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Parsi K, De Maeseneer M, van Rij AM, Rogan C, Bonython W, Devereux JA, Lekich CK, Amos M, Bozkurt AK, Connor DE, Davies AH, Gianesini S, Gibson K, Gloviczki P, Grabs A, Grillo L, Hafner F, Huber D, Iafrati M, Jackson M, Jindal R, Lim A, Lurie F, Marks L, Raymond-Martimbeau P, Paraskevas P, Ramelet AA, Rial R, Roberts S, Simkin C, Thibault PK, Whiteley MS. Guidelines for management of actual or suspected inadvertent intra-arterial injection of sclerosants. Phlebology 2024:2683555241260926. [PMID: 39046331 DOI: 10.1177/02683555241260926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/25/2024]
Abstract
BACKGROUND Inadvertent intra-arterial injection of sclerosants is an uncommon adverse event of both ultrasound-guided and direct vision sclerotherapy. This complication can result in significant tissue or limb loss and significant long-term morbidity. OBJECTIVES To provide recommendations for diagnosis and immediate management of an unintentional intra-arterial injection of sclerosing agents. METHODS An international and multidisciplinary expert panel representing the endorsing societies and relevant specialities reviewed the published biomedical, scientific and legal literature and developed the consensus-based recommendations. RESULTS Actual and suspected cases of an intra-arterial sclerosant injection should be immediately transferred to a facility with a vascular/interventional unit. Digital Subtraction Angiography (DSA) is the key investigation to confirm the diagnosis and help select the appropriate intra-arterial therapy for tissue ischaemia. Emergency endovascular intervention will be required to manage the risk of major limb ischaemia. This includes intra-arterial administration of vasodilators to reduce vasospasm, and anticoagulants and thrombolytic agents to mitigate thrombosis. Mechanical thrombectomy, other endovascular interventions and even open surgery may be required. Lumbar sympathetic block may be considered but has a high risk of bleeding. Systemic anti-inflammatory agents, anticoagulants, and platelet inhibitors and modifiers would complement the intra-arterial endovascular procedures. For risk of minor ischaemia, systemic oral anti-inflammatory agents, anticoagulants, vasodilators and antiplatelet treatments are recommended. CONCLUSION Inadvertent intra-arterial injection is an adverse event of both ultrasound-guided and direct vision sclerotherapy. Medical practitioners performing sclerotherapy must ensure completion of a course of formal training (specialty or subspecialty training, or equivalent recognition) in the management of venous and lymphatic disorders (phlebology), and be personally proficient in the use of duplex ultrasound in vascular (both arterial and venous) applications, to diagnose and provide image guidance to venous procedure. Expertise in diagnosis and immediate management of an intra-arterial injection is essential for all practitioners performing sclerotherapy.
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Affiliation(s)
- Kurosh Parsi
- International Union of Phlebology (UIP), Chatswood, NSW, Australia
- Australasian College of Phlebology (ACP), Chatswood, NSW, Australia
- Department of Dermatology, St Vincent's Hospital, Sydney, NSW, Australia
- Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
- Dermatology, Phlebology and Fluid Mechanics Laboratory, St Vincent's Centre for Applied Medical Research, Darlinghurst, NSW, Australia
| | | | - Andre M van Rij
- Australasian College of Phlebology (ACP), Chatswood, NSW, Australia
- Department of Surgical Sciences, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Christopher Rogan
- Interventional Radiology Society of Australasia (IRSA), Camperdown, NSW, Australia
- Department of Medical Imaging, Sydney Adventist Hospital, Sydney, NSW, Australia
- Macquarie University Hospital, Sydney, NSW, Australia
| | - Wendy Bonython
- Faculty of Law, Bond University, Gold Coast, QLD, Australia
| | - John A Devereux
- University of Queensland Law School, University of Queensland, Saint Lucia, QLD, Australia
| | | | - Michael Amos
- Department of Anaesthesiology, Concord Hospital, Sydney, NSW, Australia
| | - Ahmet Kursat Bozkurt
- International Union of Phlebology (UIP), Chatswood, NSW, Australia
- Department of Cardiovascular Surgery, Istanbul University, Istanbul, Turkie
| | - David E Connor
- Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
- Dermatology, Phlebology and Fluid Mechanics Laboratory, St Vincent's Centre for Applied Medical Research, Darlinghurst, NSW, Australia
| | - Alun H Davies
- European College of Phlebology, Rotterdam, The Netherlands
