Large artery vasculopathy in HIV-positive patients: Another vasculitic enigma

doi:10.1016/S0046-8177(00)80253-1

Human Pathology

Volume 31, Issue 3, March 2000, Pages 374-379

https://doi.org/10.1016/S0046-8177(00)80253-1 Get rights and content

Human immunodeficiency virus (HIV) infection has impacted on all the systems of the body, and the cardiovascular system is no exception, with small to medium-sized vessel vasculitis being most frequently described. We present 16 HIV-positive patients with large vessel disease consisting of either aneurysms (often multiple) or occlusive disease. Nine men and 7 women ranging in age from 18 to 38 years presented with rupture of aneurysm, transient ischemic attacks, hypertension, ischemia to the lower extremity, or a mass at the site of the aneurysm. Eight patients had 1 aneurysm, 2 had 2 lesions, and the remaining 6 cases had from 3 to 7 aneurysms. Arteries affected included the common carotid, abdominal aorta, common iliac, femoral, and popliteal. Three patients had intercurrent infections, but none had any obvious infective vascular lesion. Only 1 patient had a positive TPHA test for syphilis. Microbiologic culture of both blood and thrombus contents was positive for Staphylococcus aureus in 1 case; no other organisms were cultured. The key histological features were within the adventitia: leukocytoclastic vasculitis of the vasa vasora and periadventitial vessels, proliferation of slit-like vascular channels, chronic inflammation, and fibrosis. There was associated medial fibrosis with loss and fragmentation of muscle and elastic tissue. Intimal changes consisted of duplication and fragmentation of the internal elastic lamina with calcification. Atheroma and marked intimal thickening were not evident. We believe that the occurrence of this large vessel vasculopathy (mainly aneurysmal) often with multiple lesions in young HIV-positive patients, is characteristic of possible infective or immune complex origin, with leukocytoclastic vasculitis of vasa vasora and periadventitial vessels being pivotal in many cases.

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Cited by (153)

