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Background: Imaging recommendations for primary large vessel vasculitis (LVV) were developed in 2018. Several new studies have emerged since then, and an update of the original statements was required.
Objectives: To update the recommendations for the use of imaging in LVV.
Methods: A systematic literature review update was performed to retrieve new evidence on ultrasound (US), magnetic resonance imaging (MRI), computed tomography (CT) and [18F]-fluorodeoxyglucose positron emission tomography (FDG-PET) for diagnosis, monitoring and outcome prediction in LVV. The task force consisted of 24 physicians, health professionals and patients from 14 countries.
Results: Three overarching principles and eight recommendations were agreed (Table 1). Compared to the 2018 version, US is now recommended as first line imaging test in all patients with suspected GCA, and axillary arteries should be included in the standard examination. As an alternative to US, cranial and extracranial arteries can be examined by FDG-PET or MRI. For Takayasu arteritis, MRI is the preferred imaging modality; CT or FDG-PET are alternatives. Although imaging is not routinely recommended for follow-up, US, FDG-PET or MRI may be used for assessing vessel abnormalities in LVV patients with suspected relapse, particularly when laboratory markers of inflammation are unreliable. MRA, CTA or US may be used for long-term monitoring of structural damage, particularly at sites of preceding vascular inflammation.
Conclusion: The 2023 recommendations provide up-to-date guidance for the role of imaging in the diagnosis and assessment of patients with (suspected) LVV.
Recommendations for the use of imaging in large vessel vasculitis in clinical practice
| Overarching principles |
|---|
| A. In patients with suspected GCA, an early imaging test is recommended to support the clinical diagnosis of GCA, assuming high expertise and prompt availability of the imaging technique. Imaging should not delay initiation of treatment. |
| B. Imaging examination should be done by a trained specialist using appropriate equipment, standardized operational procedures and settings. |
| C. In patients in whom there is a high clinical suspicion of GCA and a positive imaging result, the diagnosis of GCA may be made without an additional test (biopsy or further imaging). In patients with a low clinical probability and a negative imaging result, the diagnosis of GCA can be considered unlikely. In all other situations (including the case of an inconclusive imaging result), additional efforts towards a diagnosis are necessary. |
| Recommendations |
| 1. Ultrasound of temporal and axillary arteries should be considered as the first imaging modality to investigate mural inflammatory changes in patients with suspected GCA. |
| 2. High resolution MRI or FDG-PET can be used as alternatives to ultrasound for the assessment of cranial arteries in patients with suspected GCA. |
| 3. FDG-PET, alternatively MRI or CT, can be used for the detection of mural inflammation or luminal changes of extracranial arteries in patients with suspected GCA. |
| 4. In patients with suspected TAK, MRI to investigate mural inflammation or luminal changes should be used as the first imaging test to make a diagnosis of TAK. |
| 5. FDG-PET, CT or ultrasound may be used as alternative imaging modalities in patients with suspected TAK. Ultrasound is of limited value for assessment of the thoracic aorta. |
| 6. Conventional angiography is not recommended for the diagnosis of GCA or TAK as it has been superseded by the previously mentioned imaging modalities. |
| 7. In case of a suspected relapse of GCA or TAK, particularly when laboratory markers of disease activity are unreliable, ultrasound, FDG-PET or alternatively MRI may be considered for the assessment of vessel abnormalities. Imaging is not routinely recommended for patients in clinical and biochemical remission. |
| 8. In patients with GCA or TAK, MRA, CTA or ultrasound of extracranial vessels may be used for long-term monitoring of structural damage, particularly at sites of preceding vascular inflammation. The frequency of screening as well as the imaging method applied should be decided on an individual basis. |
REFERENCES:
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Acknowledgments: Funding provided by EULAR (Project number: QoC13). We would like to thank Louise Falzon for her help with the literature search strategy. We also thank Lorna Neill, Luca Cimino and Fabrizio Gozzi for their help with the update of the PICO questions.
