The management of mycotic femoral pseudoaneurysms in intravenous drug abusers

Mycotic femoral pseudoaneurysms, particularly in the drug-abusing population, pose a difficult problem to the vascular surgeon. Management ranges from ligation with debridement to extra-anatomical bypass. This study reviewed the management of mycotic femoral pseudoaneurysms presenting in intravenous drug abusers to an inner city tertiary referral center. Between 2001 and 2006, 11 cases presenting in nine patients were treated. The mean age was 30.7 years with a male-to-female ratio of 1:2. Eight patients had a positive viral status for the human immunodeficiency virus and/or hepatitis C. Two patients re-presented with a contralateral pseudoaneurysm. A combination of groin pain and swelling was the most common presentation. Two patients presented with significant hemorrhage. The diagnosis was confirmed by ultrasound in the majority of cases. Nine cases were managed with arterial ligation and debridement of the necrotic tissue. The two remaining cases were managed with ultrasound-guided thrombin injection and arterial puncture closure. On follow-up, one patient required a below-knee amputation following reinjection into the postoperative wound site. One further patient underwent a fifth metatarsal amputation due to ischemia. Ligation and debridement are well tolerated in the majority of drug-abusing patients diagnosed with mycotic femoral pseudoaneurysms.     

Outcome after ligation of infected false femoral aneurysms in intravenous drug abusers.

OBJECTIVES: to determine the outcome of a policy of ligation with observation of infected false femoral aneurysms (IFFA) in intravenous drug abusers (IVDA), particularly with respect to the issue of limb preservation. DESIGN: a retrospective study. MATERIALS AND METHODS: thirty-seven consecutive cases of IFFA in 34 patients accrued over nine years were studied by case note review and by clinical or telephone interview. RESULTS: in 34 cases of ligation of primary IFFA there were no amputations, with patients describing claudication only in follow-up. In three cases of second IFFA in the same limb, repeat ligation resulted in two viable limbs with claudication only, and one above-knee amputation. At the nine year follow-up, all patients were still drug-dependent and considered unsuitable for late revascularisation. There were three deaths and all were drug-related. CONCLUSIONS: in our experience, ligation of IFFA is effective, safe and simple, and is the most appropriate method of dealing with these challenging cases.     

Spinal infection in intravenous drug abusers

The number of intravenous (IV) drug abusers has been increasing in recent years. They are generally younger and healthier than the typical patient with a spinal infection. Reviewing the English language literature, there are only a few articles discussing the relationship between IV drug abuse and spinal infection. We studied 21 IV drug abusers with spinal infection. All were male, 19 were in their 30s and 40s with a mean age of 44 years. The mean follow-up period was 41 months after surgical intervention. Mild and severe neurologic deficit were seen in 5 and 13 patients (Frankel Grade C in 5, Grade D in 8), respectively. The overall positive culture rate was 17 out of 21 (81%). Twelve patients were infected with Staphylococcus aureus and 3 with Pseudomonas aeruginosa. Two had Mycobacterium tuberculosis. All were treated with anterior debridement and strut bone grafting with or without posterior instrumentation, laminectomy and abscess excision, or with additional discectomy. All patients with neurologic deficit recovered to a normal status. At the most recent follow-up, all the spine segments had fused and no one complained of any recurrent back pain. There were no postoperative complications. Physicians need to be more alert to the possibility of spinal infection in IV drug abusers with back pain. In addition to Staphylococcus aureus, Pseudomonas aeruginosa and Mycobacterium tuberculosis may be seen among IV drug abusers.     

Infected venous pseudoaneurysm. A complication of drug addiction

There has been an increase in the incidence of major vascular complications of intravenous drug addiction. We studied five patients who had infected venous pseudoaneurysms of the femoral vein. Patients may have cryptic sepsis or an infected hematoma from venous rupture. The vein containing pus may drain through a venipuncture site. Treatment is complete excision of the involved vein with packing of the wound. Complications due to septic embolization or metastatic infection from septicemia are common. Venous reconstruction is unwarranted.     

