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Elkhoury D, Quick S, Kalloo AE, Gorantla VR. Necrotizing Fasciitis Secondary to Mycotic Femoral Aneurysm: A Narrative Review of Diagnosis and Management Strategies. Cureus 2023; 15:e37586. [PMID: 37193468 PMCID: PMC10183231 DOI: 10.7759/cureus.37586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/14/2023] [Indexed: 05/18/2023] Open
Abstract
This comprehensive literature review aims to investigate the pathophysiology, clinical manifestations, diagnostic tools, and treatment options for necrotizing fasciitis secondary to mycotic femoral aneurysm, a rare and potentially lethal infectious disease, particularly focusing on any changes throughout the years for an update of the current literature. The pathophysiology of necrotizing fasciitis and mycotic femoral aneurysms is a complex and multifaceted process that typically involves bacterial infections as a common precursor to the onset of these conditions. This can potentially lead to the formation of an aneurysm. As the infection progresses, it can spread from the aneurysm to surrounding soft tissues, resulting in significant tissue damage, obstructed blood circulation, and ultimately culminating in cell death and necrosis. Clinical manifestations of these conditions are diverse and encompass a range of symptoms, such as fever, localized pain, inflammation, skin changes, and other indicators. It is worth noting that skin color can influence the presentation of these conditions, and in patients with diverse skin tones, certain symptoms may be less noticeable due to a lack of visible discoloration. Imaging, laboratory findings, and clinical presentation are important components of the diagnosis of mycotic aneurysms. CT scans are a reliable tool for identifying specific features of infected femoral aneurysms, and elevated inflammatory laboratory results can also suggest a mycotic aneurysm. In the case of necrotizing fasciitis, clinicians should maintain a high level of suspicion as this condition is rare but life-threatening. Clinicians will need to view the big picture when an infection may be caused by necrotizing fasciitis, considering CT imaging, blood work, and clinical presentation of the patient without delaying surgical intervention. By incorporating the diagnostic tools and treatment options outlined in this review, healthcare professionals can improve patient outcomes and reduce the burden of this rare and potentially lethal infectious disease.
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Affiliation(s)
- David Elkhoury
- Anatomical Sciences, St. George's University School of Medicine, St. George, GRD
| | - Sarah Quick
- Surgery, St. George's University School of Medicine, St. George, GRD
| | - Amy E Kalloo
- Clinical Sciences, St. George's University, St. George, GRD
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Tresson P, Huvelle U, Bordet M. Femoral artery ligature for treatment of infected groin pseudoaneurysm in injected drug abusers. Clin Anat 2022; 35:1138-1141. [PMID: 35815377 PMCID: PMC9796184 DOI: 10.1002/ca.23931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Revised: 07/05/2022] [Accepted: 07/07/2022] [Indexed: 01/01/2023]
Abstract
Drug addiction is a major social and medical concern. Infected groin pseudoaneurysm (IGP) is the result of direct arterial needlestick injury associated with contamination of the arterial wall or peri-arterial area by the injection equipment. Femoral artery (FA) ligation with extensive debridement is an alternative to direct revascularization in an area of sepsis. In case of femoral bifurcation free of infection or in case of isolated FA below the femoral artery of thigh involvement, a simple ligation of the FA is performed. Ligation of each femoral vessel is indicated in case of extension of the infection to the femoral bifurcation. Proximal ligation is performed on the proximal part of the FA. Distal ligation is performed on the proximal part of the deep artery of thigh and the FA below the origin of the deep artery of thigh. Ligation is effective and represents an appropriate method to control hemorrhage and sepsis syndrome in IGP.
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Affiliation(s)
- Philippe Tresson
- Hospices Civils de Lyon, Hôpital Louis PradelDepartment of Vascular and Endovascular SurgeryBron CedexFrance,Intestinal Stroke CenterCentre rHodANien d'isChemie intEStinale (CHANCES Network, Lyon)LyonFrance
| | - Ugo Huvelle
- Hospices Civils de Lyon, Hôpital Louis PradelDepartment of Vascular and Endovascular SurgeryBron CedexFrance,Université Claude Bernard Lyon 1 (Univ Lyon)VilleurbanneFrance
| | - Marine Bordet
- Hospices Civils de Lyon, Hôpital Louis PradelDepartment of Vascular and Endovascular SurgeryBron CedexFrance,Université Claude Bernard Lyon 1 (Univ Lyon)VilleurbanneFrance
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Zhang M, Zhang H, Tang B, Fu J, Yan H, Luo H. Outcomes of Covered Stents With Vacuum Sealing Drainage For Treatment of Infected Femoral Pseudoaneurysms in Intravenous Drug Addicts. Ann Vasc Surg 2021; 81:300-307. [PMID: 34780965 DOI: 10.1016/j.avsg.2021.09.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 09/05/2021] [Accepted: 09/11/2021] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- Mingyi Zhang
- Department of Vascular Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Haolong Zhang
- Department of Vascular Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Bo Tang
- Department of Vascular Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jian Fu
- Department of Vascular Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Haiyan Yan
- Department of Vascular Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Hailong Luo
- Department of Vascular Surgery, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China.
