Ruptured Infected Femoral Artery Pseudoaneurysms in IV Drug AddictsWinston Wong, Yan Chai Hospital

JHSGR July 18 2015

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Next 10 minutes…BackgroundManagementControversies

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BackgroundIV drug abuse is an increasing problem with concomitant increase in its complicationsVascular complications from IV drug abuse is on the riseInfectious pseudoaneurysmsDeep vein thrombosisVenous gangreneArterial embolization

Infected pseudoaneurysms of the femoral artery are one of the most common arterial complications in IV drug abusers

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Pathophysiology1. Repeated non-sterile punctures aimed at finding

easy peripheral venous access

2. Extravasation of blood

3. Contamination of the subsequent hematoma

4. Erosion and eventual rupture of the vessel wall

5. Formation of infected pseudoaneurysm

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Potential complicationsDistal embolizationLimb lossSepsisRupture with rapid blood lossDeath

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PresentationGroin injection siteGroin massDrainage / bleedingPulsatilityThrillAbsent pedal pulsesInability to extend hipSepticemia

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OverviewBackgroundManagementControversies

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Adopted from Tan et al, World J Surg. 2009

Broad spectrum IV antibiotics

Universal contact precaution

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Bacteriology?Pre-antibiotic era: Enterococcus, streptococcus [1]

Post-antibiotic era: Staph aureus, Salmonella [1]

Ting & Cheng (HK)[2]MSSA

Jayaramans (US)[3], Saini (India)[4]Staph aureus (majority), Pseudomonas, E coli

Brossier et al (France)[5]Majority from atypical bacteria e.g. Campylobacter, Listeria, MTB, CoxiellaStaph aureus (4%)

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Principles of surgery1. Stop bleeding

2. Debride infective tissue

3. Preserve distal circulation

Conservative management is rarely an option

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OverviewBackgroundManagementControversies

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Proposed treatments? [6]

1. Ligation & excision (Lig-Exc) alone

2. Lig-Exc + immediate revascularization

3. Lig-Exc + delayed revascularization

+ Debridement of infective tissue

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Ligation & excision Single vs triple ligation (CFA, SFA, PFA) Benefits

Faster, more straightforwardRequire less resources & expertise

ComplicationsClaudication

(~40-50%, some studies up to 100% [7])Amputation

(none to 35.0% [6])

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Ligation & excision Cheng et al, 1992 [8]

• 21 infected femoral pseudoaneurysms• 19 ligations only, 2 with revascularization• 14 reported claudication (74% of ligation only)

Ting & Cheng, 1997 [2] • 33 infected femoral pseudoaneurysms• 24 triple ligation, 10 single ligation• 4 asymptomatic and rest had some degree of

claudication

No limb loss in both studies

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Considerations in revascularization? Revascularization is challenging and often require special technical considerations

1.Autogenous vs synthetic grafts?• Autogenous veins are more resistant to infection,

but not always available [6]

• Arterial grafts (e.g. internal iliac artery) [9]

• Synthetic grafts [6,10]

o Significantly higher risk of reinfectiono Life-threatening hemorrhage if used as route for

injections

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Considerations in revascularization?

2. Extra-anatomic vs in-situ bypass? • In-situ bypass through infected field is controversial• Extra-anatomic via lateral thigh or obturator route• High chance of graft failure requiring removal

3. Immediate vs delayed revascularization? • Close observation for signs of limb ischemia• Worse outcome if delay in revascularization

> 6 hrs [11]

4. Contraindications?• Presence of extensive tissue necrosis• Necrotizing fasciitis

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Endovascular surgery? Emerging interest as scattered reports of successful repair of infected aneurysms in several territories Minimally invasive alternative / bridge to open surgery Prosthesis in infected field is always debatable

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Endovascular surgery? Handful of case reports only for endovascular intervention for ruptured femoral infected pseudoaneurysms [15, 16] ? Prolonged / lifelong suppressive antibiotic regimen

o 6 weeks? 6 months? Lifelong? ? Antiplatelets / anticoagulation ? Long-term consequences ? Patient selection

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In the middle of the night…

1. Resuscitation

2. Surgerya) Hemostasis - ligate involved arteriesb) Infection control - excise pseudoaneurysm, debride

tissuec) Bacteriology – save pus / wall for culturesd) Wound – leave open / partial close for dressinge) Beware of needle prick!

