Management of HIV Vasculopathy – A South African Experience

Rheumatic manifestations of HIV/AIDS

Rheumatic manifestations of HIV infection encompass a wide spectrum of disorders, arising from direct viral effects, immune dysregulation, opportunistic infections, or antiretroviral therapy (ART)-induced complications. These manifestations can occur at any stage of HIV, and include arthralgia, HIV-associated arthritis, spondyloarthropathies (SpA), inflammatory myopathies, vasculitides, and opportunistic musculoskeletal infections. Arthralgia is common and self-limiting, whereas HIV-associated arthritis mimics rheumatoid arthritis. SpA, particularly reactive arthritis, psoriatic arthritis, and undifferentiated forms, often present atypically in HIV, with pathogenesis linked to immune dysfunction rather than HLA-B27. Inflammatory myopathies, including polymyositis and inclusion body myositis, exhibit distinct clinical features, often necessitating cautious immunomodulatory treatment. Opportunistic infections, such as septic arthritis and pyomyositis, are more frequent with advanced immunosuppression. The advent of HAART has modified the prevalence and presentation of these disorders, with immune reconstitution inflammatory syndrome (IRIS) emerging as a new challenge. Management strategies require balancing disease control with minimizing immunosuppressive risks.

Infection associated Vasculitides

Infections can mimic Primary Systemic Vasculitis. Many clinical features and investigations maybe very similar between the two conditions. It is very important for the clinician to be aware of the various infections which mimic vasculitis, since inadvertent immunosuppression in these patients can be fatal. Infections can mimic small, medium or large vessel vasculitis. Infections can produce autoantibodies such as Anti-neutrophil cytoplasmic antibody through molecular mimicry and could confound clinical judgement. In addition to the many infections causing vasculitis, more recently COVID-19 associated vasculitis has been described. The exact pathogenesis of infection associated vasculitis is not clear although direct spread, immune complex deposition and T/B cell activation are proposed. Infection as an etiological agent for primary systemic vasculitis has long been debated but definite evidence for the same is lacking. Many drugs used in daily clinical practice can rarely cause vasculitis. More recently Immune-check point inhibitors-induced vasculitis has been described.

HIV-Associated Pseudoaneurysms: A Comprehensive Review

A pseudoaneurysm (PSA) is a contained vascular rupture that typically occurs following catheterization, at the anastomotic site between a native artery and a synthetic graft, post-trauma, or as a result of infection. It is characterized by a hematoma surrounded by tissue, often emerging as a complication of invasive arterial interventions. In patients with HIV/AIDS, PSAs can develop due to vessel wall disruption caused by chronic inflammation, opportunistic infections (such as cytomegalovirus or tuberculosis), or the direct effects of the virus, leading to abnormal blood flow into a chamber confined by adjacent tissue. The clinical presentation of PSAs varies based on their size and location. Diagnosis can be achieved through ultrasonography with color Doppler, contrast-enhanced computed tomography (CT), magnetic resonance angiography (MRA), or digital subtraction angiography (DSA). Treatment modalities include surgery, ultrasound-guided compression, thrombin injection, and endovascular techniques. This review discusses the pathophysiology, histology, diagnosis, and therapeutic options for HIV-related PSAs. Additionally, risk factors and rare complications associated with PSAs are explored in detail.

Epidemiology of Non-Traumatic Lower Extremities Amputations in West Africa: Nationwide Data from Togo

OBJECTIVE

Non-traumatic lower limb amputation (NT-LLA) has consequences at individual and public health levels. Population based studies in sub-Saharan Africa are scarce and often related to single centre series. This study aimed to estimate the incidence of NT-LLA (minor and major) and to describe epidemiological, clinical, and prognostic aspects in Togo.

METHODS

This was a population based observational study conducted among all patients who underwent NT-LLA. Traumatic amputations were excluded. Sociodemographic, clinical, and work up data were collected from clinical files in any Togolese health centre from 1 January 2016 to 31 December 2021. Incidence rates were adjusted for age.

RESULTS

Over the six year period, 352 patients (59% males) underwent NT-LLA (mean ± standard deviation age 60 ± 15.7 years). The average age adjusted incidence rate of NT-LLA was 8.5 per million/year (95% confidence interval [CI] 7.6 - 9.4). Men were 1.7 times more likely to undergo a NT-LLA than women. The relative risk of NT-LLA was 48 times higher in patients with diabetes than in patients without diabetes. Around 61.0% of the NT-LLAs occurred within the 50 - 74 age group and 54.3% had diabetes mellitus. Among amputees, 54.5% had a diagnosis of peripheral artery disease (PAD) and 52.8% had diabetic ulcers, with co-existence of several factors. Less than 5% of participants had a history of smoking tobacco. Average length of hospital stay was 12 days. The in hospital mortality rate was 8.8% (9.0% for major, 6.7% for minor amputations). Only 18.2% had duplex ultrasound performed and 1.7% angiography prior to amputation. No patient underwent vascular intervention prior to amputation.