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Singh AA, Ashcroft J, Stather PW. Ligation Alone Versus Immediate Revascularization for Femoral Artery Pseudoaneurysms Secondary to Intravascular Drug Use: A Systematic Review and Meta-Analysis. Ann Vasc Surg 2020; 73:473-481. [PMID: 33383134 DOI: 10.1016/j.avsg.2020.11.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 11/22/2020] [Accepted: 11/25/2020] [Indexed: 01/11/2023]
Abstract
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.
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Affiliation(s)
- Aminder A Singh
- Cambridge Vascular Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK; Department of Surgery, University of Cambridge, Cambridge, UK.
| | - James Ashcroft
- Cambridge Vascular Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK; Department of Surgery, University of Cambridge, Cambridge, UK
| | - Philip W Stather
- Cambridge Vascular Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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Li K, Beckerman WE, Luo X, Peng HW, Chen KQ, He CG. Graft Infection after Prosthetic Bypass Surgery for Infectious Femoral Artery Pseudoaneurysm in Intravenous Drug Users: Manifestation, Management, and Prognosis. Ann Vasc Surg 2020; 70:449-458. [PMID: 32634568 DOI: 10.1016/j.avsg.2020.06.058] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Revised: 06/21/2020] [Accepted: 06/23/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND The aim of this study is to assess the incidence, clinical manifestations, management, and prognosis of graft infection after bypass surgery with prosthetic conduit for infectious femoral artery pseudoaneurysms (IFAPs) in patients with a history of intravenous drug use (IVDU). METHODS A single-center retrospective chart review of IVDU presenting with graft infections after previously being treated with extra-anatomic prosthetic conduit bypass surgery for IFAPs between 2009 and 2019 was performed. Relevant clinical data and patient demographics were collected and analyzed. All patients underwent procedures consisting of graft removal with analysis of operative details and complications. RESULTS Of all 122 patients who underwent IFAP resection with extra-anatomic prosthetic bypass, the incidence of graft infection was 38.5% (47 patients, 48 grafts) with an average age of 35.7 ± 7.3 years. The average interval between bypass surgery and infectious symptoms was 9.2 ± 2.5 months and average time from bypass to graft removal was 13.6 ± 3.4 months. The most common presentation was repeated or unhealable chronic ulcers with sinus formation or purulence either within the bypass area or along the graft conduit route (43, 89.6%). Occlusion of the infected bypass graft occurred in nearly all cases (46, 95.8%). Severe hemorrhage occurred in only 1 case (2.1%). After graft removal, the stumps were ligated in the majority of patients (33, 68.8%) with 15 patients (31.2%) not amenable to ligation due to a difficult dissection. The average time of operation was 35.4 ± 8.7 min with an average blood loss of 35.8 ± 6.7 mL. There were no significant complications such as infection reoccurrence, severe limb ischemia, amputation, or death observed postoperatively. CONCLUSIONS Patients who receive bypass surgery with prosthetic conduit for IFAPs carry a high incidence of graft infection and subsequent occlusion. However, the presenting symptoms are generally mild, and the incidence of fatal complications is rare. This study suggests that a safe treatment option consists of direct graft removal without reconstruction. Additionally, the procedure proved to be relatively convenient and straightforward, which provides further support toward the strategy of treating IFAPs in IVDUs with pseudoaneurysm resection and prosthetic conduit bypass surgery.
