Infected femoral pseudoaneurysms from intravenous drug abuse in young adults

Ligation Alone Versus Immediate Revascularization for Femoral Artery Pseudoaneurysms Secondary to Intravascular Drug Use: A Systematic Review and Meta-Analysis

BACKGROUND

Femoral artery pseudoaneurysms (FA-PSAs) remain a common vascular aneurysmal pathology associated with intravascular drug use (IVDU). To date no internationally agreed consensus regarding optimal surgical management of FA-PSAs exists. The aim of this systematic review and meta-analysis was to determine the optimal surgical treatment of FA-PSAs associated with IVDU.

METHODS

A systematic search was undertaken following PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines identifying original studies reporting outcomes of ligation-debridement and/or excision-revascularization of FA-PSAs secondary to IVDU. Outcomes of interest were 30-day mortality, incidence of amputation at 12 months, chronic limb threatening ischemia (CLTI) at any follow-up appointment, reintervention, and bleeding.

RESULTS

A total of 39 cohort studies describing 1,217 FA-PSA operative outcomes met inclusion criteria, 993 (81.6%) treated by ligation-debridement and 224 (18.4%) by excision-revascularization. The incidence of 30-day mortality was 0.8% (n = 8) and 1.3% (n = 3) in the ligation-debridement and excision-revascularization groups, respectively, with only one study reporting mortality in both groups. This meta-analysis found no difference in amputation (8.89% vs. 8.03%, odds ratio (OR) 0.74 95% confidence interval (CI) 0.35-1.56, P = 0.42, 11 studies) or CLTI (21.5% vs. 12.4%, OR 1.24 95% CI 0.35-4.38, P = 0.74, 9 studies) after ligation and debridement compared with excision and revascularization. There was a higher incidence of reintervention (24.7% vs. 10.6%, OR 0.31 [95% CI 0.16, 0.62], P = 0.0009, 13 studies) and rebleeding (7.1% vs. 1.6%, OR 0.61 [95% CI 0.16, 2.38], P = 0.48, 5 studies) after excision and revascularization compared with ligation alone.

CONCLUSIONS

For treatments of IVDU-related FA-PSAs, this study suggests no significant difference in association of mortality, incidence of amputation, or CLTI with ligation-debridement or excision-revascularization, but a significantly higher reintervention rate and greater rebleeding rate for revascularized patients.

[Femoral pseudoaneurysms in drug addicts: About 4 cases]

PURPOSE

To describe the therapeutic management of false aneurysms of the femoral artery in drug addicts.

PATIENTS AND METHODS

We report the cases of four drug addicts with pseudoaneurysms of the femoral artery.

RESULTS

All patients were male with a mean age of 36 years. Emergency surgical treatment involved removal of the pseudoaneurysm followed by a venous graft (n=3) or patch (n=1). The post-operative period was uneventful for three patients. One patient required early revision with a second venous bypass after bleeding from the first then later a second revision for resection of infected tissue and sartorius muscle plasty to cover the groin area. Late outcome was favorable for all patients after an average 12-month follow-up.

CONCLUSION

No consensus has been reached concerning the appropriate treatment for false aneurysms of the femoral artery in drug addicts. Analyses of larger series with longer follow-ups are needed to elucidate the best emergency surgical methods capable of reducing the risk of rupture.

Death due to an unrecognized groin abscess in a drug addict: a retrospective study

Intravenous drug injection persists despite health risks and medical complications. Venous thrombosis, septic thrombophlebitis, artery necrosis, arterio-venous fistula, mycotic aneurysm, dissecting hematoma, pseudoaneurysm formation, and soft tissues infections (i.e. abscesses, cellulitis, infected ulcers), are some of the major clinical consequences lives threatening. The aim of this work is to present this unusual autoptic case of a drug addict man died for an unrecognized groin abscess referred to the Institute of Legal Medicine, University of Chieti, causing femoral vein's erosion, and to analyse the most common patterns of vascular lesions among drug addicts. It could be stimulated a new scientific debate because groin injections and their vascular complications increase over years; while soft tissue infections may hide vascular lesions' diagnosis. So physicians should have a high index of suspicion for serious vascular problems, among intravenous drug users (IDUs): prevention for avoiding groin injection and a proper treatment are necessary.

Ruptured pseudo-aneurysm of a femoral artery in a drug abuser revealed by post-mortem CT angiography

A 35-year-old drug addict was found dead in a public toilet with a ruptured groin, which was later diagnosed to be a leaking pseudo-aneurysm. Investigation at the scene revealed impressive external hemorrhage related to a groin wound. Post-mortem computed tomography angiography demonstrated an aneurysm of the right femoral artery with leak of contrast liquid. Signs of blood loss were evident at autopsy, and histological examination revealed necrosis and rupture of the pseudo-aneurysm. Toxicological analyses were positive for methadone, cocaine, citalopram, and benzodiazepines. This is the first case report in the literature of a ruptured femoral pseudo-aneurysm with a post-mortem radiological diagnosis.

