OBJECTIVES
To compare limited, to a more extended ultrasound examination (anteromedial ultrasound, A2-ultrasound) to detect large vessels (LV) involvement in patients with newly diagnosed giant cell arteritis (GCA).


METHODS
Patients with new-onset GCA were included at the time of diagnosis. All patients were examined using limited ultrasound (ultrasound of the axillary artery as visualized in the axilla), and extended A2-ultrasound method (which also includes the carotid, vertebral, subclavian, and proximal axillary arteries), in addition to the temporal artery ultrasound.


RESULTS
One hundred and thirty-three patients were included in the study. All patients fulfilled the criteria according to a proposed extension of the 1990 American College of Rheumatology (ACR) classification criteria for GCA and had a positive ultrasound examination at diagnosis. Ninety-three of the 133 GCA patients (70,0%) had LV involvement when examined by extended A2-ultrasound, compared with only 56 patients (42,1%) by limited ultrasound (p< 0,001). Twelve patients (9.0%) had vasculitis of the vertebral arteries as the only LV involved. Five patients (3,8%) would have been missed as having GCA if only limited ultrasound was performed. Forty patients (30,0%) had isolated cranial GCA (c-GCA), 21 patients (15,8%) had isolated large vessel GCA (LV-GCA), and 72 patients (54,1%) had mixed-GCA.


CONCLUSION
Extended A2-ultrasound examination, identified more patients with LV involvement than limited ultrasound method. However, extended A2-ultrasound requires high expertise and high-end equipment and should be performed by ultrasonographers with adequate training.

Extended ultrasound examination identifies more large vessel involvement in patients with giant cell arteritis.

Takayasu arteritis (TAK) is a less common large vessel vasculitis where histopathology of involved arteries is difficult to access except during open surgical procedures. Assessment of disease activity in TAK, therefore, relies on surrogate measures. Clinical disease activity measures such as the National Institutes of Health (NIH) score, the Disease Extent Index in TAK (DEI.TAK) and the Indian TAK Clinical Activity Score (ITAS2010) inconsistently associate with acute phase reactants (APRs). Computerized tomographic angiography (CTA), magnetic resonance angiography (MRA), or color Doppler Ultrasound (CDUS) enables anatomical characterization of stenosis, dilatation, and vessel wall characteristics. Vascular wall uptake of 18-fluorodeoxyglucose or other ligands using positron emission tomography computerized tomography (PET-CT) helps assess metabolic activity, which reflects disease activity well in a subset of TAK with normal APRs. Angiographic scoring systems to quantitate the extent of vascular involvement in TAK have been developed recently. Erythrocyte sedimentation rate and C-reactive protein have a moderate performance in distinguishing active TAK. Numerous novel biomarkers are under evaluation in TAK. Limited literature suggests a better assessment of active disease by combining APRs, PET-CT, and circulating biomarkers. Validated damage indices and patient-reported outcome measures specific to TAK are lacking. Few biomarkers have been evaluated to reflect vascular damage in TAK and constitute important research agenda.

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Outcome Measures and Biomarkers for Disease Assessment in Takayasu Arteritis

We have read with great interest the observation of Dasgupta et al. 1 We would like to propose an extended definition of slope sign in giant cell arteritis (GCA) formerly named slide sign,2,3 and present our method of assessing it by using the anteromedial ultrasound examination method of the large supraaortic vessels.4

Slope sign is a pathologically increased intima-media thickness (IMT)5 that spreads over a long arterial segment and slides down to a normal brachial artery where a normal intima-media structure (double line) is observed. This definition contains a description of pathological findings in the axillary artery—a typical location for vasculitis in GCA, contrasting with normal findings in brachial artery—which is usually not involved by vasculitis.6 Slope sign may not be limited to the place of arterial bifurcation of the subscapular artery, which is a typical location of atherosclerotic plaque. A transition zone …

https://ard.bmj.com/content/annrheumdis/early/2019/11/27/annrheumdis-2019-216601.full.pdf

Correspondence to 'Slope sign': a feature of large vessel vasculitis?

GCA is the most common large vessel vasculitis in the elderly population. In recent years, advanced imaging has changed the way GCA can be diagnosed in many locations. The GCA fast-track clinic approach combined with US examination allows prompt treatment and diagnosis with high certainty. Fast-track clinics have been shown to improve prognosis while being cost effective. However, all diagnostic modalities are highly operator dependent, and in many locations expertise in advanced imaging may not be available. In this paper, we review the current evidence on GCA diagnostics and propose a simple algorithm for diagnosing GCA for use by rheumatologists not working in specialist centres.