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Affiliation(s)
- Ke Li
- Department of Vascular Surgery, The First Hospital of Changsha, Changsha, Hunan, People's Republic of China.
| | - William E Beckerman
- Division of Vascular Surgery and Endovascular Therapy, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Xing Luo
- Department of Neurology, The Third Hospital of Changsha, Changsha, Hunan, People's Republic of China
| | - Han Wu Peng
- Department of Vascular Surgery, The First Hospital of Changsha, Changsha, Hunan, People's Republic of China
| | - Ke Qin Chen
- Department of Vascular Surgery, The First Hospital of Changsha, Changsha, Hunan, People's Republic of China
| | - Chao Gui He
- Department of Vascular Surgery, The First Hospital of Changsha, Changsha, Hunan, People's Republic of China
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Elahwal M, Gaweesh AS, Elemam A, Moustafa S. Predictors of Limb Outcome Following Arterial Ligation of Infected Femoral Pseudoaneurysms in Drug Abusers. Ann Vasc Surg 2019; 65:130-136. [PMID: 31705992 DOI: 10.1016/j.avsg.2019.11.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 09/01/2019] [Accepted: 11/01/2019] [Indexed: 11/15/2022]
Abstract
BACKGROUND We aimed to study variables affecting limb outcome following ligation of infected femoral pseudoaneurysms in intravenous drug abusers (IVDA)in the emergency setting and to propose an algorithm for management. DESIGN Prospective study. METHODS We studied short-term outcomes of 26 IVDA presenting with infected femoral pseudoaneurysms who underwent arterial ligation, hematoma evacuation, and debridement. Long-term results pertaining to limb functionality were unfeasible, as all patients were lost to follow-up. We aimed to study the potential predictors that might impact limb outcome in the emergency setting, namely: 1) mode of presentation (impending versus ruptured), 2) site of arterial ligation (above versus below inguinal ligament), 3) presence or absence of pedal Doppler flow post-ligation, and 4) ankle brachial pressure index (ABI) pre- and post-ligation. RESULTS Arterial ligation without revascularization was done in 19 (73.1%) of our patients, requiring no further intervention for limb salvage during their hospital stay. Four patients (15.4%) required iliopopliteal bypass, and 3 patients (11.5%) required major amputations (2 hip disarticulations and one above-knee amputation). In total, 23 limbs (88.5%) were salvaged. Proximal arterial ligation was done below the inguinal ligament (common femoral artery) in 21 patients (80.8%), while in the remaining 5 patients (19.2%), higher ligation was done above the inguinal ligament (external iliac artery). All 19 patients who were compensated had pedal Doppler flow post-ligation, and 18 of them had arterial ligation done below the inguinal ligament. The mean preoperative ABI (±SD) was 0.87 ± 0.34, and the mean postoperative ABI (±SD) was 0.37 ± 0.27. The mean change in ABI (±SD) was 0.50 ± 0.32. CONCLUSIONS Arterial ligation with local debridement alone is a safe procedure and would have salvaged 73.1% of limbs in this study. However, implementing a selective approach for post-ligation revascularization and our proposed algorithm increased limb salvage rate to 88.5%. The detection of pedal Doppler flow after ligation can stratify patients in whom urgent revascularization might not be required for limb salvage. Additionally, all efforts should be made to ligate the femoral artery below the inguinal ligament to preserve important juxta-inguinal collateral branches.
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Affiliation(s)
- Mohamed Elahwal
- Department of Vascular Surgery, Alexandria Faculty of Medicine, University of Alexandria, Alexandria, Egypt; Vascular Surgery Department, Brighton and Sussex University Hospitals NHS Trust, Brighton, UK.
| | - Ahmed Sherif Gaweesh
- Department of Vascular Surgery, Alexandria Faculty of Medicine, University of Alexandria, Alexandria, Egypt
| | - Ali Elemam
- Department of Vascular Surgery, Alexandria Faculty of Medicine, University of Alexandria, Alexandria, Egypt
| | - Sameh Moustafa
- Department of Vascular Surgery, Alexandria Faculty of Medicine, University of Alexandria, Alexandria, Egypt
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Ben Hammamia M, Fourati M, Ziadi J, Ghedira F, Ben Mrad M, Denguir R. [Femoral pseudoaneurysms in drug addicts: About 4 cases]. JOURNAL DE MÉDECINE VASCULAIRE 2018; 43:193-197. [PMID: 29754729 DOI: 10.1016/j.jdmv.2018.02.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Accepted: 02/24/2018] [Indexed: 11/18/2022]
Abstract
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.
