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Review
Large vessels vasculopathy in systemic sclerosis
Vasculopatía de grandes vasos en la esclerosis sistémica
Beatriz Tejera Segura
Corresponding author
btejerasegura@gmail.com

Corresponding author.
, Iván Ferraz-Amaro
Servicio de Reumatología, Hospital Universitario de Canarias, Santa Cruz de Tenerife, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Systemic sclerosis &#40;SSc&#41; is a connective tissue disease characterized by excessive collagen and other extracellular matrix components deposition on different organs&#46; In general&#44; 3 components are involved in the pathogenesis of SSc&#58; vascular&#44; in which the endothelium plays a major role&#59; fibrotic&#44; fibroblasts and myofibroblasts dependent&#59; and the immune system&#44; in which lymphocytes and their mediators play a main role&#46; Somehow&#44; these 3 components are interconnected and are responsible for the disease development&#46;<a class="elsevierStyleCrossRefs" href="#bib0295"><span class="elsevierStyleSup">1&#44;2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Vascular involvement in SSc is a challenge for clinicians due to its high morbidity and mortality and the lack of effective treatment options when vasculopathy is present&#46; It is important to distinguish the concept of vascular disease and vasculitis&#58; vasculopathy encompasses any disease that affects a vessel&#44; while vasculitis is the inflammatory disease of a vessel due to an impaired immune system&#46; In this review we will focus primarily on two uncommon manifestations of scleroderma&#44; such as the involvement of large vessels and non-digital ulcers&#46; The rarity of large vessel involvement and the importance of a correct differential diagnosis justifies this review&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Pathogenesis of vascular involvement in systemic sclerosis</span><p id="par0015" class="elsevierStylePara elsevierViewall">Currently it is not known exactly what stimulus triggers vasculopathy in SSc&#46; It is thought that different infectious agents could be involved&#44; such as free radicals related to nitric oxide&#44; endothelial cells antibodies or cytotoxic T cells&#46; The point is that&#44; from a <span class="elsevierStyleItalic">precipitating factor</span> a series of processes that result in changes that start in microcirculation and eventually end up in fibrosis are activated&#46;<a class="elsevierStyleCrossRefs" href="#bib0295"><span class="elsevierStyleSup">1&#8211;3</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">This series of alterations can be summarized as follows&#58; microcirculation impairment&#44; endothelial dysfunction and pericyte involvement&#44; abnormal angiogenesis and vasculogenesis&#44; chronic activation of platelets and maintained vasoconstriction&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Impairment of microcirculation</span><p id="par0025" class="elsevierStylePara elsevierViewall">The earliest&#44; most frequent and severe SSc clinical manifestations&#44; with increased morbidity and mortality&#44; are the ones that result from changes in microcirculation&#46; Hair loss and altered capillary structure&#58; the basement membrane is thickened&#44; the endothelial cells of the capillary wall increase in size and there is a loss of intercellular junctions so gaps are formed&#44; vacuolization of the cytoplasm occurs and plasmalemma vesicles are lost&#46; Parallel to all this process&#44; intimal proliferation occurs by accumulation of proteoglycans in arteries and arterioles&#46;<a class="elsevierStyleCrossRefs" href="#bib0305"><span class="elsevierStyleSup">3&#8211;7</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Endothelial dysfunction and impaired pericytes</span><p id="par0030" class="elsevierStylePara elsevierViewall">Endothelial damage occurs early in the SSc&#46; Endothelial dysfunction triggers such an imbalance of vasoactive molecules that vasoconstrictors increase and vasodilators decrease&#46; Increased von Willebrand factor in plasma as well as endothelin-1 point to endothelial dysfunction indicators&#46; The increase in both results in platelet aggregation and vasoconstriction&#44; which in turn produces continuous platelet adhesion and fibrin accumulation&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">2</span></a> This contributes to an intravascular thrombus formation&#46;<a class="elsevierStyleCrossRefs" href="#bib0295"><span class="elsevierStyleSup">1&#44;8&#8211;10</span></a> On the other hand&#44; it is not clear that this process is associated to an apoptotic phenomenon affecting the