CONCLUSION

This is the first study to report nationwide and contemporary epidemiological data on NT-LLAs in West Africa, highlighting several specificities. Large scale interventions are needed to ameliorate the care of diabetes and PAD and improve facilities for optimal management of patients at risk of amputation in Africa.

Association of HIV infection with clinical features and outcomes of patients with aortic aneurysms

Data on the characteristics and outcomes of hospitalized patients with aortic aneurysms (AA) and HIV remain scarce. This is a cohort study of hospitalized adult patients with a diagnosis of AA from 2013 to 2019 using the US National Inpatient Readmission Database. Patients with a diagnosis of HIV were identified. Our outcomes included trends in hospitalizations and comparison of clinical characteristics, complications, and mortality in patients with AA and HIV compared to those without HIV. Among 1,905,837 hospitalized patients with AA, 4416 (0.23%) were living with HIV. There was an overall age-adjusted increase in the rate of HIV among patients hospitalized with AA over the years (14-29 per 10,000 person-years; age-adjusted p-trend < 0.001). Patients with AA and HIV were younger than those without HIV (median age: 60 vs 76 years, p < 0.001) and were less likely to have a history of smoking, hypertension, dyslipidemia, diabetes mellitus, and obesity. Thoracic aortic aneurysms were more prevalent in those with HIV (37.5% vs 26.7%, p < 0.001). On multivariable logistic regression, HIV was not associated with increased risk of aortic rupture (OR: 0.79; 95% CI: 0.61-1.01, p = 0.06), acute aortic dissection (OR: 0.73; 95% CI: 0.51-1.06, p = 0.3), readmissions (OR: 1.04; 95% CI: 0.95-1.13, p = 0.4), or aortic repair (OR: 0.89; 95% CI: 0.79-1.00, p = 0.05). Hospitalized patients with AA and HIV had a lower crude mortality rate compared to those without HIV (OR: 0.75 (0.63-0.91), p = 0.003). Hospitalized patients with AA and HIV likely constitute a distinct group of patients with AA; they are younger, have fewer traditional cardiovascular risk factors, and a higher rate of thoracic aorta involvement. Differences in clinical features may account for the lower mortality rate observed in patients with AA and HIV compared to those without HIV.

Progressive cervical tumour in an HIV-patient: giant pseudoaneurysm of the carotid artery: a case report

Background

Aneurysms of the extracranial carotid artery are a rare entity and correspond to <1% of all arterial aneurysms.

Case summary

A 58-year-old male with known human immunodeficiency virus (HIV) infection presented in the emergency department with a massive cervical tumour on the right side of the neck and a severe occipital pain. Contrast computed tomography demonstrated a pseudoaneurysm of the proximal right internal carotid artery (ICA). Open surgery of the ICA was performed with reconstruction of the posterior vessel wall, embolectomy of the ICA, and anterior pericardial patch reconstruction. After an uneventful postoperative course, the patient was readmitted 4 weeks later with a right retrobulbous haematoma caused by a carotid cavernous fistula. Therefore a coil-embolization of the fistula and finally of the distal right carotid artery was performed.

Discussion

In patients with a proven HIV infection, the occurrence of a vasculopathy in the extra- or intracranial carotid artery is significantly increased and the second most common site after the lower extremities. In patients with progredient neck swelling it should be considered in the differential. Surgical therapy is the preferred treatment strategy in the extracranial aneurysm type, especially in this patient collective.

Endovascular management of HIV vasculopathy

HIV is a multisystem disease process that can affect the cardiovascular system resulting in vasculopathy. As highly active anti-retroviral therapy has allowed patients to live longer with the disease, vascular complications such as aneurysms, occlusive disease, spontaneous arteriovenous fistulae, and arterial dissections have been described. The pathogenesis of vascular-related complications in HIV is poorly understood but is thought to involve an interplay between viral-induced inflammation, vascular smooth muscle changes, endothelial alterations, and circulating blood factors. The most well-described management strategies for symptomatic aneurysm-related complications are surgical in nature, with mostly anecdotal reports of endovascular intervention. We present a case of a 24-year-old male who was found to have findings consistent with HIV vasculopathy on angiography after presenting with acute GI hemorrhage secondary to left gastric artery bleeding. Our patient was managed with endovascular embolization. Although studies have shown promise regarding the endovascular management of HIV-related aneurysmal complications in the short term, more research is needed to evaluate the long-term success of these interventions.

Trends and Clinical Characteristics of HIV and Cerebrovascular Disease in Low- and Middle-Income Countries (LMICs) Between 1990 and 2021

PURPOSE OF THE REVIEW

To describe trends and clinical characteristics of HIV and cerebrovascular disease between 1990 and 2021 in LMICs and identify the gaps in our understanding.

