Endovascular and Open Surgical Treatment of Peripheral Artery Disease inPatients with HIV

Objective Peripheral artery disease (PAD) is a highly prevalent disease world-wide that can ultimately result in limb loss. In the HIV infected population, the condition can present at a younger age and result in a significant level of morbidity and remains understudied. The purpose of this study is to evaluate outcomes related to endovascular and open surgical management of occlusive disease in HIV infected patients at a single- center. Methods A retrospective, single-center review of peripheral vascular interventions in HIV infected patients at a tertiary vascular referral center was performed between January 1, 2010 and December 31, 2019. Data collected included patient demographics including CD4 counts, highly active antiretroviral therapy (HAART), statin use, antiplatelet and/or anticoagulation status, pre and post intervention ankle-brachial indices, limb loss, number of re-interventions, follow up in vascular clinic, and 30-day mortality. Results During the study period, 27 patients (70.4% men) underwent peripheral vascular interventions while infected with HIV. Two patients had interventions on both lower extremities which were treated as separate occurrences resulting in an N of 29. The mean age was 55 years old (range, 33-67 years, median 57). Types of interventions employed included endovascular attempts (n=11[37.9%])), open surgery (n=16 [55.2%]) or hybrid operations including endovascular and open components (n=2 [6.9%]). One third of patients (n=10[34.5%]) required an initial reintervention within 30 days of their index operation and 13 patients (45%) required more than 1 reintervention on their lower extremity. A majority of patients (n=19[66%]) required reintervention on their lower extremity. Two patients (6.9%) required amputation within 30 days of their index case. Overall amputation rate regardless of time interval was 31% for this cohort. The 30-day mortality was 3.4%(n=1). Seventeen patients (58.6%) presented for their 1-year follow-up. While data was missing for five patients, a majority of the cohort had a CD4 count >500 prior to their index operation (n=12[50%]) while 13.8% of patients (n=4) had a CD4 count of less than 200 prior to their index case. There was a significant association, as expected, with number of reinterventions performed and an increased risk of amputation (p=0.0003). Additionally, open surgery as an index operation was significantly associated with increased risk of amputation (p=0.014). Mean hospital length of stay was 8.3 days (range, 0-40). The most common indications for surgery were claudication (n=9 [31%]) and acute limb ischemia (n=9 [31%]). Interestingly, there was no significant association between indication for surgery and resulting limb loss. The limb salvage rate for this patient cohort was 69%. Conclusions Peripheral artery disease continues to be a highly prevalent condition associated with significant morbidity for patients impacted and this impact tends to be greater in patients infected with HIV. Overall, HIV infected patients at our institution had a higher limb salvage rate than those reported in the literature with a significant association with limb loss in those whohad multiple re-interventions. More studies are needed to fully categorize recommendations regarding limb salvage as it pertains to HIV infected individuals. Peripheral artery disease (PAD) is a highly prevalent disease world-wide that can ultimately result in limb loss. In the HIV infected population, the condition can present at a younger age and result in a significant level of morbidity and remains understudied. The purpose of this study is to evaluate outcomes related to endovascular and open surgical management of occlusive disease in HIV infected patients at a single- center. A retrospective, single-center review of peripheral vascular interventions in HIV infected patients at a tertiary vascular referral center was performed between January 1, 2010 and December 31, 2019. Data collected included patient demographics including CD4 counts, highly active antiretroviral therapy (HAART), statin use, antiplatelet and/or anticoagulation status, pre and post intervention ankle-brachial indices, limb loss, number of re-interventions, follow up in vascular clinic, and 30-day mortality. During the study period, 27 patients (70.4% men) underwent peripheral vascular interventions while infected with HIV. Two patients had interventions on both lower extremities which were treated as separate occurrences resulting in an N of 29. The mean age was 55 years old (range, 33-67 years, median 57). Types of interventions employed included endovascular attempts (n=11[37.9%])), open surgery (n=16 [55.2%]) or hybrid operations including endovascular and open components (n=2 [6.9%]). One third of patients (n=10[34.5%]) required an initial reintervention within 30 days of their index operation and 13 patients (45%) required more than 1 reintervention on their lower extremity. A majority of patients (n=19[66%]) required reintervention on their lower extremity. Two patients (6.9%) required amputation within 30 days of their index case. Overall amputation rate regardless of time interval was 31% for this cohort. The 30-day mortality was 3.4%(n=1). Seventeen patients (58.6%) presented for their 1-year follow-up. While data was missing for five patients, a majority of the cohort had a CD4 count >500 prior to their index operation (n=12[50%]) while 13.8% of patients (n=4) had a CD4 count of less than 200 prior to their index case. There was a significant association, as expected, with number of reinterventions performed and an increased risk of amputation (p=0.0003). Additionally, open surgery as an index operation was significantly associated with increased risk of amputation (p=0.014). Mean hospital length of stay was 8.3 days (range, 0-40). The most common indications for surgery were claudication (n=9 [31%]) and acute limb ischemia (n=9 [31%]). Interestingly, there was no significant association between indication for surgery and resulting limb loss. The limb salvage rate for this patient cohort was 69%. Peripheral artery disease continues to be a highly prevalent condition associated with significant morbidity for patients impacted and this impact tends to be greater in patients infected with HIV. Overall, HIV infected patients at our institution had a higher limb salvage rate than those reported in the literature with a significant association with limb loss in those whohad multiple re-interventions. More studies are needed to fully categorize recommendations regarding limb salvage as it pertains to HIV infected individuals.