endothelial cell&#44; resulting in phagocytosis by antigen presenting cells and cytotoxic T lymphocytes exposure&#46; Thus&#44; an alternative complement and coagulation pathway favouring thrombus formation would be activated&#46;<a class="elsevierStyleCrossRefs" href="#bib0340"><span class="elsevierStyleSup">10&#8211;12</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Pericytes are contractile cells that wrap around the endothelial cells of capillaries and venules&#46; They regulate vascular maturation and stabilization during angiogenesis&#46; They express <span class="elsevierStyleItalic">cytokines</span> such as the &#946; receptor of the platelet-derived growth factor and the melanoma associated antigen of high molecular weight&#46; Elevated levels of these <span class="elsevierStyleItalic">cytokines</span> have been observed in patients with SSc&#44; Raynaud&#39;s phenomenon and vascular lesions&#46; In addition&#44; pericytes can be differentiated to smooth muscle cells&#44; fibroblasts and myofibroblasts&#44; contributing to increase the thickness of the capillary&#46;<a class="elsevierStyleCrossRefs" href="#bib0355"><span class="elsevierStyleSup">13&#44;14</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Impaired angiogenesis and vasculogenesis</span><p id="par0040" class="elsevierStylePara elsevierViewall">Angiogenesis is the formation of new blood vessels from pre-existing vessels&#46; It depends on the activation&#44; proliferation and migration of endothelial cells&#46; It is caused by a stimulus that induces proteolytic enzymes that break the extracellular matrix&#46; The loss of capillaries and small vessels in scleroderma patients suggests a defect in the angiogenesis process&#44; due to the increase of proangiogenic and antiangiogenic agents&#46;<a class="elsevierStyleCrossRefs" href="#bib0295"><span class="elsevierStyleSup">1&#44;15</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Vasculogenesis is the formation of a vessel from stem cells and its role in SSc is not so clear&#46; Stem cells migrate to where there has been endothelial damage&#44; but there is no optimal differentiation mechanism for these new endothelial cells to repair the damage&#46;<a class="elsevierStyleCrossRefs" href="#bib0370"><span class="elsevierStyleSup">16&#8211;19</span></a> This fact shows that there may be a defect in these patients vasculogenesis&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Chronic platelet activation and impaired platelet aggregation</span><p id="par0050" class="elsevierStylePara elsevierViewall">A release of vasoactive agents that induce permanent vasoconstriction occurs&#46; This leads to a proliferation of intimal and smooth muscle cells and&#44; eventually&#44; fibrosis&#46;<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">20</span></a> In summary&#44; obliterative vasculopathy combined with progressive fibrosis occurs in the SSc&#46; It can affect capillaries&#44; arterioles and&#44; less frequently&#44; medium and large calibre vessels&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Clinical manifestations of vasculopathy in systemic sclerosis</span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Raynaud&#39;s phenomenon and digital ulcers</span><p id="par0055" class="elsevierStylePara elsevierViewall">The typical clinical manifestations of impaired microcirculation include Raynaud&#39;s phenomenon&#44; telangiectasia&#44; linear subungual bleeding or &#8220;splinter&#8221; haemorrhage and ulcer&#44; as the most severe manifestation&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Raynaud&#39;s phenomenon is a transient&#44; reversible vasospasm&#44; triggered by cold&#44; stress or spontaneous appearance&#46; It is characterized by three phases&#58; pallor&#44; cyanosis and hyperaemia&#46; It affects the acral areas and can be asymmetrical&#46; Its prevalence in the general population is less than 10&#37;&#44; however&#44; in patients with SSc&#44; the prevalence increases to 90&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">2</span></a> If Raynaud&#39;s phenomenon is maintained over time&#44; digital ulcer appears&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">The digital ulcer in SSc is defined as an ischaemic-necrotic lesion with loss of dermoepidermal tissue substance located in the palmar surface of the fingers&#44; distal to the proximal interphalangeal joint&#46;<a class="elsevierStyleCrossRefs" href="#bib0395"><span class="elsevierStyleSup">21&#44;22</span></a> These ulcers can be active &#40;less than 6 months&#41; or chronic &#40;more than 6 months&#41;&#46; It is essential to consider certain aspects such as