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Interventional Case Record

< Case 68 : March 2026 >

Primary aortic stenting for the management of resistant hypertension in a patient with Takayasu's arteritis

Contributed by : Akash L. Shah

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Introduction:

Takayasu arteritis is a chronic, idiopathic, granulomatous large-vessel vasculitis that predominantly affects the aorta and its major branches. Progressive inflammation leads to arterial wall thickening, fibrosis, stenosis, and occasionally occlusion, resulting in end-organ ischemia (1) . Among its various clinical manifestations, renovascular hypertension is a significant and potentially severe complication arising from compromised renal perfusion secondary to aortic or renal artery involvement.

Persistent hypertension in this setting is frequently resistant to pharmacological therapy alone and may substantially increase cardiovascular risk. Although immunomodulatory treatment addresses inflammatory activity, mechanical obstruction from established vascular narrowing often necessitates revascularization to achieve durable physiological improvement (2) .

Advances in endovascular techniques have enabled minimally invasive restoration of vessel patency with favorable procedural safety profiles. Carefully timed intervention during the inactive phase of disease can yield meaningful reductions in blood pressure burden and medication dependence (3) .

This report describes a case of severe, medically refractory hypertension in a patient with established Takayasu arteritis, successfully managed with primary endovascular aortic stenting. The case underscores the transformative clinical impact of targeted revascularization in selected patients and highlights the role of interventional radiology in altering the natural course of renovascular hypertension in large-vessel vasculitis.

Case presentation:

A 45-year-old man, known case of Takayasus’s aortoarteritis with uncontrolled hypertension, presented with complaints of facial puffiness, headaches, lower limb swelling and poor control of blood pressure for the past six years. Despite being on four oral antihypertensive medications, his blood pressure remained poorly controlled, with systolic values ranging between 160–180 mmHg and diastolic pressures between 90–110 mmHg. The patient was then referred by the Department of Nephrology to Interventional Radiology for further evaluation and management for renovascular hypertension.

In addition to the above, the patient reported lower limb and left upper limb claudication on both sides. The onset of symptoms for this patient was before the age of 40 years. Clinical and radiological evaluation revealed features of large-vessel vasculitis.

Following were the clinical and imaging findings supportive for diagnosis of Takayasu’s Aortoarteritis in our patient:

Major Criteria

- Age of symptom onset <40 years.

- Left Subclavian artery lesion.

Minor Criteria

- Thoracic aortic lesions.

- Abdominal aortic lesions.

- Elevated ESR and CRP levels.

- Hypertension

- Lower limb claudication.

- Blood pressure difference between both upper limbs of >20mmHg.

There was left subclavian artery occlusion, diffuse and irregular aortic wall thickening involving the thoracic and the abdominal aorta causing irregular aortic stenosis. There was complete infra-renal aortic occlusion with distal perfusion through collaterals. There was no hemodynamically significant renal artery stenosis. Laboratory investigations revealed elevated inflammatory markers, including erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP), consistent with active Takayasu arteritis as per Modified Ishikawa’s Criteria for Takayasu’s Aortoarteritis (Figure 1).

FIG 1. Modified Ishikawa’s Criteria for diagnosis of Takayasu’s Arteritis

The patient was initially managed medically with immunosuppressive therapy aimed at controlling disease activity and normalizing inflammatory markers. After achieving normalization of ESR and CRP values, and confirming a quiescent phase of the disease, the patient was planned for endovascular intervention to address the hemodynamically significant aortic stenosis contributing to renovascular hypertension due to renal hypoperfusion.

Radiological findings :

Preoperative imaging played a crucial role in delineating the extent and severity of vascular involvement. Cross-sectional imaging demonstrated significant narrowing of the thoracic and abdominal aorta (Figure 2), resulting in compromised renal perfusion. The imaging findings were consistent with chronic inflammatory changes associated with Takayasu arteritis, including concentric wall thickening and luminal stenosis.