毒品注射致股动脉假性动脉瘤破裂出血的诊治

目的探讨注射毒品引起股动脉假性动脉瘤形成并破裂出血的诊断与治疗方法。方法回顾性分析2003年3月—2009年12月收治的22例因反复注射毒品致股动脉假性动脉瘤形成并破裂出血患者的临床资料。结果 22例患者均接受手术治疗,术中行瘤体切除、清创后,8例行股动脉破口修补术;4例行破口两侧股动脉结扎术;10例行髂外动脉-股动脉人工血管移植术。22例均手术成功,手术后早期出现人工血管与股动脉吻合口破裂出血1例,急诊手术重新吻合,随后出现切口感染,经换药后切口愈合。术后患侧下肢功能均好。随访6个月至7年,平均3年。1例患者术后2年出现人工血管感染,1例出院后14d发生吻合口出血,均经再次血管吻合治愈;2例股动脉结扎患者遗留轻间歇性跛行。结论治疗股动脉假性动脉瘤形成并破裂出血的手术方式,以股动脉假性动脉瘤切除+清创+股动脉修补术最为简单、安全有效;人工血管移植术疗效确定,能最大限度保证患肢血供;股动脉修补或结扎术在选择病例中也是有效的治疗方法。     

Infected femoral artery pseudoaneurysm in drug addicts: the beneficial use of the internal iliac artery for arterial reconstruction

BACKGROUND: Infected femoral artery pseudoaneurysm (IFAP) is a severe complication in parenteral drug abusers, with difficult and controversial management. Ligation alone without revascularization is frequently associated with later intermittent claudication and limb amputation. Furthermore, arterial reconstruction with a synthetic or venous conduit is limited because of a contaminated field and, often, unavailability of autologous venous grafts. In this study, we present our experience with the internal iliac artery (IIA) as a graft for arterial reconstruction after IFAP excision in these patients. METHODS: Data of 14 consecutive patients who presented with IFAP secondary to parenteral drug abuse from 2001 to 2005 were analyzed. Twelve patients (85.7%) were male. The median age was 27 years (range, 19-42 years). In 13 cases, the IFAP involved the common femoral artery, and in 1 case it involved the profunda femoris artery (PFA). In nine patients, we used the IIA for arterial reconstruction (five as a patch and four as an interposition graft), whereas in two patients the arterial deficit was repaired with a great saphenous vein patch. In two cases, an extra-anatomic bypass with a synthetic polytetrafluoroethylene graft was performed. In one patient, the pseudoaneurysm involved the PFA and was treated with excision and ligation of the PFA. RESULTS: All nine patients who underwent revascularization with the use of IIA were free of claudication symptoms. None of them experienced any perioperative complications, had signs of reinfection, or required limb amputation during the follow-up period (median, 19 months; range, 4-52 months). Regarding the remaining five patients, one died 25 days after surgery because of multiorgan failure, and one underwent reoperation because of proximal anastomotic rupture of a synthetic graft. The latter patient finally underwent a transmetatarsal amputation. CONCLUSIONS: The use of IIA for arterial reconstruction after IFAP excision in drug abusers is safe and effective. These preliminary results indicate that the implementation of this technique offers many advantages compared with traditional treatment options.     

Surgical treatment of femoral artery infected false aneurysms in drug abusers

BACKGROUND: Post-traumatic femoral artery infected false aneurysms (pfa-IFA) in drug abusers are very common in modern societies, but their surgical management remains controversial. METHODS: A review was undertaken of the English-language literature between 1967 and 2004 for relevant articles describing at least four cases of pfa-IFA in drug-addict populations. The available surgical treatment options are discussed. RESULTS: Recent surgical therapeutic reports favour aneurysm ligation and excision (Lig-Exc) and local debridement (Ld) with observation-selective (delayed) revascularization in cases where limb viability is threatened, or Lig-Exc and Ld alone without vascular reconstruction. The former method carries the risk of delayed decision on attempted extremity salvage (12.1% amputation rate), accepting early (13.5%) and late (7.5%) claudication rate, and although the latter method has much lower early and late amputation rates (5.7 and 6.3%, respectively), it results in a high percentage of claudication and disability (early, 54.4%; late, 44.3%). Immediate (routine) revascularization using either in situ or extra-anatomic bypass has also been associated with high complication rates. Even when it occurs through non-infected tissue planes, the risk of graft infection (early, 21.1%; late, 32.4%) is of great concern, and the possibility of sepsis (together with anastomotic dehiscence (14%) and even amputation) is high (early, 9.8%; late, 11.3%). Reversing the order of revascularization produces zero early complication rates, but long-term follow up reveals that 5.5% of patients have graft infection and 5.5% have had amputation. The follow up rates reported in the literature are poor (only 31.7% completed), and are also sometimes inaccurate. CONCLUSIONS: No surgical treatment for pfa-IFA has been proved to be safe in terms of the overall surgical complications. Longer follow-up periods are needed to provide accurate results.     