edges&#44; size&#44; bed&#44; tissue exposure and the presence of subcutaneous calcinosis&#46; The most important risk factor for its development is a maintained and refractory to treatment Raynaud&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">2</span></a> In different studies with cohorts of SSc patients&#44; it has been observed that other risk factors for developing digital ulcers are&#58; male sex&#44; presence of pulmonary hypertension and&#47;or decreased diffusion&#44; diffuse type systemic scleroderma&#44; long term disease progression&#44; presence of scl-70 antibody and smoking&#46;<a class="elsevierStyleCrossRefs" href="#bib0405"><span class="elsevierStyleSup">23&#44;24</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">The association between anticardiolipin antibodies and digital ischaemia has been researched&#44; with conflicting data&#46; Herrick et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0415"><span class="elsevierStyleSup">25</span></a> found no difference in the prevalence of anticardiolipin antibodies in patients with SSc and ischaemic ulcers &#40;11&#47;31&#41; compared with those who did not present these conditions &#40;16&#47;31&#41;&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Nor did they find any differences among patients who required amputation &#40;5&#47;13&#41; and those that didn&#8217;t &#40;22&#47;55&#41;&#46; However&#44; in the Boin et al&#46;<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">26</span></a> study&#44; a positive correlation between anti-beta2-glycoprotein antibodies &#40;specifically IgA subtype&#41; and digital ischaemia was observed&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Almost 60&#37; of the patients with SSc develop an ulcer throughout their illness&#46; 30&#37; of cases correspond to ulcers with loss of soft tissue or bone and 11&#37; of cases have digital gangrene at 7 years of follow-up&#46; It is noteworthy that 25&#37; of patients with SSc have 2 or more digital ulcers in the first visit&#44; that is&#44; even before being diagnosed&#46;<a class="elsevierStyleCrossRefs" href="#bib0300"><span class="elsevierStyleSup">2&#44;27&#8211;29</span></a></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Non digital ulcers</span><p id="par0085" class="elsevierStylePara elsevierViewall">Although the prevalence of digital ulcers is well documented&#44; this is not the case with non-digital ulcers&#46; However&#44; since the last century&#44; case series highlighting the impact of these on morbidity and mortality of patients with SSc have been published&#46;<a class="elsevierStyleCrossRef" href="#bib0440"><span class="elsevierStyleSup">30</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">In the general population&#44; the most frequent causes are non-digital ulcers with venous involvement &#40;70&#37;&#41;&#44; followed by arterial &#40;15&#37;&#41; and mixed cause &#40;10&#37;&#41;&#44; for example by diabetes&#46; Instead&#44; the aetiology of non-digital ulcers in patients with SSc are mostly by arterial involvement and appear on extensor surfaces and bony prominences &#40;metacarpophalangeal joints&#44; proximal interphalangeal joints&#44; elbows&#44; ankles&#44; pretibial and forefoot regions&#41;&#46; Lower extremity ulcers are often extensive&#44; making it necessary to perform a differential diagnosis in those of vasculitic origin&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">2</span></a> Also&#44; areas where there is subcutaneous calcinosis are more likely to ulcerate&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">While vasospasm plays a fundamental role in the digital ulcers themselves&#44; in the case of non-digital ulcers&#44; repeated microtrauma is the main risk factor in areas of chronic contracture and atrophic skin&#46; Others are thinning of the skin&#44; loss of elasticity and peripheral neurological impairment that hinders tissue regeneration and repair&#44; which results in chronic ulcers&#44; making them more vulnerable to infection&#46; These ulcers respond less well to treatment with vasodilating agents compared to distal location ones&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">In a recent publication by Shanmugam et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0440"><span class="elsevierStyleSup">30</span></a> 249 cases of patients with limited and diffuse SSc were reviewed&#46; Non digital ulcer was defined as a lower extremity dermoepidermal lesion&#44; of more than 3 months&#8217; progression&#44; which has not improved despite standard treatment&#46; The prevalence of non-digital and lower limbs ulcers was 