RECENT FINDINGS

In the era of antiretroviral therapy (ART), people living with HIV (PLWH) live longer and risk excess cerebrovascular events due to ageing and HIV-driven factors. Despite the highest burden of HIV infection in low-to-middle income countries, there is underreporting in the literature of cerebrovascular events in this population. We systematically reviewed published literature for primary clinical studies in adult PLWH and cerebrovascular disease in LMICs. The clinical phenotype of cerebrovascular disease among PLWH over the last three decades in LMICs has evolved and transitioned to an older group with overlapping cerebrovascular risk factors. There is an important need to increase research in this population and standardise reporting to facilitate understanding, guide development of appropriate interventions, and evaluate their impact.

Mimics of vasculitis

While prompt diagnosis of vasculitis is important, recognition of vasculitis mimics is equally essential. As in the case of vasculitis, an approach to mimics based on the anatomic size of vessels can be useful. Infections can mimic vasculitis of any vessel size, including the formation of aneurysms and induction of ANCAs. Genetic disorders and vasculopathies are important considerations in large and medium vessel vasculitis. Cholesterol emboli, thrombotic conditions and calciphylaxis typically affect the medium and small vessels and, like vasculitis, can cause cutaneous, renal and CNS manifestations. Reversible cerebral vasoconstriction syndrome is important to distinguish from primary angiitis of the CNS. As an incorrect diagnosis of vasculitis can result in harmful consequences, it is imperative that the evaluation of suspected vasculitis includes consideration of mimics. We discuss the above mimics and outline a systematic and practical approach for differentiating vasculitis from its mimics.

Review of the neurological aspects of HIV infection

There are almost 40 million people in the world who live with the human immunodeficiency virus (HIV). The neurological manifestations associated with HIV contribute to significant morbidity and mortality despite the advances made with anti-retroviral therapy (ART). This review presents an approach to classification of neurological disorders in HIV, differentiating diseases due to the virus itself and those due to opportunistic infection. The effects of antiretroviral therapy are also discussed. The emphasis is on the developing world where advanced complications of HIV itself and infections such as tuberculosis (TB), toxoplasmosis and cryptococcal meningitis remain prevalent.

A Case of Human Immunodeficiency Virus-Positive Patient Diagnosed during the Treatment of Right Internal Iliac Pseudoaneurysm

Isolated internal iliac artery aneurysms are rare, and there are no reports of human immunodeficiency virus (HIV)-related vasculitis in Japan. We report our experience with a 51-year-old man diagnosed with acquired immunodeficiency syndrome, discovered during the postoperative course when the patient exhibited remittent fever and susceptibility to infection after emergency interventional radiology therapy for a right isolated internal iliac artery aneurysm. The patient had positive treponema pallidum particle agglutination test result before admission, and tests for sexually transmitted disease showed positive results for HIV H-1 antibodies. The repeated fevers were attributed to HIV infection-related susceptibility.

Hybrid open and endovascular treatment of an aortic arch pseudoaneurysm in a patient with human immunodeficiency virus infection

We describe an hybrid approach for aortic pseudoaneurysm with open and endovascular treatment as an alternative treatment for a high-risk patient infected with human immunodeficiency virus. A 42-year-old man, serum positive for human immunodeficiency virus, presented, with a large pseudoaneurysm of the arch aorta measuring 61 × 70 mm. An aortic arch debranching was performed, completed by thoracic endovascular aneurysm repair. A control computed tomography scan performed 3 months later showed a complete thrombosis of the pseudoaneurysm. The outcome of this treatment, particularly regarding the rate of infection, is yet to be determined, Longer follow-up is needed with a greater of patients.

Trends and perioperative outcomes of patients with human immunodeficiency virus (HIV) undergoing lower extremity revascularization

The development of highly active antiretroviral therapy (HAART) has significantly improved the life expectancy of patients with human immunodeficiency virus (HIV), but has led to the rise of chronic conditions including peripheral artery disease (PAD). However, trends and outcomes among patients with HIV undergoing lower extremity revascularization are poorly characterized. The aim of this study was to investigate the trends and perioperative outcomes of lower extremity revascularization among patients with HIV and PAD in a national database. The National Inpatient Sample (NIS) was reviewed between 2003 and 2014. All hospital admissions with a diagnosis of PAD undergoing lower extremity revascularization were stratified based on HIV status. Outcomes were assessed using propensity score matching and multivariable regression. Among all patients undergoing lower extremity revascularization for PAD, there was a significant increase in the proportion of patients with HIV from 0.21% in 2003 to 0.52% in 2014 (p < 0.01). Patients with HIV were more likely to be younger, male, and have fewer comorbidities, including coronary artery disease and diabetes, at the time of intervention compared to patients without HIV. With propensity score matching and multivariable regression, HIV status was associated with increased total hospital costs, but not length of stay, major amputation, or mortality. Patients with HIV with PAD who undergo revascularization are younger with fewer comorbidities, but have increased hospital costs compared to those without HIV. Lower extremity revascularization for PAD is safe for patients with HIV without increased risk of in-hospital major amputation or mortality, and continues to increase each year.