Management of femoral artery pseudoaneurysm due to addictive drug injection

Objective: To study surgical management for patients with femoral pseudoaneurysm resulting from addictive drug injection. Methods： Clinical data of 34 patients with femoral pseudoaneurysm resulting from addictive drug injection were retrospectively reviewed. Results: Thirteen patients underwent bypass graft ( end to side) of external iliac artery and superficial femoral artery using expanded polytetrafluoroethylene (ePTFE). Three patients who had an autogenous saphenous vein graftin situs, one of whom was then performed an ePTFE graft when rupture and bleeding occurred at the anastomotic site. Color Doppler image showed patent grafted blood vessels in all the patients after operation. Eighteen patients had their femoral arteries ligated. Limbs of all the 34 patients were saved. Conclusions： Ligating femoral artery is an effective way to treat femoral artery pseudoaneurysm if autogenous saphenous vein graft or artificial vessel graft is not applicable.     

Infected pseudoaneurysm involving a drug-eluting stent

Stent infection following percutaneous transluminal coronary angioplasty is rare. We present such a case involving a drug-eluting stent placed in the left anterior descending coronary artery that was managed surgically with removal of the stent with concomitant coronary artery bypass grafting. Early surgical intervention directed at removal of the infected stent, debridement and distal vessel revascularisation is recommended to deal with the infection and prevent myocardial compromise.     

Infected aortic pseudoaneurysm following laparoscopic cholecystectomy

A 38-year-old hemodialysis-dependent diabetic female patient underwent a laparoscopic cholecystectomy for symptomatic cholelithiasis. Postoperatively, she developed chronic back pain. Eight months following laparoscopic cholecystectomy, she developed fevers and recurrent bacteremia with methicillin-resistant Staphylococcus aureus, despite removal of all indwelling intravenous dialysis access. An abdominal CT scan demonstrated a 7-cm pseudoaneurysm extending from the right anterolateral lower abdominal aorta. Following resection of her infected aneurysm and extraanatomic bypass, she cleared her bacteremia and recovered. This first report of an aortic pseudoaneurysm following laparoscopic cholecystectomy is presented in the context of other vascular complications reported following the same procedure.     

腔内覆膜支架植入术治疗吸毒者针刺伤致股动脉假性动脉瘤

吸毒史较长的患者通常经股静脉注射毒品。股静脉距股动脉较近,易导致股动脉针刺伤,形成假性动脉瘤（pseudoaneurysm,PSA）。血管损伤形成的PSA很难自行愈合^[1],     

Soft tissue infections in parenteral drug abusers.

Thirty-four parenteral drug abusers admitted with soft tissue infections underwent bacteriologic and immunologic evaluation. Staphylococcus aureus and beta hemolytic streptococci were the most common organisms recovered. Enteric gram negative aerobes and oral flora were common and enteric anaerobes rare. Absolute lymphopenia and elevations in the IgA, IgG and IgM fractions of the immunoglobulins were common as were false positive VDRL examinations. Cutaneous anergy was found in 83% of the group and 70% of a simultaneously noninfected addict group. Staphylococcal carriage was frequent. Because of variation in the flora between this and other reported groups, ongoing bacteriologic surveillance could be a useful guide to initial antibiotic therapy. Differences in the pattern of immune reaction in this group when compared to different addict groups suggest a difference in antigenic stimulation, possibly as a result of differences in bacteriologic exposure.     

Endovascular management of an arteriovenous fistula and concomitant pseudoaneurysm in an intravenous drug abuser

An interesting case of an intravenous drug abuser who had endovascular management of an arteriovenous fistula and concomitant pseudoaneurysm, resulting from recurrent puncture of the femoral artery is reported in this study.     