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Affiliation(s)
- M Ben Hammamia
- Service de chirurgie cardio-vasculaire et thoracique, faculté de médecine de Tunis, CHU La Rabta, Bab-Saadoun, 1006 Tunis, Tunisie
| | - M Fourati
- Service de chirurgie cardio-vasculaire et thoracique, faculté de médecine de Tunis, CHU La Rabta, Bab-Saadoun, 1006 Tunis, Tunisie.
| | - J Ziadi
- Service de chirurgie cardio-vasculaire et thoracique, faculté de médecine de Tunis, CHU La Rabta, Bab-Saadoun, 1006 Tunis, Tunisie
| | - F Ghedira
- Service de chirurgie cardio-vasculaire et thoracique, faculté de médecine de Tunis, CHU La Rabta, Bab-Saadoun, 1006 Tunis, Tunisie
| | - M Ben Mrad
- Service de chirurgie cardio-vasculaire et thoracique, faculté de médecine de Tunis, CHU La Rabta, Bab-Saadoun, 1006 Tunis, Tunisie
| | - R Denguir
- Service de chirurgie cardio-vasculaire et thoracique, faculté de médecine de Tunis, CHU La Rabta, Bab-Saadoun, 1006 Tunis, Tunisie
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Affiliation(s)
- David V Feliciano
- Department of Surgery, University of Maryland School of Medicine and the Shock Trauma Center, University of Maryland Medical Center, Baltimore, MD; and Battersby Professor of Surgery Emeritus; Chief Emeritus, Division of General Surgery, Indiana University School of Medicine, Indianapolis, IN.
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Stevenson RP, Semple C, Hussey K, McGovern J, Stuart WP, Kingsmore DB. Changes in the demographics of intravenous drug users with mycotic common femoral artery pseudoaneurysm as a consequence of self-injection does not influence outcome following emergency ligation. Vascular 2017; 25:520-524. [DOI: 10.1177/1708538117700763] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objectives The reported annual incidence of mycotic pseudoaneurysm of the common femoral artery in intravenous drug users has been estimated at 0.03%. Over the past 5 years in Scotland, the proportion of people receiving specialist attention for heroin use over the age of 40 years has increased from 15 to 22%. Although routinely managed with arterial ligation (without reconstruction), some series have reported rates of major limb amputation of up to 10%. We sought to define whether this management strategy was still acceptable in an older population. Methods Retrospective review of patients presenting to a tertiary vascular service with mycotic pseudoaneurysm of the common femoral artery due to arterial injection by intravenous drug users between October 2010 and March 2016. Variables of interest included patient demographics and requirement for major amputation. Results There were 55 patients identified. The annual incidence of mycotic pseudoaneurysm of the common femoral artery in intravenous drug users was 2.1%. It was more common in men (3:1) and the mean age at presentation was 41 years (standard deviation ± 8 years). Three patients underwent major limb amputation during the index admission for severe limb ischaemia (two transfemoral amputations; one hip-disarticulation). Following discharge two patients were readmitted (134 and 200 days, respectively, following primary ligation) for major limb amputation due to of critical limb ischaemia. Conclusions Despite the increasing age of intravenous drug users presenting with mycotic pseudoaneurysm of the common femoral artery primary ligation of pseudoaneurysm would seem to remain an appropriate therapeutic intervention.
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Affiliation(s)
| | | | - Keith Hussey
- Department of Vascular Surgery, Queen Elizabeth University Hospital, UK
| | - Josh McGovern
- Department of Vascular Surgery, Queen Elizabeth University Hospital, UK
| | - Wesley P Stuart
- Department of Vascular Surgery, Queen Elizabeth University Hospital, UK
| | - David B Kingsmore
- Department of Vascular Surgery, Queen Elizabeth University Hospital, UK
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The Treatment of Infected Femoral Artery Pseudoaneurysms Secondary to Drug Abuse: 11 Years of Experience at a Single Institution. Ann Vasc Surg 2016; 36:35-43. [DOI: 10.1016/j.avsg.2016.03.030] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Revised: 03/12/2016] [Accepted: 03/23/2016] [Indexed: 11/22/2022]
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Shrestha KR, Luitel BR, Shrestha U, Shrestha UK. Femoral pseudoaneurysm rupturing into urinary bladder: A rare presentation. J Surg Case Rep 2015; 2015:rjv045. [PMID: 25887167 PMCID: PMC4400530 DOI: 10.1093/jscr/rjv045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Femoral pseudoaneurysm is a common occurrence in intravenous drug abuser due to repeated trauma to the femoral artery causing arterial leak contained by the surrounding tissue and does not contain all the layers of arterial wall. Rupture of these aneurysm to exterior is a common presentation while rupture into surrounding structure deemed an emergency surgical attention. Hence, we report an unusual case of rupture of femoral pseudoaneurysm into urinary bladder who presented us with history of hematuria and was successfully managed.
