Pseudoaneurysms of large arteries associated with AIDS

Background: Several vascular complications are known to occur in association with the acquired immunodeficiency syndrome (AIDS) and recent publications have called attention to the development of pseudoaneurysms of large arteries in patients with AIDS. Case report: We report on 2 patients with AIDS aged 23 and 31 years with pseudoaneurysms of the abdominal aorta and common iliac arteries. After clinical and radiological evaluation by arteriography and computed tomography, the patients were submitted to aneurysmectomy, with the placement of a patch of dacron in the first case and the interposition of a right aorto-iliac and left femoral prosthesis in the second. The second patient developed new aneurysms of the right subclavian and left popliteal arteries 2 months after surgery. Proximal ligation of the right subclavian artery was performed to treat the first aneurysm and resection and interposition of a reversed saphenous vein was carried out to treat the pseudoaneurysm of the popliteal artery. Histopathological examination of the popliteal artery revealed necrotizing arteritis.


INTRODUCTION
S e v e r a l c o m p l i c a t i o n s h a v e b e e n repor ted as being associated with the acquired immunodeficiency syndrome (AIDS).In addition to Kaposi's sarcoma, some vascular manifestations have been reported, such as vasculitis, [1][2][3][4] and cutaneous vascular tumors. 5Some reports have called attention to the possibility that patients with AIDS will develop pseudoaneurysms of the large arteries.

6,7
The objective of the present report was t o d e s c r i b e t w o p a t i e n t s w i t h pseudoaneurysms of the abdominal aorta and/or iliac arteries associated with AIDS.

Case 1
A 23 year old black male, a machine operator, complained of burning pain that had lasted for a period of one year on his left flank, at times with colic, which irradiated to the epigastrium and mesogastrium.The signs and symptoms had worsened during r e c e n t m o n t h s a n d s e v e r e a r t e r i a l hypertension was diagnosed on the occasion of his first medical visit, with institution of treatment.The patient reported pulmonary tuberculosis treated one year earlier.He denied alcoholism, cigarette smoking, family history of aneurysms, use of injectable drugs, sexual promiscuity or homosexuality.He reported partial amaurosis due to optic neuritis 2 years earlier.
O n o n e o f h i s r e t u r n v i s i t s f o r reevaluation, a pulsatile, expansive 5 x 5 cm tumor mass, with no mur mur, was palpated in the epigastrium, with all distal pulses palpable and symmetrical.Arterial pressure was 190 x 160 mmHg and heart rate 92 bpm.Under these conditions, the patient was referred to the Division of Vascular Surgery and Angiology of the Faculty of Medicine of Ribeirão Preto, University of São Paulo (FMRP-USP).The patient was admitted for evaluation, with a diagnosis of abdominal aortic aneurysm.Arteriography revealed two saccular abdominal aortic aneurysms, one of them suprarenal on the left, and the other infrarenal, as well as occlusion of the left renal arter y (Fig. 1).Serologic tests for syphilis, hepatitis D and Chagas' disease were negative.HIV infection was diagnosed by an immunoenzymatic test (ELISA) and by latex particle agglutination.The results of these serology tests became known after surgical treatment.Laparotomy revealed an aortic pseudoaneurysm between the left renal artery and the superior mesenteric artery.The patient was submitted to aneurysmectomy of the abdominal aorta and the arter y was closed with a dacron patch.Culture of the thrombi obtained from the aneurysm was negative.No biopsy of the abdominal artery was obtained.
The patient evolved well during the immediate postoperative period.After discharge from the hospital, he was found to continue to have arterial hypertension despite the use of various hypotensive drugs.The condition was defined as renovascular hypertension and the patient was submitted to left nephrectomy three months after the first surger y.The kidney presented hyaline arterionephrosclerosis and secondary renal atrophy.The patient had a relatively good course and has been followed up at the infectious diseases outpatient clinic for 49 months (up to November 1998) for the control of the basal disease (AIDS).operator, was referred to FMRP-USP with a complaint of pain of the iliac fossae, especially on the left, irradiating to the left thigh for the preceding 3 months.The pain a m e l i o r a t e d w i t h r e s t .H e r e p o r t e d a worsening of symptoms during the last month.He had a history of cigarette smoking, use of intravenous drugs, gonorrhea and sexual promiscuity.He denied a family history of aneurysms.Arterial pressure was 130 x 80 mmHg and heart rate 88 bpm.Laboratory work-up revealed hepatitis B and HIV infection by the immunoenzymatic test (ELISA) and by latex par ticle agglutination.A pulsatile, expansive 10 x 10 cm mass was palpable in the left iliac fossa, with systolic fremitus and murmur, and a 5 x 5 cm mass with the same characteristics as the previous one was palpable in the right iliac fossa.Computed tomography revealed pseudoaneurysms of the iliac arteries, an abdominal aortic pseudoaneurysm close to the left renal artery, spleen cysts and/or a b s c e s s e s a n d r e t r o p e r i t o n e a l a n d m e s e n t e r i c a d e n o m e g a l y ( F i g . 2 ) .Aortography revealed an abdominal aortic pseudoaneurysm close to the left renal artery and 2 enormous pseudoaneurysms of the common iliac arteries (Fig. 3).
T h e p a t i e n t w a s s u b m i t t e d t o exploratory laparotomy in April 1997 and a saccular pseudoaneurysm measuring 4 cm in diameter, with a 1.5 cm neck was detected on the anterior wall of the juxtarenal aorta, in addition to two pseudoaneurysms of the common iliac arteries, one on the right measuring 8 cm in diameter, and one on the left measuring 10 cm.A bifurcate right aortoiliac and a left common femoral dacron prosthesis were inserted.Thrombus cultures w e r e n e g a t i v e a n d h i s t o p a t h o l o g i c a l examination of preaortic lymphatic ganglia showed reactional hyperplasia accompanied by granulomatous inflammation.Ziehl-Neelsen and GMS staining did not reveal the presence of fungi.
The patient evolved well during the