4&#37; &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>10&#41;&#46; Seven patients had bilateral ulcers and 3 unilateral&#46; Ulcer biopsy was performed in 50&#37; of cases and fibrosis stood out histologically&#46; None was compatible with vasculitis&#46; An autoimmune genetic study was requested and it was observed that patients with non-digital ulcer had heterozygous or homozygous mutation for gene <span class="elsevierStyleItalic">MTHFR-C677T</span> &#40;methylene tetrahydrofolate reductase gene&#44; enzyme involved in clotting&#41; and positive antiphospholipid antibodies &#40;without meeting the criteria for antiphospholipid syndrome&#41;&#46; However&#44; it is a study with only a few patients and would require a larger sample size to confirm this finding&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">Furthermore&#44; Youssef et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0445"><span class="elsevierStyleSup">31</span></a> compared the prevalence of large vessel involvement &#40;diagnosed by the absence of peripheral pulses in the physical examination&#44; angiography or ultrasound Doppler&#41; of 31 patients with limited SSc relative to a control group adjusted for age&#44; sex and cardiovascular risk factors&#44; observing that the prevalence of macrovascular disease was higher in the group of patients with limited SSc &#40;58&#37; versus 9&#37;&#41;&#46; However&#44; no differences were found in the prevalence of coronary and cerebrovascular disease in any of the 2 groups&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">In turn&#44; there are also cases of proximal vessel involvement in upper limbs&#44; mainly the ulnar artery&#46; Through arteriography&#44; Hasegawa et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0450"><span class="elsevierStyleSup">32</span></a> evaluated the prevalence of large vessel involvement in the upper and lower limbs in 8 patients with SSc and ulcers&#46; Macrovascular upper limb involvement was higher than the lower limbs &#40;7&#47;5&#41;&#46; The vessels affected in the upper limbs were the ulnar and radial arteries&#44; while in the lower they were the posterior tibial&#44; the arcuate and the pedia arteries&#46; The palmar and plantar arches were also affected&#46; In another study&#44;<a class="elsevierStyleCrossRef" href="#bib0455"><span class="elsevierStyleSup">33</span></a> with a larger sample size &#40;20 patients with SSc&#41;&#44; a Doppler ultrasound was performed&#44; with the ulnar artery showing a narrower arterial lumen and an increased wall thickness compared to the control group&#44; although no significant differences were found with other vessels&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">In short&#44; virtually all the vascular system of patients with SSc may be affected&#46; All the studies conducted advocate the use of angiography for the diagnosis and early revascularization&#44; if possible&#46;<a class="elsevierStyleCrossRefs" href="#bib0460"><span class="elsevierStyleSup">34&#44;35</span></a></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Arteriosclerosis and systemic sclerosis</span><p id="par0120" class="elsevierStylePara elsevierViewall">In recent years&#44; in other autoimmune diseases&#44; such as rheumatoid arthritis and systemic lupus erythematosus&#44; an increase in ischaemic macrovascular diseases has been described&#44; probably related to accelerated atherosclerosis connected to the underlying inflammation&#46; It seems that this very fact may occur in patients with SSc&#46;<a class="elsevierStyleCrossRef" href="#bib0470"><span class="elsevierStyleSup">36</span></a> Emad et al&#46;<a class="elsevierStyleCrossRef" href="#bib0475"><span class="elsevierStyleSup">37</span></a> described that out of 22 scleroderma patients who underwent CT angiography&#44; 3 of them showed subclavian artery involvement&#44; 5 brachial artery involvement and 4 radial artery involvement&#46; Radiographic abnormalities appear to be of different types&#44; including vascular attenuation patterns&#44; intimal irregularities of the vessels or focal and proximal occlusions&#46; No angiographic differences were found in this report in connection with limited or diffuse SSc&#46; The only clinical manifestation of the disease that showed association with these vascular changes was pulmonary hypertension&#44; however&#44; this is not described when the origin of these changes is arteriosclerotic&#44; inflammatory&#44; vasculitic or otherwise&#46; Park et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0480"><span class="elsevierStyleSup">38</span></a> retrospectively describe the findings observed in the ulnar artery by arteriography&#46; The