Outcomes of femoral artery ligation for treatment of infected femoral pseudoaneurysms due to drug injection

Nontraumatic popliteal pseudoaneurysm: A rare entity with different etiologies

Pseudoaneurysms of the popliteal artery represent a rare vascular pathology. Leaving aside traumatic antecedents, in the presence of sudden swelling of the popliteal region, it is useful to suspect this entity, especially in the presence of infectious processes or connective tissue disorders. We present two cases from our institution where management included surgical intervention and control of the underlying diseases.

REPAIRS Delphi: A UK and Ireland Consensus Statement on the Management of Infected Arterial Pseudoaneurysms Secondary to Groin Injecting Drug Use

OBJECTIVE

Consensus guidelines on the optimal management of infected arterial pseudoaneurysms secondary to groin injecting drug use are lacking. This pathology is a problem in the UK and globally, yet operative management options remain contentious. This study was designed to establish consensus to promote better management of these patients, drawing on the expert experience of those in a location with a high prevalence of illicit drug use.

METHODS

A three round modified Delphi was undertaken, systematically surveying consultant vascular surgeons in the UK and Ireland using an online platform. Seventy five vascular surgery units were invited to participate, with one consultant providing the unit consensus practice. Round one responses were thematically analysed to generate statements for round two. These statements were evaluated by participants using a five point Likert scale. Consensus was achieved at a threshold of 70% or more agreement or disagreement. Those statements not reaching consensus were assessed and modified for round three. The results of the Delphi process constituted the consensus statement.

RESULTS

Round one received 64 (86%) responses, round two 59 (79%) responses, and round three 62 (83%) responses; 73 (97%) of 75 units contributed. Round two comprised 150 statements and round three 24 statements. Ninety one statements achieved consensus agreement and 15 consensus disagreement. The Delphi statements covered sequential management of these patients from diagnosis and imaging, antibiotics and microbiology, surgical approach, wound management, follow up, and additional considerations. Pre-operative imaging achieved consensus agreement (97%), with computed tomography angiography being the modality of choice (97%). Ligation and debridement without arterial reconstruction was the preferred approach at initial surgical intervention (89%). Multidisciplinary management, ensuring holistic care and access to substance use services, also gained consensus agreement.

CONCLUSION

This comprehensive consensus statement provides a strong insight into the standard of care for these patients.

Infective native arterial aneurysms and inflammatory abdominal aortic aneurysms: An overview with a focus on emergency settings

Infective native arterial aneurysms and inflammatory aortic aneurysms are rare but morbid pathologies seen by vascular surgeons in the emergency setting. Presentation is not always clear, and a full workup must be obtained before adopting a management strategy. Treatment is multidisciplinary and is tailored to every case based on workup findings. Imaging with computed tomography, magnetic resonance, or with fluorodeoxyglucose-positron emission tomography aids in diagnosis and in monitoring response to treatment. Open surgery is traditionally performed for definitive management. Endovascular surgery may offer an alternative treatment in select cases with acceptable outcomes. Neither technique has been proven to be superior to the other. Physicians should consider patient's anatomy, comorbidities, life expectancy, and goals of care before selecting an approach. Long-term pharmacological treatment, with antibiotics in case of infective aneurysms and immunosuppressants in case of inflammatory aneurysms, is usually required and should be managed in collaboration with infectious disease specialists and rheumatologists.

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.

Management of the infected arterial pseudoaneurysm secondary to groin injecting drug use and outcomes: a systematic review protocol

INTRODUCTION

People who inject drugs are at risk of a range of injecting-related infections and injuries, which can threaten life and limb. In parallel to escalating rates of drug-related deaths seen in Scotland and the UK, there has also been an increase in hospital admissions for skin and soft tissue infections related to injecting drug use. One such injecting complication is the infected arterial pseudoaneurysm, which risks rupture and life-threatening haemorrhage. Surgical management options for the infected arterial pseudoaneurysm secondary to groin injecting drug use remain contentious, with some advocates for ligation and debridement alone, whilst others promote acute arterial reconstruction (suture or patch repair, bypass or, more recently, endovascular stent-graft placement). Rates of major lower limb amputations related to surgical management for this pathology vary in the literature. This review aims to evaluate the outcomes of arterial ligation alone compared with arterial reconstruction, including open and endovascular options, for the infected arterial pseudoaneurysm secondary to groin injecting drug use.