Spontaneous external rupture of femoral pseudoaneurysm: fatal hemorrhage related to drug abuse

Drug abuse can lead to many life-threatening complications, the most frequent of which are overdoses and infections.We report here the case of a 38-year-old long-term drug abuser found dead in a near-sitting position on his bed at home, by his roommate. A pillow imbued with blood was recovered on his right groin region. At autopsy, we observed a ruptured pseudoaneurysm (false aneurysm) of the right common femoral artery. No obvious signs of infection were present. This article focuses the attention of the reader on an unusual complication of parenteral drug abuse with a rare but potentially lethal outcome; to the best of our knowledge, this is the first report of a fatal hemorrhage from a ruptured arterial femoral pseudoaneurysm as a complication of drug injection in the forensic literature.

Prevalence and characteristics of femoral injection among Seattle-area injection drug users

Injection drug use (IDU) into central veins, most common among long-term IDUs with no other options, can lead to severe infectious, vascular, and traumatic medical consequences. To follow-up on anecdotal reports of femoral vein injection and related medical problems in Seattle, we analyzed data from the annual survey of a community-based syringe exchange program. A total of 276 (81%) of 343 program attendees completed the survey in August 2010. Among 248 IDUs, 66% were male, 78% white, and 86% primarily injected opiates. One hundred respondents (40%) had injected into the femoral vein, 55% of whom were actively doing so, and 58% of whom reported medical complications that they attributed to the practice. Most (66%) used the femoral vein due to difficulty accessing other veins, although 61% reported other veins they could access and 67% reporting using other sites since initiating femoral injection. While injecting into muscle was more frequent among older IDUs with longer injection careers, the prevalence of femoral injection was highest among respondents in their late twenties with 2.5-6 years of injecting drugs. Multivariate analysis demonstrated an increased risk of initiating femoral injection each calendar year after 2007. Injecting into the femoral vein was also associated with white versus other race (odds ratio [OR] 2.7, 95% CI 1.3-5.4) and injection of primarily opiates versus other drugs (OR 6.3, 95% CI 1.2-32.9) and not associated with age, length of IDU career, or a history of injecting into muscle. These findings suggest a secular trend of increasing femoral injection among Seattle-area IDUs with a high rate of related medical problems. Interventions, such as education regarding the hazards of central venous injection and guidance on safe injection into peripheral veins, are needed to minimize the health consequences of femoral injection.

Injecting drug use via femoral vein puncture: preliminary findings of a point-of-care ultrasound service for opioid-dependent groin injectors in treatment

BACKGROUND

Within the UK, injecting in the femoral vein (FV), often called 'groin injecting', is a serious cause of risk and harm. This study aimed to use ultrasound scanning as a means to engage groin injectors (GIs), examine their femoral injecting sites and assess their venous health, with the intention of developing improved responses.

METHODS

Between September 2006 and March 2009, GIs attending a network of community drug treatment centres in South East England were invited to attend an ultrasound 'health-check' clinic. This paper provides a narrative account of the scanning procedure and operation of the service, with descriptive statistical analysis of GIs who attended. The analysis uses a structured, specially-developed clinical data set that incorporates a categorisation for the severity of FV damage. Case studies using ultrasound images and a link to a video are provided to illustrate the range of presentations encountered and the categorisations used for severity.

RESULTS

A total of 160 groin scans (76 bilateral and 8 unilateral) were performed in 84 GIs. The majority were men (69.0%) and the mean age of the sample was 36.8 years. The mean duration of drug use and injecting drug use was 19.7 years and 13.8 years, respectively. FV damage at the injecting site in the right groin was graded as minimal in 20 patients (25%), moderate in 27 (33.8%), severe in 16 (20.0%) and very-severe in 17 (21.3%). Corresponding figures for left FV were 24 (30.0%), 22 (27.5%), 18 (22.5%) and 16 (20.0%). Wide variation was observed in the time to the development of these grades of FV damage.

CONCLUSIONS

Modern, portable ultrasound scanners make it possible to examine the venous health of GIs in community treatment settings. Ultrasound scanning identified extensive FV damage, much hitherto-unrecognised in this population. These findings should further alert clinicians, policy-makers and patients to the urgent need for effective harm reduction responses to GI behaviour. Images of damaged FV in this paper might prove to be a useful resource for discussions about GI risks.