**7. Clinical features of HIV-associated large vessel vasculopathy**

These patients will usually have stigmata of advanced HIV disease and presence of other opportunistic infections may confound the clinical picture.

The majority of patients with thoracic ascending aortic aneurysms and abdominal aortic aneurysms are asymptomatic [5, 18]. Symptoms usually result from large aneurysms and include chest or upper back pain, or with symptoms related to compression of nearby structures leading to nerve dysfunction, or compression of the artery resulting in limb ischemia or thromboembolism. The initial presentation may be aortic dissection or rupture and is associated with high mortality.

Abdominal aortic aneurysms may present with abdominal, back, or flank pain, thromboembolism or limb ischemia [19].

An enlarging aneurysm of the carotid artery may present with dysphagia, airway compromise, hoarse voice, cranial nerve involvement, cerebrovascular accident and even rupture [5].

Occlusive disease is another manifestation of HIV vasculopathy [5]. It usually involves young males below the age of 40 years. It afflicts lower limbs more commonly than upper limbs. Clinical presentation can be acute or chronic. Acute presentation involves arterial thrombosis or occlusion. Chronic disease may manifest as critical limb ischemia in the form of rest pain or gangrene in more than half of the patients.

### **8. Imaging in HIV associated vasculopathy**

A basic chest radiograph is considered a reasonable initial test in a patient presenting with chest pain. It can exclude an alternative diagnosis and avoid unnecessary additional aortic imaging [18].

A transthoracic echocardiogram or transesophageal echocardiography are useful bedside tests to assess the presence of aortic enlargement and related complications such as aortic regurgitation, dissection and pericardial effusion.

Cardiac computed tomography and magnetic resonance angiography are the imaging modalities of choice and help determine the aortic size, branch vessel anatomy and presence of dissection (**Figure 5**) [18]. In patients with coexisting risk factors for coronary artery disease such as HIV, a cardiac CT is useful to exclude presence of coronary artery disease.

Digital subtraction arteriography provides higher resolution of lumen of the vessel and is better at evaluating branch vessel pathology [18].

The aortic measurements must be made at the aortic annulus, sinuses, sinotubular junction, ascending arch, and specific locations of the descending aorta as per the American society of echocardiography chamber quantification guidelines [20]. The aortic annulus is measured at peak systole whereas all other aortic dimensions are measured at end-diastole. Currently, a leading edge to leading edge method of measurement is recommended.

Large vessel disease has been studied with the aid of multiple imaging modalities. Arterial inflammation in patients with HIV has been demonstrated using 18flourodeoxyglucose-positron emission tomography [21]. Inflammation is associated with an increased cardiovascular risk amongst HIV patients. Carotid intima-media thickness has been studied in these patients with the aid of ultrasound technology [22]. An increased carotid intima thickness is a marker of adverse cardiovascular disease.

**73**

*Human Immunodeficiency Virus Associated Large Artery Disease*

The choice of imaging technique depends on the availability of resources and

*Transthoracic echocardiographic suprasternal views of an enlarged aortic arch (right) and descending thoracic* 

Currently all HIV patients with vascular disease must be managed according to standard guidelines [23]. Conservative management may be considered in a moribund severely immunosuppressed patient with multiple co-morbidities [5]. All patients

Data regarding management of ascending aortic aneurysm in patients with HIV is limited. Currently the standard guidelines on management of aortopathy are applied to these patients. Patients with ascending thoracic aortic aneurysms with symptoms due to aortic regurgitation, dissection and rupture should undergo emergent surgery as per the standard guidelines [23]. Those without symptoms but an enlarged ascending aorta greater than 55 mm are at high risk of rupture and dissection and therefore urgent surgery is recommended. Asymptomatic patients who display rapid growth of thoracoabdominal aortic aneurysms, expansion ≥1 cm per year for aneurysms less than 50 mm in diameter, must undergo surgery [24]. Aortic diameter is an important risk factor for aneurysm rupture, dissection and mortality [6]. An ascending aorta diameter of 6.0 and 7.0 cm in the descending aorta is associated with increased risk of rupture.

In patients with multiple comorbidities and high risk for surgery conservative management with afterload reducing agents such as angiotensin converting enzyme inhibitors or angiotensin receptor antagonists, can be utilised to reduce the shear stress on the aorta and prevent further expansion and dissection [6, 25]. Beta blockers have been shown to decrease aortic stress and are recommended even in patients

In centres where there is a lack of expertise in managing thoracic aortic disease, patients should be referred to an appropriate high volume centre in order to provide

For descending aortic and peripheral artery aneurysms, depending on the site and location of the aneurysm patients can undergo surgical repair of the aneurysm with good success [5]. Patients that are unable to tolerate major surgery due to poor

*DOI: http://dx.doi.org/10.5772/intechopen.85956*

expertise to interpret the results of the test.

*aorta dissection (left) in a patient with HIV.*

must be on HAART therapy.

**Figure 5.**

without systemic hypertension [6].

the best care and outcomes for such patients [25].

**9. Management of patients with HIV vasculopathy**

*Human Immunodeficiency Virus Associated Large Artery Disease DOI: http://dx.doi.org/10.5772/intechopen.85956*

**Figure 5.**

*Aortic Aneurysm and Aortic Dissection*

varicella zoster virus in the tissue.

thromboembolism or limb ischemia [19].