METHODS AND ANALYSIS

The methods will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist. Three electronic databases will be searched and the resultant papers screened according to the study inclusion and exclusion criteria (detailed in the Population, Intervention, Comparison, Outcomes and Study design statement). Grey literature will be excluded. All papers at each stage will be screened by two independent authors, with disagreements arbitrated by a third. Papers will be subject to appropriate standardised quality assessments.

PRIMARY OUTCOME

Major lower limb amputation.

SECONDARY OUTCOMES

Reintervention rate, rebleeding rate, development of chronic limb-threatening ischaemia 30-day mortality and claudication.

ETHICS AND DISSEMINATION

This is a systematic review based on previously conducted studies, therefore, no ethical approval is required. The results of this work will be published in a peer-reviewed journal and presented at relevant conferences.

PROSPERO REGISTRATION NUMBER

CRD42022358209.

Post-Operative Ischemia and Surgical Technique Affect Late Mortality of Femoral Artery Pseudoaneurysms Following Injection Drug Use

BACKGROUND

Surgical management of infected common femoral artery (CFA) pseudoaneurysms arising from intravenous drug use (IVDU) is clinically challenging with excellent perioperative outcomes reported for a number of techniques. Long-term outcomes after arterial ligation versus revascularization are not known. We report both short- and long-term comparison of lower extremity perfusion and outcomes for 25 patients that underwent simple or more extensive ligation or revascularization treatment.

METHODS

A retrospective analysis of 25 consecutive patients presenting primarily with infected CFA pseudoaneurysms related to IVDU at one referral institution was performed to determine short- and long-term outcomes at time of discharge, 30 days, and 1 year, including intraoperative differences, postoperative and follow-up ankle-brachial index, bacteriology, and postoperative mortality. In addition to a direct comparison between the revascularization patients (n = 12) and simple ligation patients (n = 13), a comparison within the simple ligation group was performed between those who underwent a ligation of the CFA with preservation of the femoral bifurcation (double ligation) and those who underwent ligation of the CFA, superficial femoral artery, and profunda femoral artery individually (triple ligation [TL]).

RESULTS

All techniques resulted in similar mortality at 30 days. Lower extremity perfusion at discharge was highest in the revascularization group, and lowest in the TL patients. One year mortality was significantly higher in the TL cohort.

CONCLUSIONS

This is the first report of long-term outcomes after surgery for infected CFA pseudoaneurysms, and demonstrates increased late mortality in patients treated with extensive (triple) ligation with persistent ischemia. We conclude that revascularization after resection of infected CFA aneurysms, or surgical techniques that preserve or recreate the femoral artery bifurcation cause less ischemia and late mortality in these challenging patients.

Femoral artery aneurysms

True aneurysms are dilatations of blood vessels, bounded by the tunica intima, tunica media and tunica adventitia. False aneurysms are dilatations bounded by the tunica adventitia only, and are more common than true aneurysms. The femoral artery is the second most common location for true peripheral artery aneurysms, and the most common site of false aneurysms. If left untreated, devastating complications can occur, such as infection, rupture, ischaemia and limb loss. Femoral artery aneurysms should be identified early and managed by a vascular specialist. This article outlines the evidence for the epidemiology, investigation and management of femoral artery aneurysms.