Human Immunodeficiency Virus: Opportunistic Infections and Beyond
2023, Neuroimaging Clinics of North America
Patient Characteristics, Patterns, and Repair of Aneurysms in Human Immunodeficiency Virus–Positive Patients
2021, Annals of Vascular Surgery
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.
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.
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%.
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.
Occlusion of the abdominal aorta in patients infected with the human immunodeficiency virus: Clinical case and review of the literature
2020, Annales de Cardiologie et d'Angeiologie
L’infection par le VIH s’est transformée actuellement en un maladie chronique avec une bonne espérance de vie grâce aux antirétroviraux. La mortalité actuellement est attribuée à d’autres pathologies notamment cardiovasculaires à cause de l’inflammation et des effets secondaires des médicaments. Toutes les artères peuvent être lésées dans le VIH notamment l’aorte, avec plusieurs types de lésions qui peuvent être occlusive, anévrysmale, disséquante avec même des cas de fistule artérioveineuse qui ont été décrite. L’atteinte artérielle occlusive dans le VIH est différente de la maladie athéromateuse chez les patients indemnes du VIH et ceci est confirmé par les études anatomopathologique et ultrasonographiques, ce qui rend la gestion des occlusions liées au VIH plus difficile. Le traitement chirurgical à ciel ouvert surtout dans les formes aigues est décevant avec des complications de rethrombose et infectieuses et de sepsis de prothèse vu l’immunodépression, le traitement endovasculaire commence à devenir le traitement de premier choix dans la pathologie anévrysmale et probablement il le serait dans l’avenir pour la patholgie occlusive. Nous rapportons le cas d’un jeune patient admis pour ischémie critique des deux membres inférieurs sur occlusion aortique et traité avec succès par un pontage aorto-bi-fémoral.
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.
HIV-Associated Aortitis Causing Rapid Development of an Abdominal Aortic Aneurysm
2020, Annals of Vascular Surgery
Citation Excerpt :
Vasculitis is an uncommon complication of HIV-infected patients with an incidence of less than 1%.8 The vasculitides associated with HIV tend to involve medium-sized vessels, but large vessel involvement including popliteal, femoral, common iliac, aorta, and common carotid artery has been reported.9 HIV itself is a risk factor for cardiovascular disease, although it is a complex relationship that has not been fully elucidated.
Vasculitides are rare manifestations of human immunodeficiency virus (HIV) infection. They encompass a wide range of different pathologies, both infectious and noninfectious. We present the case of a 68-year-old female with HIV, being treated with antiretrovirals, who presented with a symptomatic abdominal aortic aneurysm. The aneurysm developed within one week. The patient underwent endovascular aneurysm repair, and her aneurysm completely resolved on follow-up computed tomography imaging 16 months later. We also present a review of HIV-associated vascular pathologies.
Carotid Artery Aneurysm in HIV: A Review of Case Reports in Literature
2020, Annals of Vascular Surgery
Citation Excerpt :
Several types of vasculitis have been described previously in literature on patients with HIV, such as leukocytoclastic vasculitis, granulomatous angiitis, angiitis associated with lymphoproliferative syndromes,36 along with a higher arterial uptake on 18-fluorodeoxyglucose positron emission tomography examination in HIV-infected patients than in controls, independently by the CD4 count, viral load, duration of HIV infection, the use of and duration of HAART, and gender.37 A very interesting remark has been reported by Chetty et al.10 who have compared HIV vasculitis findings with those of lesions described for Takayasu disease. Specifically, they have observed that the temporal sequence of events leading to active and healing stages, and the absence of an obvious causative agent can be considered as common features of HIV and autoimmune condition and that also in HIV vasculitis, two patterns may be described: an acute or active phase (leukocytoclastic vasculitis of the vasa vasora and ischemia of the media) and a chronic or healed/healing phase (less obvious leukocytoclastic vasculitis and fibrosis in the media), ultimately leading to weakening of the vessel wall and aneurysm formation.10
HIV infection may affect the cardiovascular system through different physiopathological patterns. Rarely reported in HIV negative patients, aneurysms involving the carotid artery have been described for the first time in seropositive patients in 1989.
In our study, we have focused on aneurysm pathology affecting carotid arteries in HIV patients, analyzing clinical and surgical presentation, management, and outcome, through a review of cases published in the literature.
The MEDLINE (www.ncbi.nlm.nih.gov/pubmed) database was reviewed for “carotid artery aneurysm AND HIV OR AIDS OR immunodeficiency.”
Nineteen articles including a total of 46 cases were included in our report. The mean age of patients was 30.6 ± 14.2 years; 30 patients (65.2%) were male. Aneurysms were localized in the intracranial carotid (41.3%) or extracranial artery (58%). Presenting features included symptoms due to compression of neck structures; positivity for neurological symptoms occurred in 36.9%. Patients were managed surgically in 58.7% of cases; surgical morbidity and mortality were of 22.2% and 7.4% respectively, higher for endovascular procedures. The overall mortality in treated and untreated cases was 26.1%.
Aneurysms may occur in both the extracranial and intracranial carotid artery in patients with HIV at younger age than in non-HIV patients and are linked to a high morbidity and mortality. Seropositivity must be ruled out whenever this rare vascular condition may occur in the absence of a more likely aetiology and must also be suspected in HIV patients presenting with compressive symptoms of the neck, neurological impairment or stroke.
Large-vessel vasculitis in human immunodeficiency virus-infected patients
2018, Journal of Vascular Surgery
The objective of this study was to describe large-vessel vasculitis (LVV) in patients with human immunodeficiency virus (HIV) infection. It is a retrospective single-center study conducted between 2000 and 2015 through a university hospital of 11 HIV-infected patients with LVV.
The characteristics and outcome of 11 HIV-infected patients with LVV (7 patients fulfilled international criteria for Takayasu arteritis, 5 patients had histologic findings of vasculitis, and 5 patients had imaging features of aortitis) were analyzed and compared with those of 82 patients with LVV but without HIV infection.
Concerning the HIV-infected patients with LVV (n = 11), the mean age was 40 years (range, 36-56 years), and 55% of patients were female. At diagnosis of LLV, the mean initial CD4 cell count was 455 cells/mm³ (range, 166-837 cells/mm³), and the median HIV viral load was 9241 copies. Vascular lesions were located in the aorta (n = 7), in supra-aortic trunks (n = 7), and in digestive arteries (n = 3). Inflammatory aorta infiltrates showed a strong expression of interferon-γ and interleukin 6. In HIV-negative LVV patients (n = 82), the median age was 42 years, and 88% of the patients were women. Thirty patients had an inflammatory syndrome. Seventy patients had been treated with glucocorticosteroids and 57 with immunosuppressive treatments. Compared with their negative counterparts, HIV-positive patients with LVV were more frequently male (P = .014), had more vascular complications (ie, Ishikawa score; P = .017), and had more frequent revascularization (P = .047). After a mean follow-up of 96 months, four relapses of vasculitis were reported, and one patient died. Regardless of the HIV virologic response, antiretroviral therapy improved LVV in only one case.
LVV in HIV-infected patients is a rare and severe entity.

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^*: Supported by the University of Natal Research Fund and the Medical Research Council of South Africa (R.C.).

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Original ContributionLarge artery vasculopathy in HIV-positive patients: Another vasculitic enigma*

Ann Vasc Surg

J Vasc Surg

Arteriopathy in children with acquired immune deficiency syndrome

Pediatr Pathol

Systemic vasculitis in association with human immunodeficiency virus infection

Arthritis Rheum

Pattern of arterial aneurysms in acquired immunodeficiency disease

World J Surg

Arterial aneurysms associated with human immunodeficiency virus (HIV) infection

Acta Chir Belg

Original Contribution
Large artery vasculopathy in HIV-positive patients: Another vasculitic enigma*