- Vascular Surgery, Imperial College London, Charing Cross and St Mary's Hospital, London, UK
| | - Sergio Gianesini
- International Union of Phlebology (UIP), Chatswood, NSW, Australia
- Vascular Surgery, University of Ferrara, Ferrara, Italy
| | | | - Peter Gloviczki
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Anthony Grabs
- Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
- Department of Vascular Surgery, St Vincent's Hospital, Sydney, NSW, Australia
| | - Lorena Grillo
- International Union of Phlebology (UIP), Chatswood, NSW, Australia
- Vascular Surgery, University of Medical Sciences (UCIMED), San Jose, Costa Rica
| | - Franz Hafner
- Division of Angiology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - David Huber
- Art of Vein Care, Wollongong, NSW, Australia
| | - Mark Iafrati
- American Venous Forum (AVF), East Dundee, IL, USA
- Vanderbilt University Medical Center, Vanderbuilt University, Nashville, TN, USA
| | - Mark Jackson
- Australian and New Zealand Society for Vascular Surgery(ANZSVS), Melbourne, VIC, Australia
- Department of Vascular Surgery, Gold Coast University Hospital, Gold Coast, QLD, Australia
- School of Medicine, Griffith University, Gold Coast, QLD, Australia
| | - Ravul Jindal
- International Union of Phlebology (UIP), Chatswood, NSW, Australia
- Vascular Surgery, Fortis Hospital, Mohali, India
| | - Adrian Lim
- Department of Dermatology, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Fedor Lurie
- International Union of Phlebology (UIP), Chatswood, NSW, Australia
- Jobst Vascular Institute, Toledo, OH, USA
- Section of Vascular Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Lisa Marks
- Australasian College of Phlebology (ACP), Chatswood, NSW, Australia
- Brighton Day Surgery, Adelaide, SA, Australia
| | - Pauline Raymond-Martimbeau
- International Union of Phlebology (UIP), Chatswood, NSW, Australia
- Dallas Non-Invasive Vascular Laboratory and Vein Institute of Texas, Dallas, TX, USA
| | | | | | - Rodrigo Rial
- International Union of Phlebology (UIP), Chatswood, NSW, Australia
- Vascular and Endovascular Surgery, University Hospital HM Madrid, Torrelodones, Spain
| | | | - Carlos Simkin
- International Union of Phlebology (UIP), Chatswood, NSW, Australia
- Clínica Simkin, Buenos Aires, Argentina
| | - Paul K Thibault
- International Union of Phlebology (UIP), Chatswood, NSW, Australia
- Australasian College of Phlebology (ACP), Chatswood, NSW, Australia
- Central Vein and Cosmetic Medical Centre, Newcastle, NSW, Australia
| | - Mark S Whiteley
- The College of Phlebology, Guildford, UK
- The Whiteley Clinic, Guildford, UK
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Soderquist M, Delgado G, Abdelfattah H, Thoder J, Solarz M. Necrotic Upper-Extremity Infections in People Who Inject Drugs: A Case Series. J Hand Surg Am 2024; 49:459-464. [PMID: 37178065 DOI: 10.1016/j.jhsa.2023.04.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 03/15/2023] [Accepted: 04/05/2023] [Indexed: 05/15/2023]
Abstract
PURPOSE Our institution has noted an increase in severe upper-extremity infections within the last 2 years. These patients have required transhumeral amputation. This case series demonstrates some of the catastrophic outcomes of these infections in people who inject drugs, which has been postulated to be related to the addition of xylazine to injectable drugs in our community. METHODS The study included patients presenting with severe upper-extremity infections resulting from intravenous drug use and requiring upper-extremity amputation between January 1, 2020 and September 30, 2022 at a single, urban, level 1 trauma center. Patient information and clinical images were collected through retrospective chart review. RESULTS Eight patients were identified at our institution with extensive necrosis of the skin and soft tissues in the forearm and hand, resulting in exposure of the radius and ulna. None of these patients had viable motor function in the hand and presented with a lack of sensation. All underwent transhumeral amputations, including bilaterally in one case. CONCLUSIONS The patients in this case series self-reported injection of tranquilizer-containing drugs, and xylazine has been reported to be present in 91% of heroin and fentanyl samples in our community. Although more studies are needed to confirm that xylazine is the definitive cause of the extensive tissue necrosis seen in these patients, we have found the severity of these infections to be noteworthy, given the likely expansion of xylazine to drug samples beyond our region. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic V.