Exsanguination from ruptured femoral artery pseudoaneurysm - A fatal complication of groin heroin injection

Intravenous drug users (IDUs) eventually encounter a common problem- a need to turn to a new vessel to inject drugs. Whether it is because no other spot is available due to scarring or convenience, the groin is the preferred spot for some. Chronic puncture of femoral vessels can lead to a rare but significant complication- femoral artery pseudoaneurysm (FAP). Its fatal consequence- rupture and bleeding is well recognized, but the forensic literature on this subject is limited. We present eight cases of exsanguination due to the ruptured FAP in IDUs who share most or all the following characteristics: long-term heroin use and/or pronounced drug use stigmata, chronic groin injection-related lesions, absence of significant precipitating pseudoaneurysm trauma, and no or minimal concentrations of heroin metabolites in blood. The FAP presentation varied greatly, from palpable fist-sized mass or slight elevation under the skin defect to infundibular arterio-cutaneous fistula that ruptured through the skin induration. In some, surrounding skin or soft tissue showed signs of inflammation but without suppuration. The most prominent FAP characteristic was smooth-surface cavitation on cross-sections. We performed microscopic evaluation in two cases and verified disruption of the artery wall (i.e., pseudoaneurysm) with elements of acute and chronic inflammation and fibrosis; foci of fibrinoid necrosis were noticed on the arterial wall. All subjects were pale, with faint hypostasis and organ anemia, consistent with reported massive hemorrhage. Because such sudden, unwitnessed, and suspicious deaths may raise the question of injury infliction, proper autopsy evaluation is crucial, for which we propose guidelines.

Outcomes of Covered Stents With Vacuum Sealing Drainage For Treatment of Infected Femoral Pseudoaneurysms in Intravenous Drug Addicts

OBJECTIVE

For treatment of infected femoral artery pseudoaneurysms (IFAPs) with the covered stent, debridement technique is important but frequently ignored. Our study aims to review our experience and outcomes of patients undergoing covered stents placement and debridement with vacuum sealing drainage (VSD).

METHODS

This study retrospectively analyzed 41 intravenous drug addicts with IFAP who received covered stent implantation and debridement with VSD from January 2015 to December 2020. The diagnosis was based on the previous history of local injection and the presence of pulsatile mass at the injection site. All cases were confirmed by CT angiography (CTA), ultrasound, or digital subtraction angiography (DSA).  Technical success, time of wound care, and clinical outcomes were evaluated.

RESULTS

Technical success was achieved in all patients. The interval from diagnosis to treatment was 26 ± 11 hours. The time of continuous drainage with VSD was 18.79 ± 6.56 days. 38 patients (92.68%) with fresh granulation tissue were sutured and discharged from the hospital. Stents in 31(91.18%) of 34 cases were patent during follow-ups. Three patients had stent occlusion caused by thrombosis, and two of them were complicated with stent infection. The two infectious stents were removed and the femoral arteries were ligated. One of them received open-surgical reconstruction with the great saphenous because of claudication. Two patients were admitted to the hospital for rebleeding caused by  drug abuse relapse.

CONCLUSIONS

Covered stents placement is convenient and rapid to control massive hemorrhage in IFAPs of intravenous drug abuse. Early debridement of infected tissue with continued VSD may shorten the time of wound care and make the incidence of stent infection relatively low. Meanwhile, the patency in a short time follow-up is acceptable. These results indicate that covered stents implantation with VSD may be a safe, effective, and feasible measure for the treatment of IFAPs.

The Needle and the Damage Done: A Retrospective Review of the Health Impact of Recreational Intravenous Drug Use and the Collateral Consequences for Vascular Surgery

BACKGROUND

The UK has one of the highest rates of recreational drug use and consequent deaths in Europe. Scotland is the "Drug deaths capital of Europe." Intravenous drug use can result in limb- and life-threatening pathology. This study aimed to characterise limb-related admissions associated with intravenous drug use, outcomes and healthcare expenditure.

