Infected femoral false aneurysm in drug abusers: Tailoring management to individual requirements

Infected femoral false aneurysm in drug abusers: Tailoring management to individual requirements

Ahmed H Elbarbary, MD

General Surgery Department, Tanta University, Egypt.

Background: Thereismuch  controversy regarding the best management of infected  femoral false aneurysm (IFFA), with advocates of mere arterial ligation or reconstruction either routine or selective.

Aim  of  the work:  To assess  the outcome  of surgical management  of (IFFA) due to local injury in parenteral drug abusers.

Patients  and methods:  Eighteen male patients with IFFA were surgically managed and retrospectively reviewed  from October 2009 until October 2013. Data analyzed included demographic characteristics, modes of presentation, side and site of involvement, management and outcome. Arterial ligation  with excision ofpseudoaneurysm was done in (6) cases whereas vascular reconstruction  was done in (12) cases.

Results:  Overall amputation rate was 1118 (5.5%). All patients who had no revascularization experienced late  claudications  and/or rest pain. Limb salvage  without critical ischemia  was achieved  in  all cases  having  vascular  reconstruction.  Hemorrhage  followed primary  CFA repair in one case (1112,8.3%) and infection occurred in 216 {33.3%) cases of ligation versus

3/12 (25%) cases ofreconstruction.

Conclusion: Revascularization  should be selected if pedal Doppler signals are absent after excision ofpseudoaneurysm and ligation of the involved arteries, the extra anatomic route is a reasonable approach.

Key words: False aneurysm,  femoral pseudoaneurysm,  IFFA, drug abusers.

Introduction:

Arterial pseudoaneurysms due to self­ injection of drugs occur most commonly  in the groin with the development of infected femoral false aneurysm (IFFA). This complication  of drug abuse is accompanied by  systemic  sepsis,  hemorrhage,  limb  loss or death.l Deep groin infection may extend upwards to the retroperitoneum or down to the thigh and knee, where it may lead to extensive soft tissue necrosis.2 The first two cases of IFFA  in  drug  abusers  were  described   by Huebl and Read in the 1960s,3 and nowadays drug addiction  is the primary reason for the increasing frequency of infected aneurysms.4

There is much controversy regarding the best management of IFFA, with advocates of mere ligation or revascularization  either routine or selective.5-7 So the vascular surgeon is forced

to rely on a number of heterogeneous case series.8-12

Aim  of  this   study   was  to  assess  the outcome of surgical management of infected femoral false aneurysms (IFFA) due to local injury in parenteral drug abusers.

Patients and methods:

Inclusion criteria: Eighteen male patients suffering from IFFA as a result of self­ injection of drugs in the groin area were included in this retrospective study.

Exclusion              criteria:              Femoral

pseudoaneurysms  due to trauma, femoral catheterization or developing upon a previous femoral anastomosis were excluded from this study.

Patients     were     admitted     to     Vascular

Surgery   Unit,  Tanta  University   Hospitals

from October 2009 until October 2013. Their age ranged from (20) to (42) years old (mean

33.5 years). All had unilateral IFFA, (10) on the left groin and (8) on the right. Time delay between start of symptoms till presentation ranged from (2-21)  days with a mean of (8) days. Femoral artery ligation was performed as the primary treatment in (6) patients while arterial reconstruction was performed in (12) patients.

Outcomes    measured:   Amputation    and

mortality rates, postoperative infection, hemorrhage,  late  claudications  and  critical limb ischemia.

Diagnosis and preoperative management:

Table(l) illustrates the clinical findings upon admission. In most cases the diagnosis was made clinically from a history of drug injections  in the  groin.  Examination  of the groin area revealed pulsatile groin swelling with audible bruit in (9) cases, non-pulsating tender   swelling   in  (7)  cases  and  rupture with external hemorrhage in (2) cases Figure(l);  spontaneously  in  one  case  and due to misdiagnosis as an abscess and trial of surgical  drainage  outside the hospital in the other.

Examination   of   the   rest   of   the   limb

revealed thigh and leg edema in (14) cases, neurological manifestations as medial thigh numbness and pain due to femoral nerve compression  or damage  detected  in (3) patients and did not recover after surgery. Extensive necrotizing fasciitis affecting the groin, parts of the thigh and inguinal region was present in one patient. Pedal pulses were palpable  in  (16)  cases  and  ankle  brachial index (ABI) was recorded.