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Affiliation(s)
- Melissa Soderquist
- Department of Orthopaedic Surgery and Sports Medicine, Temple University Hospital, Philadelphia, PA.
| | - Gabriel Delgado
- Lewis Katz School of Medicine at Temple University, Philadelphia, PA
| | - Hesham Abdelfattah
- Department of Orthopaedic Surgery and Sports Medicine, Temple University Hospital, Philadelphia, PA
| | - Joseph Thoder
- Department of Orthopaedic Surgery and Sports Medicine, Temple University Hospital, Philadelphia, PA
| | - Mark Solarz
- Department of Orthopaedic Surgery and Sports Medicine, Temple University Hospital, Philadelphia, PA
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3
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Mannaioni G, Lugoboni F. Precautions in the management of opioid agonist therapy: from target population characteristics to new formulations and post-marketing monitoring - a focus on the Italian system. Drugs Context 2023; 12:2023-2-6. [PMID: 37664791 PMCID: PMC10470859 DOI: 10.7573/dic.2023-2-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 06/29/2023] [Indexed: 09/05/2023] Open
Abstract
Opioid use disorder (OUD) is a serious medical condition with vast social, health and economic impact. Individuals with OUD are prescribed opioid agonist therapies, such as methadone, levomethadone, buprenorphine or naloxone/buprenorphine, to reduce the risks associated with illegal substance abuse, eventually leading to opioid use abstinence. The OUD population has peculiar frailties, mainly related to the psychiatric sphere, which may jeopardize their therapeutic course. Amongst the possible phenomena that may contribute to treatment failure, opioid agonist therapy misuse and diversion are of utmost importance, leading to serious repercussions for patients as well as for national health systems. To minimize the consequences related to these practices, it is necessary to implement cross-cutting precautions, from the formulation of abuse-deterrent drugs to the implementation of a national monitoring system that oversees the health situation and signals when action is needed. Based on these premises, this article focuses on data and insights concerning the Italian territory.
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Affiliation(s)
- Guido Mannaioni
- Sezione di Farmacologia e Tossicologia dell’Università degli Studi di Firenze, Florence,
Italy
- Struttura Organizzativa Dipartimentale di Tossicologia Medica e Centro Antiveleni, Azienda Ospedaliera Universitaria Careggi, Florence,
Italy
| | - Fabio Lugoboni
- Unità di Medicina delle Dipendenze, Dipartimento di Medicina Interna, Azienda Ospedaliera Universitaria Integrata di Verona, Policlinico “G.B. Rossi”, Verona,
Italy
- International Society of Substance Use Professionals, Italian Chapter
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4
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Intra-arterial injection of Diclofenac by informal health practitioner: A rare complication of a common drug. Ann Med Surg (Lond) 2022; 83:104736. [DOI: 10.1016/j.amsu.2022.104736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 09/18/2022] [Accepted: 09/18/2022] [Indexed: 11/19/2022] Open
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5
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Blum AG, Gillet R, Athlani L, Prestat A, Zuily S, Wahl D, Dautel G, Gondim Teixeira P. CT angiography and MRI of hand vascular lesions: technical considerations and spectrum of imaging findings. Insights Imaging 2021; 12:16. [PMID: 33576888 PMCID: PMC7881081 DOI: 10.1186/s13244-020-00958-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Accepted: 12/29/2020] [Indexed: 12/30/2022] Open
Abstract
Vascular lesions of the hand are common and are distinct from vascular lesions elsewhere because of the terminal vascular network in this region, the frequent hand exposure to trauma and microtrauma, and the superficial location of the lesions. Vascular lesions in the hand may be secondary to local pathology, a proximal source of emboli, or systemic diseases with vascular compromise. In most cases, ischaemic conditions are investigated with Doppler ultrasonography. However, computed tomography angiography (CTA) or dynamic contrast-enhanced magnetic resonance angiography (MRA) is often necessary for treatment planning. MR imaging is frequently performed with MRA to distinguish between vascular malformations, vascular tumours, and perivascular tumours. Some vascular tumours preferentially affect the hand, such as pyogenic granulomas or spindle cell haemangiomas associated with Maffucci syndrome. Glomus tumours are the most frequent perivascular tumours of the hand. The purpose of this article is to describe the state-of-the-art acquisition protocols and illustrate the different patterns of vascular lesions and perivascular tumours of the hand.