authors observed that the artery involvement by angiography was frequent and note that although they have no etiopathogenic explanation for these changes&#44; patients with pathological angiograms did not differ in respect to cardiovascular risk factors compared to those without them&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">Both morphological and endothelial dysfunction ultrasound studies after an ischaemic stimulus also confirm the presence of macrovascular disease in SSc&#46; In this regard&#44; Rosato et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0485"><span class="elsevierStyleSup">39</span></a> describe ultrasound palmar artery pathological patterns in 36 patients with SSc compared with 20 controls&#46; However&#44; this involvement was not related to the presence of digital ulcers&#46; Bartoli et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0490"><span class="elsevierStyleSup">40</span></a> described a greater brachial endothelial dysfunction after ischaemic stimulus and a larger carotid intima-media thickness in 35 SSc patients compared to controls&#46; This difference remained statistically significant when adjusted for traditional cardiovascular risk factors&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Also&#44; using an ultrasound method that determines vascular elasticity coupled to a walk test in patients with SSc&#44; significantly poorer carotid &#8220;biomechanical&#8221; properties have been described&#46;<a class="elsevierStyleCrossRef" href="#bib0495"><span class="elsevierStyleSup">41</span></a> The evidence seems to be maintained when other indirect methods of macrovascular disease are used&#44; such as the ankle-brachial index&#46; Thus&#44; Zeng et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0500"><span class="elsevierStyleSup">42</span></a> in a series of 48 patients with SSc&#44; describe a higher prevalence of pathologic ankle-brachial index when compared with 46 controls without disease&#46; Also Ho et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0505"><span class="elsevierStyleSup">43</span></a> show a higher prevalence of macrovascular disease using this indirect method in 54 patients with SSc and 43 controls&#46; In the latter study&#44; a carotid ultrasound was also performed to measure the intima-media thickness with a statistically significant relationship for increased subclinical carotid atherosclerosis in patients with SSc&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">On the other hand&#44; it seems that patients with SSc have a higher prevalence of intermittent claudication&#46; Thus&#44; in a study using the WHO-Rose questionnaire to measure arterial disease of the lower limbs&#44; its presence was observed in 53 patients with SSc compared to 43 controls&#44;<a class="elsevierStyleCrossRef" href="#bib0510"><span class="elsevierStyleSup">44</span></a> recommending the screening of intermittent claudication in cases of SSc&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">We only found two studies in the literature that do not support the presence of atherosclerotic macrovascular disease in SSc&#46; The first one<a class="elsevierStyleCrossRef" href="#bib0515"><span class="elsevierStyleSup">45</span></a> is a cross-sectional study in which carotid ultrasound was used to measure the intima-media thickness in 49 scleroderma patients and 32 controls&#59; the second&#44;<a class="elsevierStyleCrossRef" href="#bib0520"><span class="elsevierStyleSup">46</span></a> also a cross-sectional study in which the brachial dilation by ischaemic stimulus was determined for 36 patients with primary Raynaud&#39;s phenomenon&#44; 42 scleroderma patients and 33 controls&#46; In both studies&#44; a higher prevalence of macrovascular disease was found even after performing a multivariate analysis adjusted for classic cardiovascular risk factors&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Vasculitis</span><p id="par0145" class="elsevierStylePara elsevierViewall">The involvement of large vessels can also result from a systemic vasculitis&#46; The differential diagnosis between vascular disease and vasculitis poses a diagnostic challenge if there is no histological study&#46; Vasculitis in SSc is rare but not unlikely&#46; In 58 autopsies performed to patients with SSc&#44; vascular disease was observed in 24&#37; versus 9&#37; of vasculitis&#44; but vascular disease coexisted with vasculitis in 5 out of 8 tissue biopsies corresponding to a digital amputation&#46;<a class="elsevierStyleCrossRefs" href="#bib0525"><span class="elsevierStyleSup">47&#44;48</span></a> Kao and Weyand<a class="elsevierStyleCrossRef" href="#bib0535"><span