3. Post-opa) +/- Revascularization

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ConclusionThe best surgical management of infected femoral pseudoanerysms remain controversial

Simple ligation & excision with debridement is the most common approach, with considerable risk of severe claudication, critical ischemia, and amputations in some individuals

Revascularization aim to avoid gangrene, maintain limb viability, and lower claudication rates, but need to accept the major risk of significant and life-threatening secondary complications

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[1] Hussain MA, Roche-Nagle G. Infected pseudoaneurysm of the superficial femoral artery in a patient with Salmonella enteritidis bacteremia. Can J Infect Dis Med Microbiol. 2013;24(1):e24-e25[2] Ting AC, Cheng SW. Femoral pseudoaneurysms in drug addicts. World J Surg. 1997;21(8):783-6[3] Jayaramans et al. Mycotic pseudoaneurysms due to injection drug use: a ten-year experience. Ann Vasc Surg. 2012;26(6):819-24[4] Saini et al. Infected pseudoaneurysms in IV drug abusers: ligation or reconstruction? Int J Appl Basic Med Res 2014;4:S23-26[5] Brossier et al. New bacteriological patterns in primary infected aorto-iliac aneurysms: A single-centre experience. Eur. J. Vasc. Endovasc. Surg 2010;240;582-88[6] Georgiadis GS et al. Surgical treatment of femoral artery infected false aneurysms in drug abusers. ANZ J. Surg. 2005; 75: 1005-1010[7] Gan et al. Outcome after ligation of infected false femoral aneurysms in intravenous drug abusers. Eur. J. Vasc. Endovasc. Surg. 2000; 19:158-61[8] Cheng SWK et al. Infected femoral pseudoaneurysm in intravenous drug abusers. Br. J. Surg. 1992; 79:510-12.[9] Tsao JW et al. Presentation, diagnosis and management of arterial mycotic pseudoaneurysms in injection drug users. Ann. Vasc. Surg. 2002; 16: 652-62[10] Reddy DJ et al. Infected femoral artery false aneurysms in drug addicts: Evolution of selective vascular reconstruction. J. Vasc. Surg. 1986; 3: 718-24[11] Benitez PR, Newell MA. Vascular trauma in drug abuse: patterns of injury. Ann Vasc Surg 1986; 1:175–181[12] Arora S et al. Common femoral artery ligation and local debridement: a safe treatment for infected femoral artery pseudoaneurysms. J. Vasc. Surg. 2001; 33: 990-3[13] Tan KK et al. Surgical management of infected pseudoaneurysms in intravenous drug abusers: single institution experience and a proposed algorithm. World J Surg. 2009 Sep;33(9):1830-5[14] Yegane RA et al. Surgical Approach to Vascular Complications of Intravenous Drug Abuse. European Journal of Vascular and Endovascular Surgery 2006; 32(4):397-401[15] Klonaris et al. Emergency stenting of a ruptured infected anastomotic femoral pseudoaneurysm. Cardiovasc Intervent Radiol 2007;30:1238-41[16] Psathas et al. Management of a complicated ruptured infected pseudoaneurysm of the femoral artery in a drug addict. Case Reports in Vascular Medicine 2012; Article ID 434768

References

Q & A

Ruptured Infected Femoral Artery Pseudoaneurysms in IV Drug Addicts

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End

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Investigation?Active bleeding Urgent surgery

CT angiographyDuplex USGAngiographyMR angiography

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Limitations of current studiesHigh proportion of patients lost to follow-upNo study ever achieved complete post-surgery follow-up

except in acutely symptomatic drug addicts

No fixed protocol for surgical managementBased on surgeon preferences

Mostly small scale, retrospective studies

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YCH 3 cases in past 6 months (Jan – June 2015) 2 ligation + excision

◦ 1 DAMA on POD1◦ 1 discharged on POD3

1 death (hemorrhagic shock)

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Prediction of need for revascularization?No reliable subjective measuresNon-palpable pulsesSystolic pressure in PFA <40 mmHg (Padberg et al, 1992)Lack of pedal Doppler scan signal after ligation or at test

clamping of EIA (Arora et al 2001)

When patient is alertClinical assessment by pain in foot and calf, decreased

power & range

Absence of pulse / positive Doppler signal does not necessitate immediate amputation

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Anatomy

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ABI Normal 1.0 – 1.4

<0.9 = PAD

>1.4 calcification / vessel hardening

0.9-1 – acceptable

0.8-0.9 – some arterial disease

0.5-0.8 – moderate disease

<0.5 – severe disease

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