Pneumothorax in drug abusers. An urban epidemic?

Although intravenous drug abuse is endemic in urban America, only 19 cases of pneumothorax from neck injections have been reported. For this reason, the experience at Detroit Receiving Hospital was reviewed. Data collected included patient demographics, size of pneumothorax, use of antibiotics, and complications related to tube thoracostomy. Of 525 diagnoses of pneumothorax between January 1, 1982 and December 31, 1984, 113 (21.5%) occurred as a result of drug abuse in 84 patients. Average patient age was 32 years (range 20 to 55 years). Thirty-eight (45%) were female. The number of admissions per year has increased, and 11 patients showed multiple admissions over the 3-year study period. Nine patients had bilateral collapse. One hundred six pneumothoraces (94%) were treated with closed thoracostomy with a tube-related hospital stay of 5 days, overall stay averaging 7 days. Only six patients received antibiotics for chest tube prophylaxis, and no in-hospital tube-related infections were identified. Thirteen patients developed residual pneumothorax following tube removal, but only two required a new tube. Pneumothorax in drug abusers is a serious urban problem and one with which physicians need be familiar.     

Infections in parenteral drug abusers. Further immunologic studies

In our previous study of soft tissue infections in parenteral drug abusers, two thirds of the infections were polymicrobial. Oral and enteric organisms were frequently recovered. These patients and a group of uninfected addicts showed frequent cutaneous anergy, lymphopenia, and hypergammaglobulinemia. An additional group of uninfected addicts was studied. The mean levels of IgA, IgG, and IgM were higher in the uninfected addicts. In the addict and control groups, elevations in IgA (17 percent of total), IgG (65 percent), and IgM (19 percent) levels were found. Zinc levels were within normal limits. T-cell populations below 70 percent were seen in five of the seven addicts and two of the four control subjects. Reversed helper to suppressor cell ratios were found in three of the seven addicts and control subjects. No consistent pattern of immunologic abnormalities emerged. The interrelationship of the abnormalities in the addict and their relationship to AIDS is unclear.     

Drugs and drug abusers

DRUG ABUSERS: Drugs are widely used by toxicomaniacs to reproduce drug effects. Drug abusers generally start with psychotrops, but other abuse drug classes. Toxicomanic behavior leads to addictive practices that are difficult to control. BARBITURATES: Both the oral and intravenous routes are used. The expected result is a state of ecstasy with a feeling of comfort. Intoxication may cause respiratory depression. Barbiturates induce physical and psychic dependence. Abuse is not widespread with this class of drugs. BENZODIAZEPINES: Drug abuses widely use benzodiazepines orally or intravenously. They search for a flash effect, with sedation and a feeling of comfort. All benzodiazepines induce physical and psychic dependence. Death may result from combinations leading to respiratory depression. Flunitrazepam is the most widely abused benzodiazepine in France. It induces serious neuropsychic disorders. ANTIDEPRESSANTS: Few are used, mostly at high doses. OPIATES: Administration gives the same effect as heroine injection. Opiates induce physical and psychic dependence. The adverse effects are similar to those of morphine with a higher risk of respiratory depression. AMPHETAMINES: Few are used, either orally or intravenously. They induce a flash with excitation, euphoria, and a period of invincibility. This is followed by a period of depression with risk of suicide. Psychic dependence is high. ANTICHOLINERGIC ANTIPARKINSONIANS: These drugs are well known to abusers for their hallucinatory effect. They induce atropinic adverse effects and physical and psychic dependence. GAMMA-HYDROXYBUTYRATE: This anesthetic is used for its euphoria and sedation effects. It may induce falling sickness or coma, with a risk of respiratory depression. KETAMINE: Administered via the intranasal route, ketamine induces a state of indifference. Death has been observed. ANABOLIC AND ANDROGENIC STEROIDS: These drugs are used for their physical and psychic stimulating effect. They induce potentially dangerous adverse effects such as cardiovascular, hepatic, neurological and psychiatric disorders. Clinical signs of addiction and weaning are observed. OTHERS: Several other drug classes are used by abusers, including analgics, beta-adrenergic agents, nasal vasoconstrictors and corticosteroids.