DISCUSSION
Since the publication of the first case of a ruptured and Salmonella 8 -infected abdominal aortic aneurysm, other reports relating aneur ysms to AIDS have been published. 6,7,9 Salmonella is known to pose a high r i s k , per se , f o r t h e d e v e l o p m e n t o f abdominal aortic infection in patients aged over 50 years. 10Johansen and Devin repor ted mycotic aor tic aneur ysms in immunodepressed patients. 11On the other hand, tuberculous mycotic aneurysms of both femoral arteries have been detected after vaccination with Calmette-Guérin bacillus in p a t i e n t s s u b m i t t e d t o i m m u n o t h e r a p y, suggesting that vascular tissue can present an inflammatory response to infection.
12 Despite the publication of cases of infected atherosclerotic aneurysm, 8,13 most HIV-infected patients probably develop necrotizing vasculitis of the vascular wall followed by the formation of false aneurysms, as was the case for the present patients.9 In a review of 14 cases of arteritis in patients with AIDS, Calabrese et al described several pathological alterations. 14 Radiological examination (computed tomography or ar teriography) usually characterizes the aneurysms of these patients a s b e i n g o f t h e s a c c u l a r t y p e o r pseudoaneur ysms.In the two patients reported here, the aneurysms were found to be saccular or pseudoaneur ysms during preoperative evaluation and confirmed as pseudoaneurysms during the transoperative period.
0][21] The latter procedure was adopted here since neither patient showed local signs of purulent secretion during laparotomy and thrombus culture was negative.Antibiotic treatment with cefotriaxone was maintained in both patients for one week and discontinued after discharge from the hospital.Some authors recommend the p r o l o n g e d m a i n t e n a n c e o f a n t i b i o t i c treatment for operated patients because of the recurrence of infection in immunodeficient subjects.
S o m e e t h i c a l a s p e c t s s h o u l d b e considered in the surgical treatment of HIVinfected patients.Should restorative vascular s u r g e r y f o r t h e c o r r e c t i o n o f a r t e r i a l aneurysms be indicated for patients with a lethal disease?Since these are usually young patients (23 and 31 years of age in the present case), with better current perspectives of survival and probable recovery and of a return to their professional activities, our team opted for surgical treatment.This ethical question was also analyzed by Dupont et al.  in 1989 and those investigators also opted for intervention when they published the first case of abdominal aortic aneur ysm in a patient with AIDS.It is clear that both in general surgery and in vascular surgery the surgical team should double its precautions in view of the risk of contamination of team members (double gloves, caps, masks, protective g l a s s e s , e t c . ) d u r i n g t h e i n t r a -a n d postoperative period.
Finally, it may be expected that, with the increase in the number of AIDS patients in the population and their extended life expectancy, the incidence of aneur ysms among these patients will increase over the next few years.

Figure 1 -
Figure 1 -Abdominal aortogram of case 1, showing a saccular aneurysm (pseudoaneurysm) of the abdominal aorta and occlusion of the left renal artery.

Figure 3 -
Figure 3 -Abdominal aortogram of case 2, showing an enormous pseudoaneurysm of the left common iliac artery.