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Affiliation(s)
- Kajan Raj Shrestha
- Department of Cardiothoracic and Vascular Surgery, Manmohan Cardiothoracic Vascular and Transplant Center, IOM, Kathmandu, Nepal
| | - Bhoj Raj Luitel
- Department of Urology, Tribhuwan University Teaching Hospital, IOM, Kathmandu, Nepal
| | - Ujma Shrestha
- Department of Anaesthesiology and Critical Care, Kathmandu Medical College Teaching Hospital, Kathmandu, Nepal
| | - Uttam Krishna Shrestha
- Department of Cardiothoracic and Vascular Surgery, Manmohan Cardiothoracic Vascular and Transplant Center, IOM, Kathmandu, Nepal
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Stent-graft placement with early debridement and antibiotic treatment for femoral pseudoaneurysms in intravenous drug addicts. Cardiovasc Intervent Radiol 2014; 38:565-72. [PMID: 25288174 DOI: 10.1007/s00270-014-0994-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2014] [Accepted: 08/16/2014] [Indexed: 10/24/2022]
Abstract
PURPOSE Explore the application of endovascular covered stent-graft (SG) placement in femoral pseudoaneurysms in intravenous drug addicts. MATERIALS AND METHODS We evaluated a consecutive series of pseudoaneurysm in intravenous drug addicts treated with SGs from August 2010 to December 2013. RESULTS 15 patients with 16 arterial pseudoaneurysms were enrolled in this study. All were males with a mean age of 36.9 years. Hemorrhage was the most common reason (93.8 %) for seeking medical care, and 3 of these patients were in hemorrhagic shock at admission. All patients received broad-spectrum antibiotics, and debridement and drainage were implemented after SG placement. 7 of the 13 cases which had microbiologic results showed mixed infections, while gram-negative bacteria were the major pathogens. Except for 2 patients, who were lost to follow-up, two new pseudoaneurysms formed due to delayed debridement, and one stent thrombosis occurred, none of the remaining cases had SG infection or developed claudication. CONCLUSIONS SG placement controls massive hemorrhage rapidly, gives enough time for subsequent treatment for pseudoaneurysms due to intravenous drug abuse, and reduces the incidence of postoperative claudication. With appropriate broad-spectrum antibiotics and early debridement, the incidence of SG infection is relatively low. It is an effective alternative especially as temporary bridge measure for critical patients. However, the high cost, uncertain long-term prospects, high demand for medical adherence, and the risk of using the conduits for re-puncture call for a cautious selection of patients. More evidence is required for the application of this treatment.
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Yiannoullou P, van Dellen D, Khambalia H, Forgacs B, Tavakoli A, Murray D, Augustine T. Successful Management of a Ruptured Mycotic Pseudoaneurysm Following Pancreas Transplantation Using Bovine Pericardial Patch: A Case Report. Transplant Proc 2014; 46:2023-5. [DOI: 10.1016/j.transproceed.2014.06.051] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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Devecioglu M, Settembre N, Samia Z, Elfarra M, Malikov S. Treatment of arterial lesions in drug addicts. Ann Vasc Surg 2013; 28:184-91. [PMID: 24200145 DOI: 10.1016/j.avsg.2012.12.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2012] [Revised: 11/14/2012] [Accepted: 12/07/2012] [Indexed: 11/16/2022]
Abstract
BACKGROUND Arterial complications among drug addicts are rare. Their appearance can engage the vital prognosis of the patient and present a major risk of amputation. The injection of products with high cellular toxicity induces septic necrosis of the arterial wall and adjacent tissues. It is frequently responsible for acute hemorrhage. The data in the literature concerning surgical treatment are discussed. The goal of our study was to analyze the immediate and midterm results of the surgical management of these arterial lesions. METHODS Between January 2005 and April 2012, 31 drug addicts (4 women; 31.4 ± 7.2 years) presenting with 33 arterial lesions were treated. They presented with a humeral (n = 15), femoral (n = 13), or axillar (n = 3) false aneurysm. Two patients had an arterial thrombosis. The clinical manifestations were an acute hemorrhage (n = 16), a septic syndrome (n = 7), a pulsatile mass (n = 6), and an acute ischemia (n = 4). In situ revascularization was carried out in 20 cases, in 15 patients with a bypass (9 venous and 6 prosthetic), in 2 with a venous patch, in 2 by direct suture, and in 1 by transposition of the superficial femoral artery in the deep femoral artery. Extra-anatomic bypass revascularization was performed in 6 cases (4 venous and 2 prosthetic). The other techniques used were ligature (n = 5) and medical care (n = 2). Two patients had an additional procedure with a musculocutaneous epigastric pedicled flap in order to fill the loss of substance. RESULTS The early rate of reinterventions was 38.7% at 30 days (12 patients), because of a suture line hemorrhage related to sepsis (n = 6), a bypass thrombosis (n = 5), and of acute ischemia after a arterial ligature. These complications occurred mainly on extremities, having had an anatomic revascularization (n = 9). Six extra-anatomic revascularizations had to be performed in second intention. The average follow-up was 8.6 months (range: 1-73.5 months), and 15 patients were lost to follow-up at 6 months. The patients were followed by duplex ultrasonography and/or angioscanner. Primary and secondary actuarial patencies at 1, 3, and 6 months were 61%, 46%, 46%, and 91%, 81%, and 71%, respectively. The rate of salvage of extremities was 100%. CONCLUSION Our study reveals the difficulty of the management of these arterial lesions. The local and general septic process is primarily responsible for early complications. Arterial restoration with extra-anatomic bypass makes it possible to be distant from the infection. This technique can be associated with a covering flap.