METHODS

Retrospective data collection between December 2011 and August 2018. Patients were identified through discharge codes. Admission details were extracted from electronic records and a database compiled. Statistical analyses were performed using Statistical Package for the Social Science, P < 0.05 denoted significance.

RESULTS

There were 558 admissions for 330 patients (1-9 admissions/patient), mean age 37 years (+/-7.6 SD) and 196 (59.2%; 319 admissions, 57.2%) were male. Three hundred forty-eight (62.4%) admissions were to surgical specialties, predominantly Vascular Surgery (247). Including onward referrals, Vascular ultimately managed 54.8% of admissions. Patients presented with multiple pathologies: 249 groin abscesses; 38 other abscesses; 74 pseudoaneurysms; 102 necrotising soft tissue infections (NSTI); 85 cellulitis; 138 deep venous thrombosis (DVTs); 28 infected DVTs and 70 other diagnoses. Two hundred and seventy-seven admissions (220 patients) required operations, with 361 procedures performed (1-7 operations/admission). There were 24 major limb amputations and 74 arterial ligations. Eleven amputations were due to NSTI and 13 followed ligation (17.6% of ligations). During follow-up 50 (15.2%) patients died, of which 6 (12%) had amputations (OR 3.2, 95% CI 1.04-9.61, P = 0.043). Cumulative cost of acute care was £4,783,241.

CONCLUSIONS

Limb-related sequalae of intravenous drug use represents a substantial surgical workload, especially for Vascular. These are complex, high-risk patients with poor outcomes and high healthcare costs.

Transient arterial insufficiency and neurologic deficit following external iliac vein stent reconstruction for malignant compression

Acute iliofemoral deep vein thrombosis may present with pain and swelling or phlegmasia cerulea dolens. When thrombosis occurs in the setting of an underlying venous obstruction, stent reconstruction should be performed after thrombus clearance to prevent rethrombosis. Stent reconstruction after thrombus clearance is associated with high technical success rates and durable patency. This report describes transient lower extremity arterial insufficiency and neurologic deficit after external iliac vein stent expansion and reconstruction within a confined space resulting from a malignant obstruction. It serves as a cautionary tale that, in rare cases, aggressive venous stenting within a confined space can transfer clinically significant forces to adjacent arteries and nerves.

Outcomes of Femoral Artery Pseudoaneurysm in Intravenous Drug Abusers Managed at a Tertiary Care Center

Objectives The aim of this study was to assess the effects of ligation and excision of femoral artery pseudoaneurysm without revascularization in intravenous drug abusers presenting in the tertiary care center. Methods This was a retrospective study conducted at Shaheed Mohtarma Benazir Bhutto Institute, Karachi, Pakistan, and included 119 patients admitted for vascular injuries of the groin between June 2016 and June 2020. Data collected from the hospital's medical records included all intravenous drug addicts presented with mass near or at groin area only, while other pseudoaneurysm locations secondary to vascular trauma, arteriovenous fistula, and hemodialysis were excluded. SPSS Version 20.0 (IBM Corp., Armonk, NY, USA) was used for data analysis. Results This study included 119 patients, all of whom presented and admitted to the Accident and Emergency Department, with a mean age of about 32 years ± 11.34 years and a mean duration of addiction of 2.47 years ± 1.37 years. Males constituted 83.2% of the patients, while females constituted 16.8%. The left femoral artery was affected more commonly than the right femoral artery, with an average of 75.6% and 24.4%, respectively. The most common presentation was bleeding from ruptured pseudoaneurysm (76.5%) and oozing with pulsatile mass (17.6%), while infected pulsatile swelling and misdiagnosis were uncommon. After surgical intervention, limb salvage was 95.8%, whereas mortality and amputation rate were 2.5 % and 1.7%, respectively. Conclusion The optimal management of femoral artery pseudoaneurysm in intravenous drug addicts is ligation and excision of the pseudoaneurysm without revascularization.