Vasculitides in HIV Infection

Purpose of Review

To review the spectrum of vasculitides in HIV-infected patients and to identify the clinical features that characterize vasculitis in sero-positive HIV.

Recent Findings

Epidemiological studies conducted in the post-HAART era described the rarity of vasculitis in the setting of HIV-infected patients. A study identified histopathological features such as leukocytoclastic vasculitis of the vasa vasorum and adventitial inflammation in the large artery pathology of HIV-positive patients compared with HIV-negative patients with critical lower limb ischemia. A recent retrospective cohort study reported that HIV-positive patients with LVV developed more vascular complications, responded less to antiretroviral therapy, and had worse outcome than HIV-negative patients with LVV.

Summary

Vasculitides continue to be a rare disease in patients with HIV. The spectrum of vasculitis ranges from life-threatening conditions to relatively mild skin conditions. Recognizing vasculitis in the setting of HIV-positive patients is important because sometimes it require immunosuppressive treatment.

[Occlusion of the abdominal aorta in patients infected with the human immunodeficiency virus: Clinical case and review of the literature]

HIV infection has now become a chronic disease with a good life expectancy thanks to antiretrovirals. The mortality currently is attributed to other pathologies in particular cardiovascular because of the inflammation and the side effects of the drugs. All arteries can be damaged in HIV, especially the aorta, with several types of lesions which can be occlusive, aneurysmal, dissecting, even with the cases of arteriovenous fistula which have been described. HIV occlusive arterial disease is different from atheromatous disease in HIV-free patients and this is confirmed by pathology and ultrasound studies, which makes it more difficult to manage HIV-related occlusions. The open surgical treatment especially in the acute forms is disappointing with complications of rethrombosis and infectious and of sepsis of prosthesis considering the immunosuppression, the endovascular treatment begins to become the treatment of choice in the aneurysmal pathology and probably it would be in the future for occlusive disease.

Patient Characteristics, Patterns, and Repair of Aneurysms in Human Immunodeficiency Virus-Positive Patients

BACKGROUND

Human immunodeficiency virus (HIV) is a multisystem disease and is associated with vascular complications including aneurysm formation. HIV-associated aneurysms are well documented and may present in unusual locations with concerning features. However, the literature regarding aneurysms in HIV-positive patients is limited to case series with limited data regarding aneurysm patterns. Furthermore, several small series have documented poor outcomes with surgical repair. Thus, our aim was to investigate the characteristics, patterns, and repair of aneurysms in HIV-positive patients in a multicenter study.

METHODS

All patients with a diagnosis of aneurysms and HIV were retrospectively identified from 2013 to 2018 across 2 institutions. Comorbidities, HIV-related characteristics, aneurysm characteristics, and repair were reviewed.

RESULTS

There were a total of 104 HIV-positive patients with 129 aneurysms. The mean age at the time of diagnosis was 57.7 ± 10.3 years, 80.8% of patients were male, and 32.0% had a history of acquired immunodeficiency syndrome. The average time from HIV diagnosis to aneurysm diagnosis was 14.1 ± 10.1 years. There were 53 (41.1%) ascending aortic, 25 (19.4%) abdominal aortic, 14 (10.9%) cerebral artery aneurysms, 13 (10.1%) descending thoracic, 9 (7.0%) iliac, 6 (4.7%) femoropopliteal, 4 (3.1%) visceral, 3 (2.9%) axillosubclavian, 1 (0.8%) carotid, and 1 (0.8%) coronary artery aneurysms. There were 23 (22.1%) patients with aneurysms in multiple vascular beds, 10 (9.6%) saccular aneurysms, and 1 (0.8%) inflammatory aneurysm. There were 7 ruptures (cerebral, descending thoracic, and iliac), 3 type A dissections (ascending aorta), and 1 thrombosis (popliteal). There were 26 (25.0%) patients who underwent surgical repair. This included 8 endovascular aneurysm repairs for abdominal aortic aneurysms, 6 endovascular coiling, clipping, and stent procedures for cerebral aneurysms, 4 open ascending aorta repairs, 2 bypasses for popliteal artery aneurysms, 2 endovascular stents for axillosubclavian artery aneurysms, 1 open descending aortic aneurysm repair, 1 endovascular aneurysm repair for an iliac aneurysm, 1 endovascular coiling for a renal artery aneurysm, and 1 open repair of a femoral artery aneurysm. Perioperative complications were common at 46.2%, although mortality was low at 3.8%.