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Affiliation(s)
- Muhamet Devecioglu
- Service de Chirurgie Vasculaire, Centre Hospitalier Universitaire Brabois, Vandoeuvre-lès-Nancy, France.
| | - Nicla Settembre
- Service de Chirurgie Vasculaire, Centre Hospitalier Universitaire Brabois, Vandoeuvre-lès-Nancy, France
| | - Zaki Samia
- Service de Chirurgie Vasculaire, Centre Hospitalier Universitaire Brabois, Vandoeuvre-lès-Nancy, France
| | - Mazen Elfarra
- Service de Chirurgie Vasculaire, Centre Hospitalier Universitaire Brabois, Vandoeuvre-lès-Nancy, France
| | - Sergueï Malikov
- Service de Chirurgie Vasculaire, Centre Hospitalier Universitaire Brabois, Vandoeuvre-lès-Nancy, France
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Wooster MD, Shames ML. Mycotic pseudoaneurysm of a superficial femoral artery stent. Vasc Endovascular Surg 2013; 47:470-3. [PMID: 23709271 DOI: 10.1177/1538574413490838] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Mycotic pseudoaneurysms are relatively infrequent entities, and the best means of management of them remain to be elucidated due to their small number and medical complexities surrounding them. We present here an interesting case of a mycotic pseudoaneurysm of the superficial femoral artery along with our management of the case and a brief review of the available literature. The particular presentation of this patient will hopefully reinforce the use of prolonged antibiotic therapy for mycotic disease and judicious reexamination of patients whose clinical picture does not immediately fit the framework of our most common diagnoses.
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Affiliation(s)
- Mathew D Wooster
- Division of Vascular and Endovascular Surgery, College of Medicine, University of South Florida, Tampa, FL 33606, USA.
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16
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Busch A, Lorenz U, Tiurbe GC, Bühler C, Kellersmann R. Femoral vein obturator bypass revascularization in groin infectious bleeding: two case reports and review of the literature. J Med Case Rep 2013; 7:75. [PMID: 23506237 PMCID: PMC3607977 DOI: 10.1186/1752-1947-7-75] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2012] [Accepted: 01/24/2013] [Indexed: 11/17/2022] Open
Abstract
Introduction Groin infections resulting in arterial bleeding due to bacterial vessel destruction are a severe challenge in vascular surgery. Patients with them most often present as emergencies and therefore need individualized reconstruction solutions. Case presentation Case 1 is a 67-year-old man with infectious bleeding after an autologous reconstruction of the femoral bifurcation with greater saphenous vein due to infection of a bovine pericard patch after thrombendarterectomy. Case 2 is a 35-year-old male drug addict and had severe femoral bleeding and infection after repeated intravenous and intra-arterial substance abuse. Both patients were treated with an autologous obturator bypass of the superficial femoral vein. We review the current literature and highlight our therapeutic concept of this clinical entity. Conclusions Treatment should include systemic antibiotic medication, surgical control of the infectious site, revascularization and soft tissue repair. An extra-anatomical obturator bypass with autologous superficial femoral vein should be considered as the safest revascularization procedure in infections caused by highly pathogenic bacteria.
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Affiliation(s)
- Albert Busch
- Department of General, Visceral, Vascular and Paediatric Surgery University Clinic of Würzburg, Oberdürrbacher Strasse 6, Würzburg, D-97080, Germany.