Diagnosing giant cell arteritis: a comprehensive practical guide for the practicing rheumatologist

Summary Background Temporal artery biopsy is considered the diagnostic gold standard for giant cell arteritis, despite approximately 39% of patients who are negative for the condition by biopsy subsequently being given a clinical diagnosis of giant cell arteritis. We aimed to assess the diagnostic accuracy of ultrasound examination in patients with suspected giant cell arteritis. Methods In this prospective, multicentre, non-interventional, cohort study (evaluation of ultrasound's role in patients suspected of having extracranial and cranial giant cell arteritis; EUREKA), we consecutively recruited patients aged 50 years or older, with clinically suspected giant cell arteritis from three Danish hospitals (South West Jutland Hospital in Esbjerg, Silkeborg Regional Hospital, and Rigshospitalet, Glostrup). Participants had a bilateral ultrasound of the temporal, facial, common carotid, and axillary arteries. Ultrasounds were done by ultrasonographers who were systematically trained in vascular ultrasound using appropriate equipment and settings. Participants then had a temporal artery biopsy within 7 days of initiation of corticosteroid treatment. A blinded ultrasound expert assessed all ultrasound images. Ultrasound vasculitis was defined in cranial arteries as a homogeneous, hypoechoic, intimamedia complex thickness and a positive compression sign and as a homogeneous intimamedia complex of 1 mm in thickness or wider in the axillary arteries and of 1·5 mm thickness or wider in the common carotid artery. Participants were followed up at 6 months. During this 6 month period, clinicians were able to collect data from all clinical examinations to enable a full clinical diagnosis at 6 months. Clinical diagnosis was based on the expert opinion of the treating rheumatologist. The diagnostic criterion standard was diagnosis confirmed after 6 months of follow-up. We used logistic regression analyses to calculate the odds ratio and 95% CI of ultrasound as a predictor for giant cell arteritis. Findings Between April 1, 2014, and July 31, 2017, 118 patients were screened for inclusion, of whom 106 had both ultrasound examinations and an eligible temporal artery biopsy and were included in the intention-to-diagnose population. The mean age was 72·7 years (SD 7·9), 63 (59%) participants were women, and 43 (41%) were men. Temporal artery biopsy was positive in 46 (43%) of 106 patients, and 62 (58%) of 106 patients had a clinically confirmed diagnosis of giant cell arteritis at 6 months (temporal artery biopsy sensitivity 74% [95% CI 62–84], specificity 100% [95% CI 92–100]). Cranial artery ultrasound was positive in all patients who had a positive temporal artery biopsy, and seven (58%) of 12 patients who were positive by ultrasound and negative by temporal artery biopsy were confirmed to have large-vessel giant cell arteritis via other imaging methods. The sensitivity of ultrasound diagnosis of giant cell arteritis was 94% (84–98) and specificity was 84% (70–93). Logistic regression analysis confirmed that ultrasound was the strongest baseline predictor for a clinically confirmed diagnosis of giant cell arteritis at 6 months (crude odds ratio 76·6 [95% CI 21·0–280·0]; adjusted for sex and age 141·0 [27·0–743·0]). Interpretation Vascular ultrasound might effectively replace temporal artery biopsy as a first-line diagnostic method in patients suspected of having giant cell arteritis when done by systematically trained ultrasonographers using appropriate equipment and settings. Funding The Institute for Regional Research at Hospital of Southwest Jutland, Esbjerg, Denmark.

Diagnostic accuracy of vascular ultrasound in patients with suspected giant cell arteritis (EUREKA): a prospective, multicentre, non-interventional, cohort study

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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

Giant Cell Arteritis (GCA) and Takayasu’s arteritis (TAK) involve predominantly the large vessels and may lead to ischaemic manifestations in the end organs or development of life-threatening aneurysms. GCA is mainly seen in individuals >50 years while TAK in individuals <40 years. Both diseases have a predilection for the aorta and the aortic tree, in addition, GCA involves the cranial arteries (temporal, facial, maxillary and occipital). European League against Rheumatism (EULAR) recommends ultrasound as a first-line evaluation in patients suspected to have GCA [1]. Ultrasound yields a high sensitivity and specificity in the diagnostics of GCA [2]. Ultrasound can be useful in diagnosing TAK, however, a major limitation being the non-visualization of the descending aorta (Dejaco et al. in Ann Rheum Dis. 77:636–643, 2018). Ultrasound is a highly operator-dependent modality and requires specialized skills.

Anne Bull Haaversen

Papers

Extended ultrasound examination identifies more large vessel involvement in patients with giant cell arteritis.

Correspondence to 'Slope sign': a feature of large vessel vasculitis?

Diagnosing giant cell arteritis: a comprehensive practical guide for the practicing rheumatologist

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

Ultrasound in Large Vessel Vasculitis