FIG 2. Coronal reformatted CT aortogram showing diffuse, irregular thoraco-abdominal aortic stenosis with wall thickening and calcifications.

There was complete left subclavian artery occlusion (Figure 3). The thoraco-abdominal aortic narrowing was hemodynamically significant and was identified as the likely cause of renovascular hypertension due to reduced renal blood flow.

FIG 3. Coronal reformatted CT aortogram showing left subclavian artery occlusion with distal reformation via collaterals.

No evidence of active inflammation was noted at the time of intervention planning, and inflammatory markers were within normal limits. After multidisciplinary discussion involving nephrology and interventional radiology teams, the patient was considered an appropriate candidate for endovascular aortic stenting to improve renal perfusion and achieve better blood pressure control.

Interventional technique:

The procedure was performed under appropriate aseptic precautions, after obtaining informed consent, vascular access was secured via the right brachial artery. The right brachial approach was selected considering the anatomical considerations and left subclavian artery occlusion as well as complete infra-renal aortic occlusion.

Following arterial puncture and sheath placement, an aortogram was performed which confirmed the severity of the thoracic and abdominal aortic stenosis which correlated with preoperative imaging, demonstrating a significant narrowing of the thoraco-abdominal aorta. (Video 1).

Video 1 - Aortogram demonstrating thoraco-abdominal aortic stenosis.mp4

Video 1: Aortogram demonstrating diffuse irregular moderate to severe narrowing of the thoraco-abdominal aorta.

A guidewire was carefully navigated across the stenotic segment under fluoroscopic guidance. After adequate positioning, two overlapping self-expanding stents (14 mm x 60 mm) were deployed across the diseased segment of the aorta (Videos 2 and 3).

Video 2 - Self expanding stent deployment 1.mp4

Video 3 - Self expanding stent deployment 2.mp4

Video 2, 3 Deployment of 2 overlapping self expanding stents (14mm x 60mm)across the involved thoraco-abdominal aortic stenosis.

The stents were then dilated upto the point of pain response elicited while balloon dilatation (Figure 4). Care was taken as to not perform dilatation beyond the point of significant pain sensation in the back region as the possibility of development of aortic rupture as a complication is higher in patients suffering from Takayasu’s aortoartertis.

FIG 4: Balloon dilatation across the stented portion of the thoraco-abdominal aorta. Utmost care was taken as to not dilate the stents beyond the point of appearance of pain response.

Post stenting angiography demonstrated significant and satisfactory expansion of the stent with significant luminal gain and improved antegrade flow dynamics across the previously narrowed segment. Renal artery perfusion improved visibly (Video 4 and Figure 5). There was no evidence of dissection, distal embolization, or other immediate complications. Hemostasis was achieved at the access site, and the patient was monitored in the post-procedure recovery area. The procedure was completed successfully without intraoperative complications.

Video 4 - Post stenting aortogram.mp4

Video 4. Post stenting angiogram showing significant luminal gain, reduction in the collaterals as well as improved renal perfusion as compared to pre-stenting.

FIG 5. Comparison Pre-Stenting and Post-Stenting demonstrating aortograms shows significant luminal gain (arrows), Significant reduction of collaterals (arrows), Improved renal perfusion as compared to pre stenting (star).

Follow-Up

Within the immediate post-intervention period, systolic blood pressure decreased to approximately 140 mmHg and diastolic pressure to around 90 mmHg, with minor fluctuations of ±10 mmHg.

The complaints of episodic facial swelling completely resolved starting from post operative day 2. There were no episodes of headaches or lower limb swelling.The patient reported a perceivable improvement in the feeling of well being as early as post operative day 2.

The patient was then discharged and asked to visit us for follow up after 1 month with advise to monitor his blood pressures daily for comparison with pre-procedure BP values and mark appearance of any symptoms that he was earlier experiencing.