CONCLUSIONS

Although aneurysms were widespread, most HIV-positive patients had large vessel aneurysms in this study. There was a high prevalence of saccular and multiple aneurysms, and repair was associated with low rates of mortality despite high rates of complications. Additional studies are necessary to characterize this rare entity.

The role of cardiac imaging in the management of non-ischemic cardiovascular diseases in human immunodeficiency virus infection

Infection with human immunodeficiency virus (HIV) has become the pandemic of the new century. About 36.9 million people are living with HIV worldwide. The introduction of antiretroviral therapy in 1996 has dramatically changed the global landscape of HIV care, resulting in significantly improved survival and changing HIV to a chronic disease. With near-normal life expectancy, contemporary cardiac care faces multiple challenges of cardiovascular diseases, disorders specific to HIV/AIDS, and those related to aging and higher prevalence of traditional risk factors. Non-ischemic cardiovascular diseases are major components of cardiovascular morbidity and mortality in HIV/AIDS. Non-invasive cardiac imaging plays a pivotal role in the management of these diseases. This review summarizes the non-ischemic presentation of the HIV cardiovascular spectrum focusing on the role of cardiac imaging in the management of these disorders.

Higher prevalence of peripheral arterial disease in Ghana compared to Ghanaian migrants in Europe: The RODAM study

BACKGROUND

Evidence suggests that the burden of peripheral artery disease (PAD) is rising more rapidly than other forms of cardiovascular diseases in sub-Saharan Africa, but the extent to which they differ between rural and urban settings in Africa and upon migration to Europe is unknown. We assessed the burden of PAD among Ghanaians living in rural- and urban-Ghana and Ghanaian migrants living in three European countries.

METHODS

Cross-sectional analyses of baseline data from the multicenter Research on Obesity and Diabetes among African Migrants (RODAM) study were done. Data from 5516 participants living in Europe (1487 Amsterdam, 546 Berlin, 1047 London) and Ghana [1419 urban and 1017 rural] aged 25-70years were included. PAD was defined as ankle brachial index≤0.90. Comparisons among sites were made using logistic regression analysis.

RESULTS

The age-standardized prevalence of PAD was higher in Ghanaians living in rural [7.52%, 95% CI = 5.87-9.51] and urban [8.93%, 7.44-10.64] Ghana than for their compatriots living in Europe [5.70%, 4.35-7.35 for London; 3.94%, 2.96-5.14 for Amsterdam; and 0.44%, 0.05-1.58 for Berlin]. The differences persisted even after adjustment for age, sex, education and the conventional cardiovascular risk factors [adjusted odds ratio = 3.16, 95% CI = 2.16-4.61, p < .001 for rural-Ghana; and 2.93, 1.87-4.58, p < .00 for urban-Ghana, compared with Ghanaian migrants in Europe].

CONCLUSIONS

Our study shows that Ghanaians living in Ghana have higher prevalence of PAD than their migrant compatriots. Further work is needed to identify potential factors driving the high prevalence of PAD among non-migrant Ghanaians to assist interventions aimed at reducing PAD burden.

Vasculitis in Africa

PURPOSE OF REVIEW

Systemic vasculitides are characterized by inflammation of blood vessel walls leading to a myriad of organ disorders depending on the size, site, and location of the affected blood vessel. The epidemiology of vasculitis in the developing world has been inadequately documented. The description of the vasculitides in Africa, both from hospital series as well as taking into consideration, previous epidemiological studies in the community, indicates that these conditions have been rare until relatively recently. In view of these past observations, this review of publications on the topic looks to shed light on the current state of vasculitis in Africa.

RECENT FINDINGS

Takayasu and Kawasaki appear to be the most commonly reported vasculitides in Africa. Most of the published reports are from North and South Africa. Furthermore, the contribution of vasculitis associated with infections, and in particular HIV, is significant. There are increasing numbers of publications reflecting a growing recognition of the vasculitides in Africa.

The effect of stage of HIV disease as determined by CD4 count on clinical outcomes of surgical sepsis in South Africa