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Affiliation(s)
- Alain G Blum
- Service D'imagerie Guilloz, CHRU Nancy, 54 000, Nancy, France.
| | - Romain Gillet
- Service D'imagerie Guilloz, CHRU Nancy, 54 000, Nancy, France
| | - Lionel Athlani
- Department of Hand Surgery, Plastic and Reconstructive Surgery, Centre Chirurgical Emile Gallé, CHRU de Nancy, 54 000, Nancy, France
| | | | - Stéphane Zuily
- Vascular Medicine Division and Regional Competence Center for Rare Vascular and Systemic Autoimmune Diseases and Vascular Medicine Division, CHRU Nancy, INSERM UMR-S 1116 University of Lorraine, 54 000, Nancy, France
| | - Denis Wahl
- Vascular Medicine Division and Regional Competence Center for Rare Vascular and Systemic Autoimmune Diseases and Vascular Medicine Division, CHRU Nancy, INSERM UMR-S 1116 University of Lorraine, 54 000, Nancy, France
| | - Gilles Dautel
- Department of Hand Surgery, Plastic and Reconstructive Surgery, Centre Chirurgical Emile Gallé, CHRU de Nancy, 54 000, Nancy, France
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Détriché G, Goudot G, Khider L, Galloula A, Guillet M, Lillo-Le Louët A, Messas E, Mirault T. Acute Digital Ischemia After Arterial Injection of Crushed Zolpidem Tablets: Role of Microcrystalline Cellulose? A Case Report. Front Pharmacol 2020; 11:560382. [PMID: 33390940 PMCID: PMC7775664 DOI: 10.3389/fphar.2020.560382] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 10/23/2020] [Indexed: 11/13/2022] Open
Abstract
Literature is scarce on acute ischemia after intra-arterial injection of crushed tablets and no effective medical treatment against the progression of lesions is reported. The only factor able to modify the outcome is the delay between injection and management by a specialized vascular team. Moreover the risk of necrosis seems higher after benzodiazepine intra-arterial injection than with other drugs. We tried to find out mechanistic explanations. We report on the case of a 31-year-old drug addict woman who self-injected into her left brachial artery crushed tablets of zolpidem. She developed an acute ischemia of the left hand, with necrosis of the intermediate and distal phalanges of fingers II, III, and IV. Angiogram of the left upper arm confirmed the distal arterial occlusions with no run-off after the palmar arch in the necrotic fingers. Once she was admitted into our vascular unit, intravenous vasodilator therapy by iloprost, heparin and local protective care were rapidly introduced. After delineation between living and necrotic tissues, she required distal amputations of the affected fingers. The clinical severity of arterial injections of benzodiazepine tablets is linked to the association of several pathophysiological mechanisms. Rather than related benzodiazepine pharmacologic effects with tissue ischemia, by the inhibition of phosphodiesterase, a vasodilator intermediate, or through the peripheral benzodiazepine-type receptor, the predominant mechanism is more likely in relation with microcrystalline cellulose, one component of zolpidem tablets, known as potential embolic agents. They are insoluble and resistant to degradation in water. These properties are probably prominent in the case we described here. Through this case report we want to drag attention of physicians in charge of a patient with acute ischemia after crushed tablet accidental intra-arterial injection, not only to look at the drug injected but also the other components of the tablet and especially to microcrystalline cellulose.
