Surgical Intervention for HIV Related Vascular Disease

Abstract

Objectives. To determine the outcome of surgical intervention in patients with HIV associated vascular disease. Design. Prospective clinical survey. Materials and methods. Routine voluntary testing for HIV/AIDS was performed in patients who presented to our unit with peripheral vascular disease. One hundred and nine patients (5.7%) were prospectively identified over a 5year period (2001-2006). Results. 24 patients presented with aneurysmal disease whilst occlusive disease was present in 66 patients. There was not much difference between patients with aneurysmal disease and patients with occlusive disease as to age, CD4 count and other risk factors for vascular disease. The peri-operative mortality for aneurysmal disease was 10.6% versus 3.6% for occlusive disease (p = 0.264). Long-term mortality was significantly worse (p = 0.049) for patients with aneurysmal disease. The results of revascularization in occlusive disease were poor with a limb salvage rate of 31.6%. There was no significant difference in CD4 T-cell counts between primary amputation and revascularization groups (p = 0.058). Conclusion. Patients with aneurysmal disease have a high peri-operative and long-term mortality and it appears that surgical intervention should be reserved for life-threatening aneurysms only. Patients with occlusive disease have a better survival rate but limb salvage is poor. Primary amputation may be preferable to bypass surgery in patients with critical limb ischaemia.

Anaesthesia for vascular procedures:How do South African patients differ?

“…30 Of the patients with HIVassociated vasculopathy, 26% present with aneurysmal disease, 69% with occlusive disease and 3% with arterio-venous fistula. 30 Vascular patients who are HIV positive appear to present two distinct clinical entities (aneurysmal or occlusive) with possibly different outcomes. The characteristics of patients with HIV vasculopathy presenting for surgery are presented in Table IV.…”

“…28 Similarly, cardiac death was attributed to AMI in 67% of patients in the South African study, 4 and 66% of patients in the predominantly American and European studies. 28 However, if the analysis is conducted only on patients of age >39 years, in order to remove the majority of trauma (mean age of 28.7 (± 9.2) years) and HIV-related vascular patients (median age 30 to 40 years), [30][31][32] then the all-cause mortality rises to 10.8% and the cardiac mortality to 4.4% (see Table II) (Biccard, unpublished).…”

Ruptured Mycotic Aortic Aneurysm Secondary to Escherichia Coli Bacteremia in an HIV-Positive Patient

“…His white blood disease, and aneurysm formation. HIV-related aneurysms often occur in multiple and atypical locations, preferentially affecting the carotid and superficial femoral arteries [1,3,14]. Typical histologic features include leukocytoclastic vasculitis of the vasa vasora and periadventitial vessels, chronic inflammation, and medial fibrosis with loss of elastic and muscular tissue [3,15].…”

“…Typical histologic features include leukocytoclastic vasculitis of the vasa vasora and periadventitial vessels, chronic inflammation, and medial fibrosis with loss of elastic and muscular tissue [3,15]. While the etiology of HIV-related aneurysms remains unclear, it has been hypothesized that immunosuppression in HIV-positive patients makes them more susceptible to bacteremia and secondary mycotic aneurysm formation [1,2]. In this case, it has been suspected that the patient's back and flank pain reflected underlying urinary tract infection, subsequently leading to bacteremia and seeding of the aorta with progression to MAA.…”

“…HIV-related vasculopathy comprises a broad spectrum of disease, including occlusive disease, aneurysm formation, and microangiopathy [1,2]. HIV-related aneurysmal disease has been shown to be a distinct pathologic entity from atherosclerotic and mycotic aneurysms [3] and can be distinguished by several features-the presence of multiple aneurysms in atypical locations, younger patient age, fewer traditional atherosclerotic risk factors, and unique histopathology defined by peri-adventitial inflammatory infiltrates [4][5][6][7][8].…”