class="elsevierStyleSup">49</span></a> describe various types of vasculitis associated with SSc&#46; The most common is the ANCA-positive vasculitis&#44; particularly with perinuclear fluorescein pattern &#40;p-ANCA&#41;&#46; The following is a summary of the most important aspects&#46;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">&#40;a&#41;</span><p id="par0150" class="elsevierStylePara elsevierViewall">Temporal arteritis and Takayasu vasculitis&#46;</p></li></ul></p><p id="par0155" class="elsevierStylePara elsevierViewall">3 cases of temporal arteritis have been described in women with an average age of 60 and limited SSc&#46; The clinical manifestations were the typical ones for this disease&#44; except for a case that developed a lower extremity ulcer and normal erythrocyte sedimentation rate&#46; A temporal artery biopsy was performed in all cases&#44; confirming the diagnosis&#46; Glucocorticoids were used as treatment and the outcome was favourable&#46;<a class="elsevierStyleCrossRef" href="#bib0535"><span class="elsevierStyleSup">49</span></a></p><p id="par0160" class="elsevierStylePara elsevierViewall">Takayasu vasculitis was described in 4 patients with diffuse and limited SSc&#46; The presentation was similar to that of the general population with the exception of 2 cases&#44; where age of presentation was over 40&#46; There was no biopsy&#44; so the question remains whether it was a Takayasu vasculitis or vascular involvement in SSc&#46; The authors do not provide any data on the treatment used&#46;<a class="elsevierStyleCrossRef" href="#bib0535"><span class="elsevierStyleSup">49</span></a><ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">&#40;b&#41;</span><p id="par0165" class="elsevierStylePara elsevierViewall">Vasculitis of medium and small vessel&#46;</p></li></ul></p><p id="par0170" class="elsevierStylePara elsevierViewall">Polyarteritis nodosa manifested in a patient with diffuse SSc in the form of nodular lesions in the lower limbs&#46; The patient had no constitutional syndrome characteristic of polyarteritis nodosa nor involvement of other organs or multiple mononeuritis&#46; Vasculitis was confirmed by histological study&#46; Methotrexate treatment was used subcutaneously &#40;dose of 20 <span class="elsevierStyleHsp" style=""></span>mg&#47;wk&#41; and glucocorticoids&#46; The progression was favourable&#46; There are 4 other cases of polyarteritis nodosa in medical literature whose initial manifestation was multiple mononeuritis<a class="elsevierStyleCrossRefs" href="#bib0540"><span class="elsevierStyleSup">50&#8211;52</span></a> and one case also associated with Sj&#246;gren&#39;s syndrome&#46;<a class="elsevierStyleCrossRef" href="#bib0550"><span class="elsevierStyleSup">52</span></a></p><p id="par0175" class="elsevierStylePara elsevierViewall">There are also cases CNS vasculitis and mixed cryoglobulinemia&#46;<a class="elsevierStyleCrossRefs" href="#bib0535"><span class="elsevierStyleSup">49&#44;53&#44;54</span></a></p><p id="par0180" class="elsevierStylePara elsevierViewall">ANCA-positive vasculitis is the most common by far&#44; p-ANCA vasculitis to be more precise&#46; Of the 88 cases of vasculitis described in the article by Kao and Weyand&#44;<a class="elsevierStyleCrossRef" href="#bib0535"><span class="elsevierStyleSup">49</span></a> 74 correspond to p-ANCA vasculitis&#44; specific for the myeloperoxidase antigen&#46; This vasculitis was observed in both the diffuse SSc as well as the limited&#44; though it was more prevalent in the first&#46; Renal involvement in the form of glomerulonephritis was the most common form of presentation&#46; In recent years&#44; cases of vasculitis of medium and small vessel associated with SSc have been reported&#44;<a class="elsevierStyleCrossRefs" href="#bib0560"><span class="elsevierStyleSup">54&#8211;56</span></a> which stresses the importance of taking their diagnosis into account in the case of these patients&#46;</p></span></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Conclusions</span><p id="par0185" class="elsevierStylePara elsevierViewall">Macrovascular disease in the SSc may have a severe outcome unless it is diagnosed early&#46; It is essential to conduct a thorough case history emphasizing the presence of cardiovascular risk factors and symptoms and&#47;or signs suggestive of vasculopathy or vasculitis&#46; On physical examination&#44; all peripheral pulses should be palpated&#44; performing the Allen&#44; the Adson and the hyperabduction tests&#44; which will help in assessing the patency of the radial and ulnar artery and the presence of vascular or neural compression&#46; Doppler ultrasound