**8. Imaging in HIV associated vasculopathy**

such as aortic regurgitation, dissection and pericardial effusion.

vessel and is better at evaluating branch vessel pathology [18].

sary additional aortic imaging [18].

presence of coronary artery disease.

measurement is recommended.

and even rupture [5].

macrophages of the arterial wall, as well as identification of agents such as

These patients will usually have stigmata of advanced HIV disease and presence

The majority of patients with thoracic ascending aortic aneurysms and abdominal aortic aneurysms are asymptomatic [5, 18]. Symptoms usually result from large aneurysms and include chest or upper back pain, or with symptoms related to compression of nearby structures leading to nerve dysfunction, or compression of the artery resulting in limb ischemia or thromboembolism. The initial presentation

Abdominal aortic aneurysms may present with abdominal, back, or flank pain,

An enlarging aneurysm of the carotid artery may present with dysphagia, airway compromise, hoarse voice, cranial nerve involvement, cerebrovascular accident

Occlusive disease is another manifestation of HIV vasculopathy [5]. It usually involves young males below the age of 40 years. It afflicts lower limbs more commonly than upper limbs. Clinical presentation can be acute or chronic. Acute presentation involves arterial thrombosis or occlusion. Chronic disease may manifest as critical limb

A basic chest radiograph is considered a reasonable initial test in a patient presenting with chest pain. It can exclude an alternative diagnosis and avoid unneces-

A transthoracic echocardiogram or transesophageal echocardiography are useful bedside tests to assess the presence of aortic enlargement and related complications

Cardiac computed tomography and magnetic resonance angiography are the imaging modalities of choice and help determine the aortic size, branch vessel anatomy and presence of dissection (**Figure 5**) [18]. In patients with coexisting risk factors for coronary artery disease such as HIV, a cardiac CT is useful to exclude

Digital subtraction arteriography provides higher resolution of lumen of the

The aortic measurements must be made at the aortic annulus, sinuses, sinotubular junction, ascending arch, and specific locations of the descending aorta as per the American society of echocardiography chamber quantification guidelines [20]. The aortic annulus is measured at peak systole whereas all other aortic dimensions are measured at end-diastole. Currently, a leading edge to leading edge method of

Large vessel disease has been studied with the aid of multiple imaging modalities. Arterial inflammation in patients with HIV has been demonstrated using 18flourodeoxyglucose-positron emission tomography [21]. Inflammation is associated with an increased cardiovascular risk amongst HIV patients. Carotid intima-media thickness has been studied in these patients with the aid of ultrasound technology [22]. An increased carotid intima thickness is a marker of adverse cardiovascular disease.

ischemia in the form of rest pain or gangrene in more than half of the patients.

**7. Clinical features of HIV-associated large vessel vasculopathy**

may be aortic dissection or rupture and is associated with high mortality.

of other opportunistic infections may confound the clinical picture.

**72**

*Transthoracic echocardiographic suprasternal views of an enlarged aortic arch (right) and descending thoracic aorta dissection (left) in a patient with HIV.*

The choice of imaging technique depends on the availability of resources and expertise to interpret the results of the test.

## **9. Management of patients with HIV vasculopathy**

Currently all HIV patients with vascular disease must be managed according to standard guidelines [23]. Conservative management may be considered in a moribund severely immunosuppressed patient with multiple co-morbidities [5]. All patients must be on HAART therapy.

Data regarding management of ascending aortic aneurysm in patients with HIV is limited. Currently the standard guidelines on management of aortopathy are applied to these patients. Patients with ascending thoracic aortic aneurysms with symptoms due to aortic regurgitation, dissection and rupture should undergo emergent surgery as per the standard guidelines [23]. Those without symptoms but an enlarged ascending aorta greater than 55 mm are at high risk of rupture and dissection and therefore urgent surgery is recommended. Asymptomatic patients who display rapid growth of thoracoabdominal aortic aneurysms, expansion ≥1 cm per year for aneurysms less than 50 mm in diameter, must undergo surgery [24]. Aortic diameter is an important risk factor for aneurysm rupture, dissection and mortality [6]. An ascending aorta diameter of 6.0 and 7.0 cm in the descending aorta is associated with increased risk of rupture.

In patients with multiple comorbidities and high risk for surgery conservative management with afterload reducing agents such as angiotensin converting enzyme inhibitors or angiotensin receptor antagonists, can be utilised to reduce the shear stress on the aorta and prevent further expansion and dissection [6, 25]. Beta blockers have been shown to decrease aortic stress and are recommended even in patients without systemic hypertension [6].

In centres where there is a lack of expertise in managing thoracic aortic disease, patients should be referred to an appropriate high volume centre in order to provide the best care and outcomes for such patients [25].

For descending aortic and peripheral artery aneurysms, depending on the site and location of the aneurysm patients can undergo surgical repair of the aneurysm with good success [5]. Patients that are unable to tolerate major surgery due to poor physiologic reserve can be offered endovascular repair. Data comparing endovascular repair versus surgery are limited in patients with HIV. Descending aortic aneurysms depending on the size and in absence of complications can be managed with medical therapy under close observation and follow-up [6].

The medical management of patients with HIV-related vasculopathy involves a combination of HAART, treatment of hyperlipidaemia and control of traditional risk factors associated with cardiovascular disease [5].