Disclosure of Interests: Christian Dejaco Consultant of: AbbVie, Novartis, Janssen, Sanofi, Speakers bureau: Abbvie, Eli Lilly, Janssen, Novartis, Pfizer, Roche, Galapagos and Sanofi, Grant/research support from: AbbVie, Sofia Ramiro Consultant of: AbbVie, Eli Lilly, Galapagos, MSD, Novartis, Pfizer, Sanofi, UCB, Speakers bureau: AbbVie, Eli Lilly, Galapagos, MSD, Novartis, Pfizer, Sanofi, UCB, Grant/research support from: AbbVie, Eli Lilly, Galapagos, MSD, Novartis, Pfizer, Sanofi, UCB, Milena Bond Consultant of: AbbVie, Philipp Bosch Speakers bureau: Janssen, Grant/research support from: Pfizer, Cristina Ponte Consultant of: AbbVie, Sanofi, Novartis, Vifor, AstraZeneca, GlaxoSmithKline, and Roche, Speakers bureau: Vifor, AstraZeneca, GlaxoSmithKline, and Roche, Sarah Mackie Consultant of: Roche/Chugai, Sanofi, AbbVie, AstraZeneca, Sanofi, GSK, Sparrow, Speakers bureau: Roche/Chugai, Vifor, Pfizer and Novartis, Torsten Bley Consultant of: BioTel Research, Chugai, Guerbet, Novartis, Roche and Siemens Healthineers, Speakers bureau: BioTel Research, Chugai, Guerbet, Novartis, Roche, Sanofi and Siemens Healthineers, Daniel Blockmans Consultant of: Roche and GSK, Sara Brolin Grant/research support from: Novartis, Ertugrul Cagri Bolek: None declared, Rebecca Cassie: None declared, Maria C. Cid Consultant of: GSK, SCL-Vifor, AbbVie, AstraZeneca and Janssen, Grant/research support from: Kiniksa Pharmaceuticals, Juan Molina Collada Consultant of: Abbvie, Lilly, Janssen, Novartis, Pfizer, UCB, MSD, Speakers bureau: Abbvie, Lilly, Janssen, Novartis, Pfizer, UCB, MSD, Bhaskar Dasgupta Consultant of: Novartis, Abbvie,Roche,Chugai,Sanofi, Grant/research support from: Novartis, Abbvie,Roche,Chugai,Sanofi, Berit Dalsgaard NIelsen Consultant of: Roche and Novartis, Speakers bureau: Roche and Novartis, Eugenio de Miguel Consultant of: Novartis, AbbVie, Pfizer, Janssen, Lilly, Speakers bureau: Abbvie, Novartis, Pfizer, Roche, Janssen, Lilly, MSD, BMS, UCB, Grunental and Sanofi, Grant/research support from: Novartis, AbbVie, Pfizer, Janssen, Lilly, Haner Direskeneli Consultant of: Abbvie and Novartis, Grant/research support from: Pfizer, Amgene, Celltrion, UCB and Roche, Christina Duftner Consultant of: Abbvie, AOP Orphan, Astra-Zeneca, Bristol-Myers-Squibb, Eli-Lilly, Janssen, Galapagos, Merck-Sharp-Dohme, Novartis, Pfizer, Roche, Sandoz, UCB, Vifor, Speakers bureau: Abbvie, AOP Orphan, Astra-Zeneca, Bristol-Myers-Squibb, Eli-Lilly, Janssen, Galapagos, Merck-Sharp-Dohme, Novartis, Pfizer, Roche, Sandoz, UCB, Vifor, Grant/research support from: Eli-Lilly, Pfizer, UCB, ALOJZIJA HOCEVAR: None declared, Anna Moltó Consultant of: AbbVie, BMS, Biogen, Eli Lilly, Galapagos, Janssen, MSD, Novartis, and UCB, Grant/research support from: AbbVie, BMS, Biogen, Eli Lilly, Galapagos, Janssen, MSD, Novartis, and UCB, Valentin Schäfer: None declared, Luca Seitz Grant/research support from: iQone and Sandoz, Riemer Slart Grant/research support from: Siemens Healtineers and Pfizer, Wolfgang Schmidt Consultant of: Abbvie, Chugai, GlaxoSmithKline, Medac, Novartis, Roche, and Sanofi, Speakers bureau: Abbvie, Chugai, GlaxoSmithKline, Medac, Novartis, Roche, and Sanofi.