The associated patients' conditions related

to IFFA are shown in Table(2). Color duplex ultrasound was performed for (16) patients prior to surgery (excluding the (2) cases presented with hemorrhage).  CT angiograms were obtained in (8) cases to confirm the diagnosis and to plan the operative procedures Figure(2).

In  all  patients  blood  and tissue  cultures

were     drawn,     hepatitis     markers,     HIV testing, complete blood count and tests for coagulation efficiency were done. All patients

received empirical preoperative intravenous antibiotics, which were continued throughout the operative procedure and (4-6) weeks postoperative  and modified according to culture results.

Surgical technique: In all cases a supra­ inguinal incision was designed above and parallel to the inguinal ligament so that the external  iliac artery (EIA) was the proximal vascular control. Pseudoaneurysm was then exposed  through  a  vertical  incision  in the groin area, with local debridement of the infected area to apparently clean margins together  with excision of the false aneurysm Figure(4).   In  the  seven  patients  who  had lateral extra-anatomical  PTFE bypass, a third incision was made in the medial thigh, below the lower limit of the IFFA, to expose the superficial  femoral  artery  (SFA)  in  a clean area. The involved arterial segments in the study cases are shown in Table(3).

Choice     of   ligation   or   reconstruction:

Reconstruction was considered when i) pedal Doppler signals were absent after ligation or test clamping ofCFAor EIA, ii)triple ligation was necessary, iii) ischemic signs appeared. Reconstruction  method was judged by i) the extent of sepsis; extra-anatomic route was preferred whenever widespread sepsis was present, ii) extent of arterial damage; whether primary repair or patch can be done safely or not iii) availability of conduit material; the autologous was preferred whenever suitable otherwise PTFE was chosen.

Ligation was done in (6) cases; CFA only

and SFA only each in one case and triple ligation  in (4)  cases  without  reconstruction due to necrotizing fasciitis in one case, septicemia in another and hemorrhage, shock with  no  available  conduit  material  in  (2) cases. Reconstruction  methods (n=12) were, (7)  lateral  extraanatomic  PTFE  bypass,  (2) in-situ GSV interposition graft, (2) direct arterial repair and one venous patch.

Post-operative   follow   up:   All  patients with (IFFA) undergoing ligation and excision were given heparin for one week to prevent thrombosis of the collateral circulation, and they were kept on an antiplatelet thereafter. Ankle/brachial  indices (ABI)  were obtained

before discharge from the hospital. The mean duration of follow up was 18.5 months (range,

1-34 months).

Results:

The  local  or  systemic   associated conditions, related to drug abuse are presented in Table (2),  in six cases DVT diagnosed by duplex necessitated post-operative treatment with oral anticoagulation for 3-6 months and prohibited the use of superficial veins of this limb as bypass material. One patient presented with  septicemia   was  treated  according  to the general protocol with post-operative admission   to  the   intensive   care  unit  for further management.  He improved gradually over (3) weeks and was discharged after (29) days.  The mean  duration  of hospitalization was (21) days (range 10-55  days). There was no peri-operative deaths.

Post-operative outcome Table(4): Arterial

ligation (n=6) resulted in late intermittent claudications   (Fontaine   stage   IIa-IIb)    in (4/6) cases (66.7%), rest pain in (1/6) case (16.7%) at 4-10 months offollow up. Above­ knee amputation in (1/6) case (16.7%) who presented with necrotizing fasciitis and underwent  triple  ligation.  However,  no further   arterial  intervention   was  done  for the ischemic patients due to improvement under medical treatment in (3) cases and patients' refusal in the other (2). Groin wound infection was observed in (2/6) cases (33.3%) and resolved with further debridement and culture- specific antibiotics.

Arterial   reconstruction   (n=12)  was  not

associated  with  any  claudication,  rest  pain or   amputation.   Infection   was   present   in (3/12) cases (25%), (2) groin infections  and one  superficial   inguinal   wound   infection, all resolved with dressings, antibiotics and debridement of groin wounds. Hemorrhage followed  primary CFA repair on the second post-operative   day  in  (1112) case  (8.3%), he was transferred to the operating theatre, resuscitated,  and  the  anastomosis  was repaired.

Overall amputation rate was (1118, 5.5%).

The  mean   post-reconstruction   (ABI)   was

(0.82),  while  the  mean  post-ligation  (ABI)

was (0.57).