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Affiliation(s)
- Grégoire Détriché
- Vascular Medicine, Hôpital Européen Georges-Pompidou, Assistance Publique Hôpitaux de Paris, APHP centre Université de Paris, Paris, France.,INSERM U970, Paris Cardiovascular Research Center, Paris, France
| | - Guillaume Goudot
- Vascular Medicine, Hôpital Européen Georges-Pompidou, Assistance Publique Hôpitaux de Paris, APHP centre Université de Paris, Paris, France.,Physics for Medicine Paris, INSERM U1273, ESPCI Paris, CNRS FRE 2031, PSL Research University, Paris, France
| | - Lina Khider
- Vascular Medicine, Hôpital Européen Georges-Pompidou, Assistance Publique Hôpitaux de Paris, APHP centre Université de Paris, Paris, France.,Physics for Medicine Paris, INSERM U1273, ESPCI Paris, CNRS FRE 2031, PSL Research University, Paris, France
| | - Alexandre Galloula
- Vascular Medicine, Hôpital Européen Georges-Pompidou, Assistance Publique Hôpitaux de Paris, APHP centre Université de Paris, Paris, France
| | - Matthieu Guillet
- Vascular Medicine, Hôpital Européen Georges-Pompidou, Assistance Publique Hôpitaux de Paris, APHP centre Université de Paris, Paris, France
| | - Agnès Lillo-Le Louët
- Centre Régional de Pharmacovigilance de Paris-Hôpital Européen Georges-Pompidou, Assistance Publique Hôpitaux de Paris, APHP centre Université de Paris, Paris, France
| | - Emmanuel Messas
- Vascular Medicine, Hôpital Européen Georges-Pompidou, Assistance Publique Hôpitaux de Paris, APHP centre Université de Paris, Paris, France.,INSERM U970, Paris Cardiovascular Research Center, Paris, France.,Physics for Medicine Paris, INSERM U1273, ESPCI Paris, CNRS FRE 2031, PSL Research University, Paris, France.,VASC European Research Network, Centre de Référence des Maladies Vasculaires Rares, Hôpital Européen Georges-Pompidou, Assistance Publique Hôpitaux de Paris, APHP centre Université de Paris, Paris, France
| | - Tristan Mirault
- Vascular Medicine, Hôpital Européen Georges-Pompidou, Assistance Publique Hôpitaux de Paris, APHP centre Université de Paris, Paris, France.,INSERM U970, Paris Cardiovascular Research Center, Paris, France.,Physics for Medicine Paris, INSERM U1273, ESPCI Paris, CNRS FRE 2031, PSL Research University, Paris, France.,VASC European Research Network, Centre de Référence des Maladies Vasculaires Rares, Hôpital Européen Georges-Pompidou, Assistance Publique Hôpitaux de Paris, APHP centre Université de Paris, Paris, France
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7
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8
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Bianchini Massoni C, Mariani E, De Troia A, Perini P, Nabulsi B, D'Ospina RM, Freyrie A. Outcomes of Surgical and Endovascular Treatment for Arterial Lesions in Intravenous Drug Abusers. Ann Vasc Surg 2020; 69:133-140. [PMID: 32561239 DOI: 10.1016/j.avsg.2020.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 05/28/2020] [Accepted: 06/01/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND The objective of this study is to report an 18-year single-center experience in the surgical and endovascular treatment of arterial complications due to self-injection in drug abuser patients. METHODS This retrospective single-center study was conducted analyzing a prospectively collected database including all endovascular or surgical procedures performed from January 2007 to December 2019 for any arterial complication due to self-injection in drug abuser patient. Collected data were patient demographic and comorbidity, site and type of arterial lesion (pseudoaneurysm [PA], arteriovenous fistula [AVF]), signs of systemic or local infection, and procedural data (endovascular/surgical treatment). End points were rate of postoperative complications, reintervention rate, limb salvage, and patients' early and long-term survival. RESULTS In 11 patients (median age 36 years, range 27-47; male 73%), 13 arterial lesions were treated: 10 (77%) PA, 2 (15%) PA associated with AVF, and 1 (8%) isolated AVF. Arterial lesion involved common femoral artery in 5 (38%), superficial femoral artery in 4 (31%), profunda femoral artery in 1 (8%), brachial artery in 2 (15%), and subclavian artery in 1 (8%). Signs of infections were present in 9 of the 13 cases (69%). The treatment was surgical in 11 (85%) cases: 7 interposition graft (6 great saphenous vein, 1 arterial cryopreserved homograft), 2 direct reconstruction, 1 patch plasty with pericardium bovine patch, and 1 arterial ligation. Endovascular treatment was performed in 2 cases: 1 noninfected PA of the superficial femoral artery, and 1 55-mm PA of the postvertebral segment of the right subclavian artery with clinical sign of hemodynamic instability. At 1 month, postoperative complication rate was 8% (one lower limb claudication after superficial femoral artery ligation). Reintervention rate was 8% (interposition graft rupture for repeated self-injections). Limb salvage and patient survival were both 100%. Median follow-up was 5 years (range 1 month to 11.3 years); surgical group: median 8.2 years (range 2 months to 11.3 years); endovascular group: median 3.5 months (range 1-6). During follow-up, neither complications nor reinterventions occurred, and limb salvage was 100% for both groups. At 2, 4, and 6 years, overall estimated patient survival was 91%, 81%, and 81%, respectively, with no procedure-related death. CONCLUSIONS After surgical or endovascular management of arterial lesions due to self-injection in drug abuser patients, complications occur mainly in the postoperative period. During follow-up, the surgical procedures have low rate of complications, reinterventions, and procedure-related mortality, whereas for the endovascular treatment the mid-term outcomes remain unknown.
