002;137(4):232-8.6. Schmidt WA, Seifert A, Gromnica-Ihle E, Krause A, Natusch A. Ultrasoundof proximal upper extremity arteries to increase the diagnostic yield in large-vessel giant cell arteritis. Rheumatology (Oxford). 2008 ;47(1):96-101.Page 12 of 12

Three-dimensional vascular ultrasound imaging in medium and large vessel vasculitis: our experience

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Three-dimensional vascular ultrasound imaging in medium and large vessel vasculitis: our experience

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