How is a temporal artery biopsy (TAB) performed in the workup of giant cell arteritis (GCA) (temporal arteritis)?

Updated: Sep 03, 2020
  • Author: Mythili Seetharaman, MD; Chief Editor: Herbert S Diamond, MD  more...
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Answer

TAB may be performed by ophthalmologists, general surgeons, head and neck surgeons, plastic or vascular surgeons, or dermatologic surgeons. The frontal branch of the superficial temporal artery is preoperatively identified by visualization, palpation, or Doppler ultrasonography and then marked with a pen or with dye. In approximately 16% of cases, the frontal branch is atrophic or absent, in which case a biopsy should be performed on the main trunk of the superficial temporal artery using a preauricular approach. [131]

To improve the yield and to avoid complications, proper site selection is important. Focal symptoms or signs, such as erythema, tenderness, absent pulsations, arterial nodularity or swelling, inflammation, bruit, or thickening, help guide biopsy site selection and may improve the yield of the biopsy.

Localizing findings are often absent or misleading, however; frequently, the physical examination findings correlate poorly with the biopsy results. In the absence of localized arterial findings, the zone between the tragus of the ear and the lateral canthus is usually not biopsied, to avoid damage to the temporal branch of the facial nerve. Knowledge of the anatomy and careful dissection above and within the superficial temporal fascia help prevent nerve damage during the procedure.

A small area of hair may have to be shaved. It is essential to accurately mark the location of the artery with a marking pen prior to any local anesthetic administration. If there is concern that the vessel markings will be obscured by the prep solution, the vessel location can be scratched with a needle tip prior to the antiseptic scrub. [132]

In patients with a readily visible or palpable artery, epinephrine can be included with the initial local anesthetic injection. If the artery is difficult to visualize or palpate, avoid epinephrine in the local anesthetic until after the vessel is visualized subcutaneously. Local anesthetic is administered approximately 1 cm from either side of the vessel but not into the vessel.

With the site selected and the patient under local anesthesia, a shallow incision just into the underlying fat is made directly over the artery. The artery is bluntly dissected free from within the superficial temporal fascia. To avoid nerve injury, it is important to undermine just below the dermis in the superficial fat and above the superficial fascia. [133]

A segment of artery is ligated proximally and distally, removed, and sent for histopathologic review. Hemostasis is obtained with electrocoagulation, and a layered closure is performed.

Traditionally, excision of 2-3 cm of artery is recommended to provide accurate diagnosis of temporal arteritis because some studies have noted higher positive rates with longer specimens. Temporal arteritis may have a patchy distribution among extracranial arteries and within small segments of these arteries. In general, longer biopsy specimens provide more tissue in which to demonstrate short, noncontiguous foci of giant cell arteritis, the so-called skip areas.

Skip areas are not commonly identified, but patches of arteritis as short as 0.29 mm have been clearly demonstrated on serial sectioning. Serial sectioning, proper tissue handling, and adequate specimen length are critical to ensure maximum yield from the biopsy. Surgeons should be aware that fixation results in shrinkage of the biopsy specimen. [134]


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