Cardiovascular Journal of Africa: Vol 26 No 2 (March/April 2015)

CARDIOVASCULAR JOURNAL OF AFRICA • Volume 26, No 2, March/April 2015

AFRICA

Review Article

HIV-associated large-vessel vasculopathy: a review of

the current and emerging clinicopathological spectrum

in vascular surgical practice

Balasoobramanien Pillay, Pratistadevi K Ramdial, Datshana P Naidoo

Abstract

An established relationship exists between human immunode-

ficiency virus (HIV) and the vascular system, which is char-

acterised 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 media-

tors 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.

Keywords:

human immunodeficiency virus, vasculopathy, aneu-

rysms, occlusive disease, atherosclerosis, vascular surgery

Submitted 3/7/14, accepted 27/1/15

Cardiovasc J Afr

2015;

: 70–81

www.cvja.co.za

DOI: 10.5830/CVJA-2015-017

Since the first description of human immunodeficiency virus

(HIV) disease more than three decades ago,

HIV infection

has become a global phenomenon, afflicting approximately 40

million people worldwide.

Over 70% of infected individuals

reside in sub-Saharan Africa.

HIV is implicated in a multisystem disease process and the

cardiovascular system is not spared. Many infected patients

are in the advanced stages of disease and present with vascular

complications.

3,4

The unique vascular manifestations of

HIV-related disease, documented as early as 1987 in children,

may present with a diverse spectrum of aneurysms, occlusive

disease, spontaneous arteriovenous fistulae and dissections. In

addition, despite the heightened recognition of the spectrum

of HIV and other HIV-associated infective vasculitic and

vasculopathic reactions,

6-10

the exact pathogenetic mechanisms

and reasons underpinning the varied manifestations of the

HIV-associated vascular pathology remain enigmatic.

This review discusses the spectrum of HIV-associated

large-vessel disease in vascular surgical practice, including

the current understanding of pathogenetic mechanisms, the

clinicopathological profile of aneurymal and occlusive disease,

and the impact of highly active anti-retroviral therapy (HAART)

in the development of atherosclerosis in this patient population.

Pathogenesis of HIV-associated large-vessel

vasculopathy

The pathogenesis of HIV-associated large vessel vasculopathy

involves intricate, dynamic interactions between viral-induced

inflammatory responses, vascular smooth muscle changes,

endothelial alterations and circulating blood factors that result

in pathological vessel wall alterations and symptomatic clinical

disease (Fig. 1A, B).

11,12

Inflammatory alterations

The hallmark pathological feature common to aneurysmal and

occlusive disease is an HIV-associated vasculitic process, the

exact mechanism of which is poorly understood (Fig. 1A, B).

13,14

Department of Vascular/Endovascular Surgery, Nelson R

Mandela School of Medicine, Durban, South Africa

Balasoobramanien Pillay, BSc, BSc (Hons), MB ChB, FCS (SA),

CVS (SA),

balapil@ialch.co.za

;

balapillay@vodamail.co.za

Department of Anatomical Pathology, School of Laboratory

Medicine and Medical Sciences, University of KwaZulu-

Natal and National Health Laboratory Service, Durban,

South Africa

Pratistadevi K Ramdial, FCPath (Anat) (SA)

Department of Cardiology, University of KwaZulu-Natal,

Durban, South Africa

Datshana P Naidoo, FRCP (SA)