Severe atherosclerotic aortoiliac occlusive disease in a young HIV-infected patient

Abstract

A 39-year-old white man with CDC stage C3 HIV infection who had been diagnosed at 23 years of age presented with complaints of progressive lower limb pain, which had been aff ecting him during periods of exertion for 6 months. His lowest CD4 T-lymphocyte count had been 50 cells per μL. After 11 years of various combinations of antiretroviral drugs, the count had stabilised at 150 cells per μL despite persistent undetectable viraemia. The limb pain appeared after a 100 m walk and disappeared after a few minutes at rest. His cardiovascular risk factors were smoking and modest hypercholesterolaemia. Femoral, popliteal, and ankle pulses were palpable on both legs. There was an abdominal bruit. Ankle arterial pressure was measured with a Doppler probe: ankle-brachial pressure index was 0·98 right and 0·84 left at rest (normal more than 0·90), and fell deeply to 0·41 right, 0·30 left after a 100 m walk on the treadmill, which reproduced the claudication. A duplex ultrasound of the lower limb arteries identifi ed an 80% stenosis of the distal abdominal aorta resulting from a large atherosclerotic plaque. This fi nding was confi rmed by CT scan (fi gure, A; arrow indicates plaque), which showed extension of the plaque to the proximal lumen of both common iliac arteries. A surgical endarteriectomy and enlargement of the aortoiliac junction was done with resection of a large, partly calcifi ed and thrombosed plaque of atheroma (fi gure, B and C). 1 month later the patient completed 500 m on the treadmill (12% uphill, 3·5 km/h) without any pain or decrease of ankle-brachial pressure index. Lifestyle modifi cation and drug intervention were initiated to decrease his risk of cardiovascular event. Now, almost 1 year after surgery, the patient enjoys walking and remains free of any claudication. Coronary, cerebral, and peripheral arterial diseases are frequently seen in HIV-infected patients, since potent antiviral treatments have off ered prolonged survival. Premature atherosclerosis can result from long exposure to drug-induced hyperlipidaemia and hyperglycaemia, and also from chronic infl ammation, magnifying a classic cardiovascular risk factor such as heavy smoking.