INTRODUCTION This paper reviews the impact of the stage of human immunodeficiency virus (HIV) disease on the outcome of surgical sepsis. METHODS All adult emergency general surgical patients (aged >15 years) who fulfilled the criteria for sepsis or septic shock, with a documented surgical source of infection, and who were HIV positive were reviewed. RESULTS During the 5-year study period, a total of 675 patients with a documented surgical source of sepsis were managed by our service; 142 (21%) of these were HIV positive. Among the individuals who were HIV positive, the CD4 count was <200 cells/µl in 21 patients and ≥200 cells/µl in 121 patients. There was no difference between these two cohorts in terms of demography or spectrum of surgical conditions. The range of surgical procedures and complications was also similar in both groups. Nevertheless, patients with a CD count of <200 cells/µl had a significantly longer length of hospital stay than those in the cohort with ≥200 cells/µl. For HIV positive patients with a CD4 count of <200 cells/µl, the mortality rate was 66.7% (14/21) while the mortality rate for individuals with HIV and a CD4 count of ≥200 cells/µl was 2.5% (2/121). This difference was statistically significant (p<0.001). CONCLUSIONS The clinical presentation and spectrum of surgical sepsis disease in cases with stage 1 and stage 2 HIV is not markedly different. However, in patients with a CD4 count of <200 cells/µl, the length of hospital stay and mortality is significantly higher. Stage of HIV disease must be considered when stratifying patients' risk for surgery.

HIV and Nonischemic Heart Disease

Human immunodeficiency virus (HIV)-associated heart disease encompasses a broad spectrum of diseases. HIV infection may involve the pericardium, myocardium, coronary arteries, pulmonary vasculature, and valves, as well as the systemic vasculature. Access to combination antiretroviral therapy, as well as health resources, has had a significant influence on the prevalence and severity of the effects on each cardiac structure. Investigations over the recent past have improved our understanding of the epidemiology and pathophysiology of HIV-associated cardiovascular disease. This review will focus on our current understanding of pathogenesis and risk factors associated with HIV infection and heart disease, and it will discuss relevant advances in diagnosis and management of these conditions.

Thoracoabdominal Aortic Aneurysm in a HIV-positive Patient

Advent of antiretroviral therapy has increased survival of patients with human immunodeficiency virus (HIV) infections, with the result that some of these patients now develop degenerative diseases, such as atherosclerotic aneurysms. Degenerative thoracoabdominal aortic aneurysm is rare in HIV patients. In this report, a 63-year-old male patient with HIV submitted to open repair of thoracoabdominal aortic aneurysm. The patient did not suffer any type of complication in the perioperative period and remained well in a 28-month follow-up period. In summary, open repair still remains a good alternative for aortic complex aneurysms even in HIV patients.

Endovascular Therapy for Large Vessel Vasculopathy in HIV-infected Patients

OBJECTIVES

To evaluate outcomes after endovascular treatment of patients with aneurysmal or occlusive vasculopathy in HIV-infected patients.

METHODS

Retrospective analysis of a prospective database of treatment outcomes in patients with HIV related vasculopathies between April 2005 and September 2015.

RESULTS

Sixty HIV patients presented with post-traumatic pseudoaneurysm formation (n = 7), aneurysmal disease (n = 24) or occlusive disease (n = 29 (48%)). The majority were male (42/60 (70%)), with a mean age of 43.9 years (SD ± 12.6). All seven patients with a post-traumatic pseudoaneurysm were treated by insertion of a covered stent (n = 6) or coiling (n = 1). All were successfully treated at 30 days, but only one patient returned for late surveillance. 23/24 patients who underwent insertion of a stent graft/covered stent for aneurysmal disease returned for 30 day review (one asymptomatic stent graft occlusion). Only 11 patients attended for late surveillance; 9/11 were asymptomatic with patent stent grafts. Late stent occlusion occurred in two (no further action (n = 1), major limb amputation (n = 1). In the 29 patients who underwent endovascular treatment for occlusive disease, 9 (31%) had immediate treatment failure (including 8 amputations (28%)). Of the sixteen who returned for serial review, 8 (50%) suffered further complications including 4 amputations. Overall, 12/29 treated patients (41%) ultimately underwent amputation.

CONCLUSIONS

In the immediate short term, an 'endovascular first' strategy was associated with good outcomes in HIV patients with aneurysmal disease. By contrast, outcomes were poor in HIV patients with occlusive disease. Whether this relates to the underlying natural history of HIV occlusive vasculopathies remains unclear. One major problem in trying to formulate meaningful management strategies is a generalised reluctance for HIV patients to return for surveillance.

Human Immunodeficiency Virus-Associated Cerebral Aneurysmal Vasculopathy: A Systematic Review

BACKGROUND

Human immunodeficiency virus (HIV)-associated cerebral aneurysmal vasculopathy is a rare complication of HIV affecting pediatric and adult patients and has been the subject of many case reports and case series.

METHODS

We performed a systematic literature search of PubMed, EMBASE, Scopus, Web of Science, Science Direct, and Google Scholar up to April 10, 2015. Our inclusion criteria encompassed all reported original case series and reports of HIV-associated cerebral aneurysms diagnosed radiologically. We analyzed the clinical characteristics and management of the reported cases.