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Management of a complicated ruptured infected pseudoaneurysm of the femoral artery in a drug addict. Case Rep Vasc Med 2012; 2012:434768. [PMID: 23227421 PMCID: PMC3514812 DOI: 10.1155/2012/434768] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2012] [Accepted: 11/06/2012] [Indexed: 11/18/2022] Open
Abstract
Infected pseudoaneurysm of the femoral artery represents a devastating complication of intravenous drug abuse, especially in the event of rupture. Operative strategy depends upon the extent of arterial injury and the coexistence of infection or sepsis. Options range from simple common femoral artery (CFA) ligation to complex arterial reconstruction with autologous grafts (arterial, venous, or homografts). We report herein the management of a 29-year-old male patient who was urgently admitted with a ruptured pseudoaneurysm of the right CFA, extending well above the inguinal ligament. Multidisciplinary approach with multiple arterial reconstructions and subsequent coverage of the tissue defect with a rectus abdominis musculocutaneous flap transposition was performed.
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Guggenbichler JP, Assadian O, Boeswald M, Kramer A. Incidence and clinical implication of nosocomial infections associated with implantable biomaterials - catheters, ventilator-associated pneumonia, urinary tract infections. GMS KRANKENHAUSHYGIENE INTERDISZIPLINAR 2011; 6:Doc18. [PMID: 22242099 PMCID: PMC3252661 DOI: 10.3205/dgkh000175] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Health care associated infections, the fourth leading cause of disease in industrialised countries, are a major health issue. One part of this condition is based on the increasing insertion and implantation of prosthetic medical devices, since presence of a foreign body significantly reduces the number of bacteria required to produce infection. The most significant hospital-acquired infections, based on frequency and potential severity, are those related to procedures e.g. surgical site infections and medical devices, including urinary tract infection in catheterized patients, pneumonia in patients intubated on a ventilator and bacteraemia related to intravascular catheter use. At least half of all cases of nosocomial infections are associated with medical devices.Modern medical and surgical practices have increasingly utilized implantable medical devices of various kinds. Such devices may be utilized only short-time or intermittently, for months, years or permanently. They improve the therapeutic outcome, save human lives and greatly enhance the quality of life of these patients. However, plastic devices are easily colonized with bacteria and fungi, able to be colonized by microorganisms at a rate of 0.5 cm per hour. A thick biofilm is formed within 24 hours on the entire surface of these plastic devices once inoculated even with a small initial number of bacteria.The aim of the present work is to review the current literature on causes, frequency and preventive measures against infections associated with intravascular devices, catheter-related urinary tract infection, ventilator-associated infection, and infections of other implantable medical devices. Raising awareness for infection associated with implanted medical devices, teaching and training skills of staff, and establishment of surveillance systems monitoring device-related infection seem to be the principal strategies used to achieve reduction and prevention of such infections. The intelligent use of suitable antiseptics in combination with medical devices may further support reduction and prevention of such infections. In addition to reducing the adverse clinical outcomes related with these infections, such reduction may substantially decrease the economic burden caused by device-related infection for health care systems.
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Emergency endovascular treatment of early spontaneous nonaneurysmal popliteal artery rupture in a patient with Salmonella bacteremia. J Vasc Surg 2010; 52:751-7. [DOI: 10.1016/j.jvs.2010.04.031] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2010] [Revised: 04/14/2010] [Accepted: 04/14/2010] [Indexed: 11/24/2022]
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Mycotic aneurysm of the femoral artery complicating Staphylococcus aureus bacteremia: a case report. CASES JOURNAL 2009; 2:9386. [PMID: 20072682 PMCID: PMC2806398 DOI: 10.1186/1757-1626-2-9386] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/06/2009] [Accepted: 12/22/2009] [Indexed: 11/16/2022]
Abstract
Introduction Staphylococcus aureus is the major cause of bacteremia, with the potential for some complications, namely mycotic aneurysms, defined as irreversible dilatation of an artery due to destruction of the vessel wall by infection. Case presentation The authors present the case of a 52 year-old-Caucasian male, admitted with Staphylococcus aureus bacteremia and mycotic aneurysm of the right superficial femoral artery, associated with advanced atherosclerotic process. Conclusion Mycotic aneurysms are rare, and a high index of suspicion is needed, because appropriate treatment will certainly affect the outcome, as they are associated with high morbidity and mortality.
