Graft Infection after Prosthetic Bypass Surgery for Infectious Femoral Artery Pseudoaneurysm in Intravenous Drug Users: Manifestation, Management, and Prognosis

Comparison between covered-stents grafting and ligation in the treatment of infected femoral pseudoaneurysm due to intravenous drug abuse

OBJECTIVES

The study compared the outcomes between covered-stents grafting (CSG) and ligation of femoral artery (LFA) in the treatment of infected femoral pseudoaneurysm (IFP) caused by intravenous drug injection.

METHODS

From 1st January 2016 to 30th November 2021, the clinical data of patients with IFP caused by intravenous drug injection who underwent CSG (n = 31, 55.4%) and LFA (n = 25, 45.4%) are retrospectively analyzed. We compared the baseline characteristics and clinical outcomes of the two groups, including early and late mortality and morbidity.

RESULTS

A total of 56 patients were enrolled in the study, comprising 50 (89.3%) men and 6 (10.7%) women, with a mean age of 34.3 years. There was no significant difference observed between the two groups in terms of 30-day mortality (3.2% vs 0%, p = .365) and length of stay (9 [7, 12] vs 11 [8.5, 12.5] days, p = .236). However, group CSG exhibited a lower rate of intermittent claudication (0% vs 32%, p = .001), less blood loss (67.1 ± 22.5 mL vs 177.0 ± 59.8 mL, p < .001), and shorter surgery duration (57.5 ± 9.9 min vs 84.4 ± 22.8 min, p < .001) compared to group LFA. The LFA group were divided into subgroups according to the ligation site. The amputation rate of superficial femoral artery ligation group (0 vs 27.3%, p = .014) was significantly lower than common femoral artery ligation.

CONCLUSIONS

Covered-stents grafting may be a preferable treatment to LFA for IFP due to intravenous drug abuse, particularly when the entry tear is located in the common femoral artery.

An out of the box treatment for an infected pseudoaneurysm: Deep to superficial femoral artery transposition

An infected pseudoaneurysm is a condition that has become more common in recent years, with the proliferation of endovascular intervention and the use of intravenous drugs. If left untreated, an infected pseudoaneurysm can progress to rupture, which can lead to life-threatening hemorrhage. No clear consensus has been reached among vascular surgeons regarding the management of infected pseudoaneurysms, and the literature describes a wide range of treatment techniques. In the present report, we describe an "out of the box" approach to infected pseudoaneurysms: a superficial femoral artery to deep femoral artery transposition, as an alternative to ligation with or without bypass reconstruction. We also describe our experience with six patients who underwent this procedure with 100% technical success and limb salvage rates. Although we implemented this technique for cases of infected pseudoaneurysms, we believe it can also be applied to other cases of femoral pseudoaneurysms when angioplasty or graft reconstruction is not feasible. However, further research with larger cohorts is warranted.

Leriche Syndrome with Digital Gangrene: Is Aortic Bypass Grafting Safe in Intravenous Drug Abusers? A Case Report and Literature Review

A 47-year-old male with Leriche syndrome presented with digital gangrene due to TASC II type-D occlusion of the distal aorta and common iliac arteries. Open revascularization was performed using a Dacron aorto-biiliac bypass graft; however, the postoperative course revealed a nondisclosed history of intravenous opioid abuse as he went into withdrawal psychosis. Our report highlights ways to mitigate infection risk associated with prosthetic aortic grafts in suspected or confirmed intravenous drug abusers. The literature review suggests alternative strategies like aortoiliac endarterectomy, total endovascular approach using non-covered stents, or a hybrid approach. The primary use of autologous venous grafts should be considered as a last resort so that the veins are retained for future use in case of graft infection. Patient factors like comorbidities, fitness to undergo surgery, anatomical extent of occlusion, and availability of facilities/expertise can further guide the management plan owing to a lack of evidence-based guidelines.

Successful endovascular treatment with long-term antibiotic therapy for infectious pseudoaneurysm due to Klebsiella pneumoniae: A case report

BACKGROUND

Infectious common femoral artery pseudoaneurysm caused by Klebsiella pulmonary infection is a relatively infrequent entity but is potentially life and limb threatening. The management of infectious pseudoaneurysm remains controversial.

CASE SUMMARY

We reported a 79-year-old man with previous Klebsiella pneumoniae pulmonary infection and multiple comorbidities who presented with a progressive pulsate mass at the right groin and with right lower limb pain. Computed tomography angiography showed a 6 cm × 6 cm × 9 cm pseudoaneurysm of the right common femoral artery accompanied by occlusion of the right superficial femoral artery and deep femoral artery. He underwent endovascular treatment (EVT) with stent–graft, and etiology of infectious pseudoaneurysm was confirmed. Then, 3-mo antibiotic therapy was given. One-year follow-up showed the stent–graft was patent and complete removal of surrounding hematoma.

CONCLUSION

The femoral artery pseudoaneurysm can be caused by Klebsiella pneumoniae deriving from the pulmonary infection. Moreover, this unusual case highlights the use of EVT and prolonged antibiotic therapy for infectious pseudoaneurysm.