and angiography will help in determining the degree of vascular involvement and&#44; if possible&#44; revascularization by angioplasty&#46; Lab tests with screening for vasculitis are also necessary&#44; and if in doubt&#44; a tissue biopsy is a choice procedure to reach a definitive diagnosis&#46; The diagnosis of one or the other is as complicated as essential&#44; as the therapeutic approach is far from similar&#46; Treatment depends on the degree of vascular involvement and the cause behind it&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">In the case of digital ulcers&#44; non-pharmacological and pharmacological measures &#40;antiplatelet and vasodilator agents&#41; should be taken into account&#46;<a class="elsevierStyleCrossRef" href="#bib0575"><span class="elsevierStyleSup">57</span></a> Non-digital ulcers are often refractory to conventional treatment and very painful&#44; so the analgesic treatment should be adequate and revascularization should always be considered as first choice in these patients&#46; Surgical sympathectomy could be an alternative when revascularization is not possible&#44; although not always effective&#46;<a class="elsevierStyleCrossRef" href="#bib0580"><span class="elsevierStyleSup">58</span></a> Antibiotic treatment of superinfected lesions to prevent osteomyelitis and sepsis is also paramount&#46; If there is an underlying vasculitis&#44; this should be treated urgently to prevent a fatal outcome&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">SSc is a rare disease among the connective tissue diseases and this complicates conducting clinical trials&#44; and therefore&#44; researching the pathogenesis of vascular involvement and developing new therapies&#46; It is important to know each and every one of the different manifestations of macrovascular disease&#44; as these may vary in each patient&#44; hindering diagnosis and early treatment&#46; However&#44; with what has been published so far&#44; there is enough data to enable us to approach the correct diagnosis&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conflict of interests</span><p id="par0200" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interest&#46;</p></span></span>"
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          "identificador" => "xres632579"
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          "identificador" => "sec0005"
          "titulo" => "Introduction"
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          "identificador" => "sec0010"
          "titulo" => "Pathogenesis of vascular involvement in systemic sclerosis"
          "secciones" => array:4 [
            0 => array:2 [
              "identificador" => "sec0015"
              "titulo" => "Impairment of microcirculation"
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            1 => array:2 [
              "identificador" => "sec0020"
              "titulo" => "Endothelial dysfunction and impaired pericytes"
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            2 => array:2 [
              "identificador" => "sec0025"
              "titulo" => "Impaired angiogenesis and vasculogenesis"
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            3 => array:2 [
              "identificador" => "sec0030"
              "titulo" => "Chronic platelet activation and impaired platelet aggregation"
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        6 => array:3 [
          "identificador" => "sec0035"
          "titulo" => "Clinical manifestations of vasculopathy in systemic sclerosis"
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              "identificador" => "sec0040"
              "titulo" => "Raynaud&#39;s phenomenon and digital ulcers"
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            1 => array:2 [
              "identificador" => "sec0045"
              "titulo" => "Non digital ulcers"
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            2 => array:2 [
              "identificador" => "sec0050"
              "titulo" => "Arteriosclerosis and systemic sclerosis"
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            3 => array:2 [
              "identificador" => "sec0055"
              "titulo" => "Vasculitis"
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        7 => array:2 [
          "identificador" => "sec0060"
          "titulo" => "Conclusions"
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          "titulo" => "Conflict of interests"
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          "titulo" => "References"
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    "fechaRecibido" => "2014-09-30"