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Salimi J. On the management of mycotic femoral pseudoaneurysms in intravenous drug abusers. Ann Vasc Surg 2009; 23:824. [PMID: 19875020 DOI: 10.1016/j.avsg.2009.07.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2008] [Revised: 05/02/2009] [Accepted: 07/27/2009] [Indexed: 11/17/2022]
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Surgical Management of Infected Pseudoaneurysms in Intravenous Drug Abusers: Single Institution Experience and a Proposed Algorithm. World J Surg 2009; 33:1830-5. [DOI: 10.1007/s00268-009-0123-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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23
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The Management of Mycotic Femoral Pseudoaneurysms in Intravenous Drug Abusers. Ann Vasc Surg 2009; 23:345-9. [DOI: 10.1016/j.avsg.2008.08.013] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2007] [Revised: 05/28/2008] [Accepted: 08/11/2008] [Indexed: 11/19/2022]
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Salimi J, Shojaeefar A, Khashayar P. Management of infected femoral pseudoaneurysms in intravenous drug abusers: a review of 57 cases. Arch Med Res 2007; 39:120-4. [PMID: 18068005 DOI: 10.1016/j.arcmed.2007.07.004] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2007] [Accepted: 07/08/2007] [Indexed: 11/26/2022]
Abstract
BACKGROUND The present study was carried out to evaluate the clinical characteristics and surgical methods used for the management of infected femoral pseudoaneurysms secondary to illegal drug injections. METHODS Fifty seven consecutive patients who presented with infected pseudoaneurysm of the lower limb and were admitted to the emergency department of Sina Hospital during a 5-year period were enrolled in this study. Surgical methods performed consisted of vein angioplasty, simple ligation of femoral artery, and emergent or delayed revascularization. RESULTS All participating patients were males with a mean age of 36.7 years. Three (5.3%) and two (3.5%) patients underwent primary repair and emergent vascular bypass, respectively; whereas delayed revascularization was performed in only eight (14%) cases. Forty four (77.2%) patients achieved a normal lifestyle without any vascular bypass. Early critical ischemia and late claudication was reported in two (3.5%) and eight (14%) patients, respectively. Other complications such as amputation and mortality were rarely reported. CONCLUSIONS In our study, simple ligation of the external iliac or femoral artery was the most frequent management method for treating infected femoral pseudoaneurysms. Simple ligation of the external iliac or femoral artery seems to be a safe procedure in drug abusers presenting with infected femoral pseudoaneurysms.
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Affiliation(s)
- Javad Salimi
- Subspecialties in Vascular Surgery, Sina Trauma and Surgery Research Center, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran.
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Georgiadis GS, Bessias NC, Pavlidis PM, Pomoni M, Batakis N, Lazarides MK. Infected False Aneurysms of the Limbs Secondary to Chronic Intravenous Drug Abuse: Analysis of Perioperative Considerations and Operative Outcomes. Surg Today 2007; 37:837-44. [PMID: 17879032 DOI: 10.1007/s00595-006-3495-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2006] [Accepted: 12/28/2006] [Indexed: 10/22/2022]
Abstract
PURPOSE To discuss the perioperative considerations and operative outcomes of 26 intravenous (i.v.) drug abusers who presented with infected false aneurysms of the limbs. METHODS The subjects were 20 men and 6 women with pseudoaneurysms (mean age 34 years, range 19-53 years). The femoral and brachial arteries were most commonly involved. All patients, except for those with active bleeding, underwent digital subtraction angiography or Doppler ultrasonography, or both. Treatment consisted of excision and ligation of the aneurysm and local debridement, followed by revascularization with a vein graft or vein patch angioplasty. RESULTS The presenting symptoms and signs included a pulsatile mass (69%), ischemic pain (23%), active bleeding (38.5%), signs of inflammation (61.5%), and positive blood culture (31%). Bleeding complications developed in two patients, who underwent subsequent extra-anatomic bypass. One of these patients had hip disarticulation and eventually died. None of the remaining patients had claudication or required an amputation. The mean follow-up period was 24 months (range: 3-50 months). Only five (19.2%) patients received drug rehabilitation, whereas the remaining patients admitted to continued drug abuse after discharge from hospital. CONCLUSIONS Limb salvage with immediate revascularization is safe and achieves functionality; therefore, its use is justified. Recidivism and continued abuse is the usual consequence after discharge from hospital, making recovery difficult.
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Affiliation(s)
- George S Georgiadis
- Department of Vascular Surgery, Demokritos University Hospital, Alexandroupolis, Greece
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Georgiadis GS. Regarding "Infected femoral artery pseudoaneurysm in drug addicts: The beneficial use of the internal iliac artery for arterial reconstruction". J Vasc Surg 2007; 46:613; author reply 613-4. [PMID: 17826259 DOI: 10.1016/j.jvs.2007.04.065] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2007] [Accepted: 04/03/2007] [Indexed: 10/22/2022]
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