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Affiliation(s)
| | - Erica Mariani
- Department of Medicine and Surgery, Vascular Surgery, University of Parma, Parma, Italy
| | - Alessandro De Troia
- Department of Medicine and Surgery, Vascular Surgery, University of Parma, Parma, Italy
| | - Paolo Perini
- Department of Medicine and Surgery, Vascular Surgery, University of Parma, Parma, Italy
| | - Bilal Nabulsi
- Department of Medicine and Surgery, Vascular Surgery, University of Parma, Parma, Italy
| | - Rita Maria D'Ospina
- Department of Medicine and Surgery, Vascular Surgery, University of Parma, Parma, Italy
| | - Antonio Freyrie
- Department of Medicine and Surgery, Vascular Surgery, University of Parma, Parma, Italy
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9
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Shah P, Patel J, Gandhi F. Evaluation and management of accidental intra-arterial injection in the antecubital fossa. INDIAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY 2020. [DOI: 10.4103/ijves.ijves_7_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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10
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Lokoff A, Maynes JT. The incidence, significance, and management of accidental intra-arterial injection: a narrative review. Can J Anaesth 2019; 66:576-592. [PMID: 30877587 DOI: 10.1007/s12630-019-01327-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Revised: 12/05/2018] [Accepted: 12/08/2018] [Indexed: 10/27/2022] Open
Abstract
This narrative review discusses the incidence, risk factors, mechanisms of injury, complications, and treatment regimens for accidental intra-arterial injection of medications. Despite awareness of the issue and the establishment of safety recommendations by national agencies, accidental iatrogenic intra-arterial injection of medications continues to occur. Most of these injuries are caused by accidental injection into an established arterial cannula or the inadvertent and unrecognized cannulation of an artery instead of a vein. Although many medications have been injected into arteries without significant consequence, a number of drugs are consistently associated with severe morbidity, including the need for amputation, making early incident recognition and treatment vital. Accidental intra-arterial injection of medications has also been increasingly reported in those who use illicit drugs, as these intravenous injection attempts can be misdirected into an artery. These reports have improved understanding of these injuries and possible treatment modalities. While the characteristics of injuries from illicit injections are diverse and the optimal treatment modalities are still uncertain, a regimen that includes anticoagulation and intra-arterial injection of thrombolytics and prostaglandins may improve outcomes. Steroids, vasodilators, and sympathetic blocks do not appear to influence amputation rates. Owing to the small and sporadic number of cases, no definitive clinical trial evidence exists, but the treatment modalities found to be useful in the illicit intra-arterial injection group may benefit treatment of similar iatrogenic injuries.
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Affiliation(s)
- Andrew Lokoff
- Department of Anesthesia and Pain Medicine, Hospital for Sick Children, Toronto, ON, Canada. .,Department of Anesthesia, University of Toronto, Toronto, ON, Canada.
| | - Jason T Maynes
- Department of Anesthesia and Pain Medicine, Hospital for Sick Children, Toronto, ON, Canada.,Department of Anesthesia, University of Toronto, Toronto, ON, Canada
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11
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Zhang H, Kumar S. Unintended intra-arterial injection of contrast of an intracranial CT angiography. Radiol Case Rep 2018; 14:41-43. [PMID: 30305864 PMCID: PMC6175775 DOI: 10.1016/j.radcr.2018.09.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2018] [Revised: 08/30/2018] [Accepted: 09/03/2018] [Indexed: 12/02/2022] Open
Abstract
Computed tomography angiography (CTA) is widely used to evaluate intracranial vascular disease. We report a case of intracranial CTA with unintended intra-arterial (IA) injection of contrast due to IA placement of an intravenous cannula, which results in a selective left vertebral artery IA CTA. Knowledge of anatomy is essential in analyzing the whole study and identifying the error. In clinical practice, it is important to avoid and recognize a wrongly placed intravenous cannula. And bolus tracking protocol might play a role as a gatekeeper.
