Endovascular Treatment of Femoral Artery Pseudoaneurysm in a HIV Positive Patient – A Case Report
Article Outline
Arterial pseudoaneurysm formation has been increasingly reported in HIV positive patients and generally surgery is indicated. We paced an endovascular stent in a femoral artery pseudoaneurysm of a 30-year-old HIV-positive male. Early results of this procedure are good. We believe that implantation of an endovascular stent graft can result in a shorter hospital stay and can significantly reduce morbidity for HIV-positive patients with pseudoaneurysms.
Keywords: HIV, Pseudoaneurysms, Endovascular stent
Introduction
Vascular complications associated with HIV infection include a broad and heterogenous spectrum of vasculopathies affecting small, medium and large sized vessels. This can lead to occlusive disease, aneurysm formation and formation of arteriovenous fistulae.1
Most cases reported in the literature are of open surgical repair of aneurysms. Placement of an endovascular stent graft, an alternative modality in the treatment of pseudoaneurysms, is minimally invasive and few complications are described. Herein we describe successful endovascular management of a femoral artery pseudoaneurysm in a HIV positive patient.
Case report
A 30-year old male patient, HIV-seropositive for two years, presented with a history of left leg pain and swelling for 3 months. The patient was not on anti retroviral therapy and he did not have any previous opportunistic infections. There was no history of trauma to the groin or a history of previous arteriograms. On examination a hard mass was felt in the left inguinal area. The patient had a CD4 count of 395
cells/μl, haemoglobin of 8g/dl and a white cell count of 11.8×109/l. Ultrasound with Doppler evaluation, showed a pseudo aneurysm of the left common femoral artery associated with a heterogeneous soft tissue mass. This was followed by a CT angiogram which showed a pseudoaneuysm of the left femoral artery measuring 3.5×3.8cm together with a large adjacent hematoma. A small pseuodoaneurysm was also noted involving the right femoral artery (Fig. 1). The aorta and its branches were normal with no evidence of atherosclerosis or other vascular disease. Due to the extensive vessel wall destruction associated with HIV vasculitis thrombin injection into the pseudoaneurysm was thought to be associated with a significant risk of thrombosis of the femoral artery and was not considered as a treatment option. The patient was treated the following day with an endovascular stent. An 8mm diameter self-expanding nitinol stent graft with a poyltetrafluroethylene lining (GORE, HEMOBAHN, W.L.GORE & Associates, Signa, General Electric, Flagstaff, Arizona, USA) was inserted from the ipsilateral side using the Seldinger technique. A post-implantation angiogram showed successful exclusion of the false aneurysm (Fig. 2a and b). The small right femoral pseudoaneurysm was not stented but is being followed up clinically. He was discharged after two days and is well on four months follow up.
Fig. 1
3D reconstruction of CT angiogram shows the right and left common femoral artery pseudoaneurysms.
Fig. 2
a and b. Femoral angiogram shows the large left common femoral artery pseudoaneurysm (2a) and post stent implantation angiography shows successful occlusion of the pseudoaneurysm (Fig. 2b).
Discussion
The first report of arterial aneurysms in patients with HIV infection was by Sinzobahamvya et al. in 1989.2 Since this initial report there have been several reports describing aneurysms in patients with HIV infection.
Aneurysmal disease in patients with HIV/AIDS appears to follow two principal patterns, those associated with an identifiable infective organism and those without. Chetty and coworkers have proposed that nonmycotic aneurysmal disease occurring in HIV infected individuals may be due to a large vessel vasculitic process. Weakening of the vessel wall due to the arteritic process usually results in the formation of saccular type aneurysms. Rupture is common at an early stage with the development of pseudoaneurysms.3
Marks and Kuskov4 identified some special clinical features of HIV associated aneurysms: (1) young age; (2) no signs of atherosclerosis; (3) rapid development of focal necrotizing vasculitis with aneurysm formation and rupture; or (4) slow progressive development of granulomatous vasculitis.
The management of HIV related complications needs sound clinical judgment with individualized decision making for each patient. In patients with full-blown AIDS and severe co morbidity conservative therapy is considered appropriate. In patients with no clinical and laboratory evidence of advanced immunosupression, surgical treatment according to standard vascular practice should be offered.5
Implantation of an endovascular stent graft can result in a shorter hospital stay and a significantly shorter period before returning to normal life. General anesthesia and surgical dissection are avoided, thus diminishing morbidity. However, there have been very few reports in the literature describing the use of stents to treat such lesions as most of the reports of pseudoaneurysms are from African countries where there is considerable shortage of resources.
In conclusion, aneurysms occur in the HIV positive population and endovascular management should be considered in patients with good baseline health and when resources are available.
References
- . Vascular surgical complications of the acquired immunodeficiency syndrome. Eur J Vasc Endovasc Surg. 2002;24:473–479
- . Arterial aneurysms associated with human immunodeficiency virus (HIV) infection. Acta Chir Belg. 1989;89:185–188
- . Large artery vasculopathy in HIV-positive patients: another vasculitic enigma. Hum Pathol. 2000;31:374–379
- . Patterns of arterial aneurysms in acquired immunodeficiency disease. World J Surg. 1995;19:127–132
- . Clinical Profile of HIV-related Aneurysms. Eur J Vasc Endovasc Surg. 2000;20:235–240
PII: S1533-3167(07)00007-6
doi:10.1016/j.ejvsextra.2007.02.002
© 2007 Elsevier Ltd. All rights reserved.
Refers to article:
- Endovascular Treatment of Femoral Artery Pseudoaneurysm in a HIV Positive Patient – A Case Report , 10 May 2007