    "fechaAceptado" => "2014-12-11"
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          "clase" => "keyword"
          "titulo" => "Keywords"
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            0 => "Systemic sclerosis"
            1 => "Vasculopathy"
            2 => "Large vessels"
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        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
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          "palabras" => array:3 [
            0 => "Esclerosis sist&#233;mica"
            1 => "Vasculopat&#237;a"
            2 => "Gran vaso"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Vasculopathy in systemic sclerosis is a severe&#44; in many cases irreversible&#44; manifestation that can lead to amputation&#46; While the classical clinical manifestations of the disease have to do with the involvement of microcirculation&#44; proximal vessels of upper and lower limbs can also be affected&#46; This involvement of large vessels may be related to systemic sclerosis&#44; vasculitis or atherosclerotic&#44; and the differential diagnosis is not easy&#46; To conduct a proper and early diagnosis&#44; it is essential to start prompt appropriate treatment&#46; In this review&#44; we examine the involvement of large vessels in scleroderma&#44; an understudied manifestation with important prognostic and therapeutic implications&#46;</p></span>"
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        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La vasculopat&#237;a en la esclerosis sist&#233;mica es una manifestaci&#243;n grave&#44; y en muchas ocasiones irreversible&#44; que puede llevar a la amputaci&#243;n&#46; Si bien las manifestaciones cl&#237;nicas cl&#225;sicas de la enfermedad tienen que ver con la afectaci&#243;n de la microcirculaci&#243;n&#44; tambi&#233;n los vasos proximales de extremidades superiores e inferiores pueden afectarse&#46; Esta afectaci&#243;n de grandes vasos puede tener un origen relacionado con la esclerosis sist&#233;mica&#44; vascul&#237;tico o arterioscler&#243;tico por lo que llegar al diagn&#243;stico no es f&#225;cil pero s&#237; fundamental para empezar cuanto antes un tratamiento adecuado&#46; En esta revisi&#243;n repasamos la afectaci&#243;n de los grandes vasos en la esclerosis sist&#233;mica&#44; manifestaci&#243;n poco estudiada y con importantes repercusiones pron&#243;sticas y terap&#233;uticas&#46;</p></span>"
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        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Tejera Segura B&#44; Ferraz-Amaro I&#46; Vasculopat&#237;a de grandes vasos en la esclerosis sist&#233;mica&#46; Med Clin &#40;Barc&#41;&#46; 2015&#59;145&#58;488&#8211;492&#46;</p>"
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                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
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                    0 => array:2 [
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                      "titulo" => "Raynaud&#44; &#250;lceras digitales y calcinosis en esclerodermia"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
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                            0 => "A&#46; Nitsche"
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            2 => array:3 [
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              "etiqueta" => "3"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Vascular disease in scleroderma&#58; mechanisms of vascular injury"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
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                            0 => "B&#46; Kahaleh"
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                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.rdc.2007.12.004"
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            3 => array:3 [
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              "etiqueta" => "4"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Sequential dermal microvascular and perivascular changes in the development of scleroderma"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "R&#46;J&#46; Prescott"
                            1 => "A&#46;J&#46; Freemont"
                            2 => "C&#46;J&#46; Jones"
                            3 => "J&#46; Hoyland"
                            4 => "P&#46; Fielding"
                          ]
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es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

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