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Affiliation(s)
- Han Zhang
- Neuroradiology, Level B1, National Neuroscience Institute, 11 Jalan Tan Tock Seng, Singapore 308433, Singapore
| | - Sumeet Kumar
- Neuroradiology, Level B1, National Neuroscience Institute, 11 Jalan Tan Tock Seng, Singapore 308433, Singapore
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12
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Kamphuis SJM, Jandali AR, Jung FJ, Sproedt J. [Compartment syndrome of the forearm after intra-arterial self-injection : With a mixture of methadone, flunitrazepam, saliva and water]. Unfallchirurg 2018; 121:669-673. [PMID: 29556689 DOI: 10.1007/s00113-018-0482-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
A drug-addicted patient injected himself intra-arterially with a mixture of methadone, flunitrazepam, saliva and water. The resulting compartment syndrome could be treated by fasciotomy and multiple debridement, with which a major amputation could be prevented. The course of the treatment and the resulting functional results are described, as well as a brief overview of the literature and a treatment proposal for similar cases.
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Affiliation(s)
- S J M Kamphuis
- Klinik für Hand- und Plastische Chirurgie, Departement Chirurgie, Kantonsspital Winterthur, Brauerstrasse 15, 8401, Winterthur, Schweiz.
| | - A R Jandali
- Klinik für Hand- und Plastische Chirurgie, Departement Chirurgie, Kantonsspital Winterthur, Brauerstrasse 15, 8401, Winterthur, Schweiz
| | - F J Jung
- Klinik für Hand- und Plastische Chirurgie, Departement Chirurgie, Kantonsspital Winterthur, Brauerstrasse 15, 8401, Winterthur, Schweiz
| | - J Sproedt
- Klinik für Hand- und Plastische Chirurgie, Departement Chirurgie, Kantonsspital Winterthur, Brauerstrasse 15, 8401, Winterthur, Schweiz
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Shon HC, Park JK, Kang SW, Yang JY. Necrosis of the thumb after inadvertent injection of diclofenac in the radial artery: a case report. J Pain Res 2017; 10:2803-2806. [PMID: 29263695 PMCID: PMC5732554 DOI: 10.2147/jpr.s150306] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Inadvertent intra-arterial drug injection occurs rarely, but it can cause very serious clinical complications, and thus, awareness of inadvertent intra-arterial drug injection is needed. The complications mainly result from iatrogenic reasons and can occur because of vascular variations in the arteries, under circumstances where normal intravenous injection is difficult, or in drug abusers who perform self-injection. The adverse effect associated with intra-arterial drug injection is serious and may lead to necrosis, requiring amputation of the affected extremity, infection, pseudoaneurysm, rhabdomyolysis, compartment syndrome, and permanent disability. However, the etiology of such adverse effects has not been clearly identified and treatment methods have not yet been established. We encountered a patient who developed necrosis of the thumb after an inadvertent injection of diclofenac sodium in the radial artery due to variations in the forearm arteries. Here, we report the prevention and treatment of, and precautions against, the dangers of intra-arterial drug injection.
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Affiliation(s)
- Hyun-Chul Shon
- Department of Orthopaedic Surgery, College of Medicine, Chungbuk National University, Cheongju, Korea
| | - Ji-Kang Park
- Department of Orthopaedic Surgery, College of Medicine, Chungbuk National University, Cheongju, Korea
| | - Sang-Woo Kang
- Department of Orthopaedic Surgery, College of Medicine, Chungbuk National University, Cheongju, Korea
| | - Jae-Young Yang
- Department of Orthopaedic Surgery, College of Medicine, Chungbuk National University, Cheongju, Korea
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Abstract
Intravenous injection of drugs is associated with a host of medical complications, notably soft-tissue infections. On the contrary, intra-arterial injections of drugs have also been reported, largely restricted to inadvertent injections. Here we describe a patient who engaged in repeated intra-arterial injections of heroin when she exhausted most of her venous access, and presented acutely with a radial artery occlusion requiring thrombolytic therapy. Clinicians should have a high index of suspicion for intra-arterial injection in injection drug users who present with limb pain, ischemia, and motor/sensory deficits. Given the reluctance patients may have in discussing their injection practices, clinicians should proactively discuss and counsel patients about safe injection practices and the dangers of intra-arterial injections.
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