RESULTS

We identified 61 patients reported in the literature (45 pediatric and 16 adult patients). The median age was 9.8 years for pediatric patients and 36.5 years for adult patients. Weakness was the most common presenting symptom in adult and pediatric patients. The most common affected artery was the middle cerebral artery. Approximately 87.2% of pediatric patients and 42.9% of adult patients were on antiretroviral therapy (ART) at presentation. The mortality rate was 60% and 35.7% among pediatric and adult patients, respectively. The optimal management is not well established. Variable response to ART was reported with possible survival benefits when ART was initiated early.

CONCLUSIONS

HIV-associated cerebral aneurysmal arteriopathy is associated with high mortality. The optimal management is not well established, but early initiation of ART may improve the survival rate.

Surgical repair of descending thoracic and thoracoabdominal aortic aneurysms in patients with human immunodeficiency virus infection: a 10-patient series

BACKGROUND

Major surgery in patients with human immunodeficiency virus (HIV) infection increases the risk of complications such as cardiovascular morbidity and opportunistic infections.

METHODS

This study reports our experience with open surgical repair of 10 descending thoracic and thoracoabdominal aortic aneurysms in patients with HIV.

RESULTS

Seven were men, and their median age was 49 years. All patients were controlled with highly active antiretroviral therapy (mean CD4+: 613/mm(3)). Three patients died (1 preoperatively, 1 after rupture, and 1 after elective surgery). No patient had spinal cord ischemia or infectious complications, either early or after a median follow-up of 29 months. Bacteriologic and histologic analyses did not determine any specific etiology for the aneurysms.

CONCLUSIONS

Surgical repair of descending thoracic and thoracoabdominal aortic aneurysms in patients with HIV infection is feasible and may not lead to remote infectious complications.

Initial Presentation of HIV Infection With Two Successive Acute Arterial Thromboses: A Case Report

Introduction:

One of the complications of HIV infection is greater risk of thromboembolic events. A variety of mechanisms has been found to be responsible for prothrombotic tendency in patients with HIV infection.

Case Presentation:

A 27-year-old heterosexual smoker man was referred to our center due to a sudden-onset severe left lower extremity pain and claudication since three days prior to admission. In physical examination, end extremity coldness and discoloration as well as left lower extremity pulselessness were found. Color-Doppler sonography revealed a large thrombus in the left common iliac artery and two thrombi in the distal halves of both anterior and posterior tibialis arteries, so the patient was transferred to the operating room for proximal thrombectomy where the blood flow was reestablished and all pulses were then detectable. Two days later, the patient developed another similar episode from knee down and underwent the second thrombectomy. In evaluation, HIV Ab had positive result by ELISA.

Conclusions:

This case inspires consideration of HIV infection as a leading cause of thromboembolic event in individuals affected by the first episode of unprovoked one in whom diagnosis of HIV infection has not been established yet.

HIV-associated large-vessel vasculopathy: a review of the current and emerging clinicopathological spectrum in vascular surgical practice

An established relationship exists between human immunodeficiency virus (HIV) and the vascular system, which is characterised by clinical expressions of aneurysmal and occlusive disease that emanate from a common pathological process. The exact pathogenesis is currently unknown; attempts to implicate opportunistic pathogens have been futile. Theories converge on leucocytoclastic vasculitis with the vaso vasora as the vasculopathic epicentre. It is thought that the virus itself or viral proteins trigger the release of inflammatory mediators that cause endothelial dysfunction and smooth muscle proliferation leading to vascular injury and thrombosis. The beneficial effects of highly active anti-retroviral therapy alter the natural history of the disease profile and promote longevity but are negated by cardiovascular complications. Atherosclerosis is an emerging challenge. Presently patients are managed by standard surgical protocols because of non-existent universal surgical interventional guidelines. Clinical response to treatment is variable and often compounded by complications of graft occlusion, sepsis and poor wound healing. The clinical, imaging and pathological observations position HIV-associated large-vessel vasculopathy as a unique entity. This review highlights the spectrum of HIV-associated large-vessel aneurysmal, occlusive and atherosclerotic disease in vascular surgical practice.

Endovascular interventions for human immunodeficiency virus-associated iliac artery aneurysms

OBJECTIVE

Aneurysms associated with human immunodeficiency virus (HIV) are pseudo-aneurysms and the pathology is unique to HIV vasculopathy. We report outcomes of endovascular therapy for HIV iliac artery aneurysms in a series of patients to augment the sparse literature on these aneurysms.

METHODS

The records from January 2010 to December 2013 of all patients treated for HIV-related iliac artery aneurysms were extracted from a prospectively maintained database at our institution.

