HIV-occlusive vascular disease.

OBJECTIVES: To evaluate peripheral arterial occlusive disease in HIV-infected patients regarding clinical presentation and outcome of surgical intervention. DESIGN: Prospective clinical survey. PATIENTS AND METHODS: Routine voluntary testing for HIV/AIDS was performed in all patients presenting to our vascular unit. HIV+ patients were enrolled in a registry and followed up prospectively. RESULTS: We identified 154 HIV+ patients, of whom 91 (59%) presented with occlusive disease. There were 71 males and 20 females with a mean age of 44.2 years. The usual risk factors for atherosclerosis were present, but the incidence was less than reported in the classic atherosclerosis population. More than 90% of the patients presented with advanced stage vascular disease (Fontaine III/IV), which explains the high rate (31.9%) of primary amputation. Eighty-seven patients presented with lower-limb ischaemia, 2 patients with upper-limb ischaemia and 2 patients with symptomatic carotid artery stenosis. Seventy-eight procedures were performed on 72 patients, with a perioperative mortality of 6.95%. The limb salvage rate for femoro-popliteal bypass procedures was poor (36.1%), resulting in a high incidence of secondary amputations and prolonged hospital stay. Long-term mortality for the operated patients was 20% over a mean follow-up period of 15.4 months. Hypo-albuminaemia was found to be an important predictor of outcome. CONCLUSION: Patients presenting with HIV-associated peripheral arterial disease should be carefully selected for intervention, taking into consideration nutritional and immune status, stage of the vascular disease and selecting the appropriate procedure.

Surgical intervention for HIV related vascular disease.

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 5-year 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.

Cerebral monitoring during carotid endarterectomy--a comparison between electroencephalography, transcranial cerebral oximetry and carotid stump pressure.

OBJECTIVE: Various modalities are used for cerebral monitoring during carotid endarterectomy (CEA). The aim of this study was to evaluate whether transcranial cerebral oximetry (TCO) and carotid stump pressure (SP) are as accurate as electroencephalography (EEG) for monitoring cerebral ischaemia during carotid cross-clamping. METHODS: One hundred consecutive patients who underwent CEA were studied with continuous and simultaneous EEG and TCO. SP was measured for each patient. The percentage decrease of oxygenation on TCO was calculated during cross-clamping and surgery. EEG findings were used as the benchmark to detect cerebral ischaemia and were the indication for insertion of a temporary shunt. The relationship with TCO was observed in terms of percentage decrease in oxygenation. RESULTS: A total of 6 patients were shunted on the basis of their EEG changes. TCO changed more than 20% in these 6 patients, but an additional 12 patients had TCO changes with a normal EEG. This correlated with a decrease in blood pressure (BP) and was corrected by increasing the BP. The positive predictive values (PPVs) and negative predictive values (NPVs) for shunting based on TCO (as compared with EEG) were 33% and 100% respectively. Thirty-four patients had SP <50 mmHg, of whom 4 were shunted based on EEG changes. Two of 66 patients with SP >50 mmHg were shunted based on EEG changes. If a shunting policy had been based on a SP of 50 mmHg, 30 patients would have been shunted unnecessarily (PPV 12%), whereas the non-requirement for a shunt was predicted correctly in 64 of 66 patients (NPV 97%). There were 2 major strokes: 1 contralateral on day 3 in a patient with bilateral severe stenoses, and 1 ipsilateral in a nonshunted patient with normal EEG, TCO and SP >50 mmHg. CONCLUSION: Compared with EEG, TCO is a practical and non-invasive monitoring system with a high sensitivity (100%) but a low specificity. TCO is more sensitive to a drop in BP and responds earlier to these changes than EEG. SP should not be used as the sole predictor for shunting during CEA.

Vascular disease in HIV/AIDS patients.

OBJECTIVES: An ongoing prospective clinical survey to determine the spectrum of vascular disease in HIV/AIDS patients and the risk factors affecting clinical outcome in order to formulate a management protocol for future use. METHODS: Comprehensive screening for risk factors for vascular disease as well as HIV/AIDS-related conditions. Disease pattern and presentation are noted and patients treated accordingly. Vascular emergencies are managed regardless of HIV status because this information is usually not available at the time of presentation. Elective management is based on immune status and risk stratification. RESULTS: 42 patients tested positive for HIV. The majority of patients presented with occlusive disease (57%), followed by aneurysms (21%) and vascular trauma (19%). A variety of vascular surgical procedures were performed on 36 patients. There was no surgical mortality and 10 patients developed complications, including 2 amputations and 7 cases of minor wound sepsis. The 3 patients who received preoperative antiretroviral therapy showed a marked reduction in viral count and a significant improvement in CD4 T-cell count. CONCLUSION: Surgery can be safe and effective in HIV-positive patients provided the necessary precautions are taken to reduce surgical morbidity.