On his first follow up visit, the patient had drastic improvement in his blood pressure control. His daily blood pressure readings were in the range of 120-140mmHg systolic and 60-80 mmHg diastolic. No episodes of facial swelling, headaches, blurring of vision or lower limb swelling were reported in the one month follow up.

Notably, the number of antihypertensive medications was reduced from four to two, with sustained good control of blood pressure. This reduction in pharmacological burden significantly improved patient compliance and quality of life. Inflammatory markers remained within normal limits during follow-up, indicating continued remission of Takayasu arteritis.

Regular follow-up with clinical assessment and imaging surveillance was advised to monitor stent patency and detect any disease progression or restenosis.

Discussion

Takayasu arteritis is a chronic granulomatous large-vessel vasculitis predominantly affecting the aorta and its major branches. Progressive inflammatory changes lead to wall thickening, fibrosis, and luminal stenosis, which can result in significant end-organ ischemia. Renovascular hypertension is a well-recognized complication due to renal hypoperfusion secondary to aortic or renal artery involvement (4) .

Management of Takayasu arteritis requires a combination of medical therapy to control active inflammation and revascularization strategies to address fixed stenotic lesions (5). Intervention during the active inflammatory phase is associated with higher complication and restenosis rates; hence, normalization of ESR and CRP prior to intervention is crucial (6) . Endovascular therapy, including balloon angioplasty and stenting, has emerged as a less invasive alternative to open surgical bypass, with favorable short- and intermediate-term outcomes (7,8) . In this case, the use of a self-expanding stent provided effective luminal scaffolding, accommodating the dynamic nature of the aorta while restoring adequate renal perfusion.

The clinical success of this case is highlighted by the significant reduction in blood pressure levels and the decreased requirement for antihypertensive medications. Transitioning from four antihypertensives with poor control to two medications with satisfactory blood pressure represents a substantial therapeutic achievement. This improvement underscores the importance of recognizing renovascular components in resistant hypertension, particularly in patients with underlying large-vessel vasculitis.

This case exemplifies the value of a multidisciplinary approach and timely endovascular intervention in appropriately selected patients with Takayasu arteritis. Aortic stenting, when performed during the quiescent phase of the disease, can lead to dramatic clinical improvement and enhanced patient outcomes.

Continued follow-up is essential to monitor long-term stent patency and detect potential recurrence or progression of disease. Nonetheless, the immediate and short-term results in this patient clearly demonstrate procedural and clinical success, making this case a significant and educational contribution to interventional case records.

References

1. 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. Circulation. 2012;125(6):813–819.

2. Tyagi S, Verma PK, Gambhir DS, Kaul UA, Saha R, Arora R. Early and long-term results of balloon angioplasty and stenting in Takayasu arteritis. Am J Cardiol. 1998;82(12):1533–1537.

3. Lee BB, Laredo J, Neville R, Villavicencio JL. Endovascular management of Takayasu arteritis: is it a durable option? J Vasc Surg. 2004;39(4):799–805.

4. Park MC, Lee SW, Park YB, Chung NS, Lee SK. Clinical characteristics and outcomes of Takayasu arteritis: analysis of 108 patients using standardized criteria. Arthritis Rheum. 2005;52(2):599–605.

5. Johnston SL, Lock RJ, Gompels MM. Takayasu arteritis: a review. J Clin Pathol. 2002;55(7):481–486.

6. Keser G, Aksu K, Direskeneli H. Takayasu arteritis: an update. Curr Opin Rheumatol. 2018;30(1):51–56.

7. Moriwaki R, Noda M, Yajima M, Sharma BK, Numano F. Clinical manifestations of Takayasu arteritis in India and Japan—new classification of angiographic findings. Angiology. 1997;48(5):369–379.

8. Tso E, Flamm SD, White RD, Schvartzman PR, Mascha EJ, Hoffman GS. Takayasu arteritis: utility and limitations of magnetic resonance imaging in diagnosis and treatment. Arthritis Rheum. 2002;46(6):1634–1642.

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