RESULTS

Preprocedural, periprocedural, and postprocedural data were retrieved for five black patients (three males and two females), who were treated for HIV-associated iliac artery aneurysms. All patients underwent endovascular therapy. There were seven aneurysms (three common iliac arteries, three internal, and one external). Pain was a common presenting feature, and two patients presented with rupture. One patient was receiving antiretroviral therapy, and one patient was receiving treatment for pulmonary tuberculosis. Three patients had significant weight loss. The average hemoglobin value was 8 g/dl. Six aneurysms were managed with covered stents and one (internal iliac artery) with coil embolization. There were no procedure-related complications, and only one patient required a blood transfusion. Symptoms resolved in all patients. One re-intervention was required for stent thrombosis after 30 days.

CONCLUSION

Endovascular therapy for the HIV-associated iliac artery aneurysm has good short-term results and avoids pelvic dissection with its associated morbidity and mortality.

HIV, vascular surgery and cardiovascular outcomes: a South African cohort study

Risk factors for peri-operative cardiac morbidity are poorly described in HIV-positive patients. This prospective observational study describes cardiovascular risk factors in a cohort of vascular surgical patients of known HIV status. We recruited 225 patients with 73 (32%) being HIV-positive. When compared with HIV-negative patients, the HIV-positive patients were younger (mean (SD) 56.4 (13.3) vs 40.5 (10.4) years, respectively, p < 0.01). They had fewer Revised Cardiac Risk Index cardiovascular risk factors (median (range [IQR]) 1 (0-5 [0-2]) vs 0 (0-2 [0-0]), respectively, p < 0.001), with the exception of congestive cardiac failure (p = 0.23) and renal dysfunction (p = 0.32), and so were of a significantly lower Revised Cardiac Risk Index risk category (p < 0.01). HIV-positive and -negative patients had similar outcomes in: 30-day mortality (p = 0.78); three-day postoperative troponin leak (p = 0.66); and a composite outcome of mortality and troponin release (p = 0.69). We conclude that although HIV-positive patients have fewer cardiovascular risk factors, they have similar peri-operative major adverse cardiac events to HIV-negative patients. Research should focus on why this is the case, and if alternative clinical risk predictors can be developed for HIV patients.

Recent advances in HIV-associated cardiovascular diseases in Africa

The last decade has witnessed major advances in our understanding of the epidemiology and pathophysiology of HIV-related cardiovascular disease in sub-Saharan Africa. In this review, we summarise these and discuss clinically relevant advances in diagnosis and treatment. In the Heart of Soweto Study, 10% of patients with newly diagnosed cardiovascular disease were HIV positive, and the most common HIV-related presentations were cardiomyopathy (38%), pericardial disease (13%) and pulmonary arterial hypertension (8%). HIV-related cardiomyopathy is more common with increased immunosuppression and HIV viraemia. With adequate antiretroviral therapy, the prevalence is low. Contributing factors such as malnutrition and genetic predisposition are under investigation. In other settings, pericardial disease is the most common presentation of HIV-related cardiovascular disease (over 40%), and over 90% of pericardial effusions are due to Mycobacterium tuberculosis (TB) pericarditis. HIV-associated TB pericarditis is associated with a greater prevalence of myopericarditis, a lower rate of progression to constriction, and markedly increased mortality. The role of steroids is currently under investigation in the form of a randomised controlled trial. HIV-associated pulmonary hypertension is significantly more common in sub-Saharan Africa than in developed countries, possibly as a result of interactions between HIV and other infectious agents, with very limited treatment options. It has recently been recognised that patients with HIV are at increased risk of sudden death. Infection with HIV is independently associated with QT prolongation, which is more marked with hepatitis C co-infection and associated with a 4.5-fold higher than expected rate of sudden death. The contribution of coronary disease to the overall burden of HIV-associated cardiovascular disease is still low in sub-Saharan Africa.

Arterial thrombosis in patients with human immunodeficiency virus: two-case reports and review of the literature

Thrombosis during HIV infection was commonly vein thrombosis. Arterial thrombosis is also more and more described. We report two cases detected in the Abidjan Cardiology Institute. Case Reports. Case 1: an HIV infected female presented with sudden loss of consciousness and right hemiplegia. She had been taking HAART regimen for five years. Neck vessels ultrasonography revealed thrombosis on left ICA. Anticoagulant treatment leads to reduction of symptoms and left ICA partial recanalization. Case 2: male HIV infected taking HAART therapy was admitted for an acute pain of left lower limb; examination showed a decrease of heat, sensitivity, and mobility of this limb with popliteal and tibial pulses abolished. Arterial ultrasonography and CT angiography showed occlusion on the lower third of superficial femoral artery and homolateral popliteal artery suggesting a thrombosis of this artery. He underwent a femorotibial bypass surgery and anticoagulant treatment. The outcome was good with reappearance of local heat of the limb and tibial pulses. Probable etiology is early carotid atherosclerosis associated with protein S deficiency in the first case and antiphospholipid syndrome in the second case. Conclusion. Arterial thrombosis might occur in HIV infection. Several etiological factors could be involved in the pathogeny of these arterial thromboses.