Tissue cultures were positive for Staphylococcus  aureus  in  (16)  patients (88.8%); of them 3 (19%) were resistant to methicillin (MRSA). Mixed cultures were reported   in  one  patient   and  consisted   of Staph.  aureus   with  Candida   albicans   and group B streptococcus.  Anaerobic organisms were cultured from one patient, who returned microaerophilic  streptococcus.  Viral markers revealed   (4)   cases   positive   for   hepatitis C antibodies and other (2) for hepatitis B surface  antigen.  The  mean  leukocyte  count was (14500) cells I cubic millimeter, (range

9200/mm3 - 19900/mm3).

Discussion:

Parenteral    drug    abuse    results    m    a variety of challenging vascular and non­ vascular complications. Of these, infected pseudoaneurysms   are  among  the  most serious,  posing a definite threat to both life and limb.6 The patient may be immune­ compromised from human immunodeficiency virus    (HIV),    hepatitis,    or   malnutrition; this makes widespread local and systemic sepsis more likely.2 Moreover, these patients usually come to the hospital late and often escape   from   follow-up.   Infection   makes some  recent  treatment  methods  unsuitable, at least until now, as percutaneous thrombin injection,  para-aneurysmal   saline  injection or duplex guided compression. Patients often use superficial vascular grafts as valuable access for drug injection.6  For these reasons valid comparisons cannot be made between these patients and those who have femoral pseudoaneurysms resulting from trauma, infected  femoral  grafts,  post-catheterization or other reasons. In view of this, the current study has been limited to treatment of femoral pseudoaneurysms   arising  from  substance abuse. Pseudoaneurysm  develops as a result of inadvertent intra-arterial or periarterial injection of drugs. Extravasation of blood and subsequent infection of the hematoma causes vessel wall breakdown with the resultant infected pseudoaneurysm.l3

The diagnosis is usually straightforward with a history of groin injection, followed in

one to (30) days by pain, limb edema and groin swelling with or without expansile pulsation.5

In  fact,  one-half  of  the  cases  reported   here presented  with   pulsating  whereas   (38.8%) presented with  non-pulsating painful  mass, this  compares well  with  results  of  previous studies.14,15 In cases  presenting as a painful groin  swelling alone,  it is  helpful  to  try  to distinguish  a   localized    abscess,    cellulitis or   hematoma   from    an    IFFA.    Although angiography will show  an  IFFA and  can  be useful  also  in delineating vascular anatomy, some  surgeons   prefer  duplex   ultrasound J,9

In the  current  study  duplex  ultrasound scan was  found  to be  extremely  helpful  and accurate  in confirming clinical  diagnosis, in contrast to  the  findings  of Reddy  et aF and Sandler  et al,16 they  did  not find  ultrasound scan  useful,  in another  study  by Gan  et al,5 (23)   cases   were  studied   with   duplex   and four  cases  were  misdiagnosed as  abscesses. However these studies  were done  more than (14) years ago and refinements in technology may explain  the superior  accuracy of duplex ultrasound scan  today.  Duplex  scan  is  also useful for imaging the femoral and great saphenous   veins    for   thrombosis,   which can be commonly found  in this patient population.9    Evidence    of   ibsilateral  DVT was detected  in (33.3%) of patients  in the present  study. CT Arteriography may support duplex  for accurate  diagnosis, determination of  distal  runoff  and  the  involvement of the CFA  bifurcation, which  would  indicate  the

increased risk of limb loss, if arterial  ligation is  to  be  performed. 1° CT  angiograms were

obtained in (8) cases to confirm the diagnosis in the current  study.

Many  organisms  have been reported  to be isolated  from   IFFA,  but  the  most  common is   Staphylococcus  aureus   and,   indeed,   in this  series  it proved  to  be the most  frequent infecting   organism    where    it   represented (88.8%)  of  cultures; of  them   (19%)   were resistant to methicillin (MRSA). Comparable results           were     reported           in   previous           case

series.5,9,14

The   optimal    surgical    management   of IFFA  has  long  been  debated.   However,   it has  always  been  agreed  upon  that  the  most

important part is adequate  local debridement of  infected  tissues  and  ensuring  healthy arterial    margins.2,4,6,7,1 O       Revascularization following excision  of IFFA is controversial from  the  aspects  of necessity,  method,  route and timing,10,13,17,18 the available options are:

- Primary repair with standard vascular techniques.7,14,19

-  Single   or  triple   ligation   and  exclSlon of IFFA, followed by:  a) Immediate reconstruction either by (i) extra-anatomic bypass    (obturator  or   lateral   thigh18,20-22) using  PTFE,  or  by  (ii)  in  situ  autogenous

repair,  (vein  patch14,17,23 or  bypass).19,24 b)

No  arterial   reconstruction8-10,14,17,25  except if pedal Doppler signals are absent after test clamping of  EIA9  or  ligation  of  CFA.14 c) Selective   (delayed) revascularization  where the  viability of  the  leg  is in  danger  due  to critical  ischaemia.7,20,23,26

- Primary  amputation if reconstruction in any form is not feasible_26,27

In the current study the overall amputation rate  was  1118 (5.5%)   in  the  case  of  triple ligation with  extensive necrotizing fasciitis. All patients who had no revascularization experienced  late   claudications  and/or   rest pain,  while  limb salvage  without  critical ischemia was achieved in all cases  having vascular     reconstruction.    Hemorrhage followed  primary   CFA  repair   in  one  case (8.3%) and infection  occurred in 2/6 (33.3%) cases   of  ligation   versus   3/12  (25%)   cases of  reconstruction. Likewise, several  authors confirmed that severe claudication more often follows  triple  than  single  ligation.6,7,26,28 In the study  by Cheng  et al (15.3%)  of patients with triple  ligation IFFA developed  severe ischaemia, and (84.6%) of patients  exhibited claudication on follow  up28. Reddy  et al7 reported  high rates of limb  loss, up to (33%) in triple  ligation,  while single-vessel ligation resulted    in   claudication   in   all   patients. Gan et aP found that both triple and single ligation with limb observation resulted  in (100%)  claudication.  They   did   not   check for the presence of pedal Doppler signals following trial  clamping of the CFA/EIA intraoperatively4. On the other hand, Sadeghi et al performed ligation-excision only in (27)

Figure {1): Ruptured IFFA.

Figure {3): IFFA with leg ulcers.

Figure   {2):  CT  angiogram   of  bifurcation

IFFA.

Figure {4): IFFA treated by excision-ligation.

Table (1): Clinical presentation of the study cases:

IFFAs, infection developed in (18.51%), claudication   in  (14.8%),   and  (7.4%)   lost their limbs.29 Similarly, Cheng et al and Lashkruizadeh  et  al  recommended   ligation as  the  safer  method,  on  the  basis  of  their

observations.26,28

In order to solve the problem of selecting as to which patient undetgoes reconstmction. Arora   et   al   made   use   of   intraoperative Doppler   examination    of   a   pedal   attety

Table (2): The associated conditions:

Table (3): Different treatment  methods  and involved arterial segment:

CFA: Common femoral artery       DFA: Deep femoral artery

PTFE: Poly-tetra-fiouro-ethylene   GSV: Great saphenous vein

Table (4): Post-operative  outcomes relative to treatment method:

after test-clamping  of the EIA or CFA. If Doppler  signals  were  present,  common femoral artery would be simply ligated. This approach prevented amputation in all of their patients.9  However,  it  must  be  noted  that

audible  recognition  of  the  Doppler  signal is a qualitative assessment that may not be infallible; with a larger series of patients, occasional  inaccurate predictions  may occur.30

Ligation offers definitive local treatment, removes thethreat ofhemorrhage, and controls the septic process. It represents the simplest and most straightforward  surgical treatment for   the   IFFA.l4  However,   some   patients will have ischemic gangrene if immediate collateralization  is inadequate.  Furthermore, it should be noted that even if a graft is not contaminated  at the  time  of its insertion,  it may become so afterwards following puncture with dirty needles.2 Thus, simple ligation­ excision  reduces  minor  complications  such as hemorrhage and infection, and predisposes to major complications such as claudication and amputation.

Two  series   presented   poor  mean   ABI

(0.41) in  cases  with  triple  ligation,8,28 but Padberg et al. had two patients able to walk several blocks after triple ligation.l4 An ABI of (0.41) could result  in a viable  limb,  but this is not correlated with limb functionality. It is unclear why claudication  and disability should be accepted in young drug addicts who need supplies and sufficient rehabilitation  in order to be candidates of regaining a normal life  while  it  is  not  accepted  in  old,  frail patients of atherosclerotic disease undergoing intervention.

Conclusion:

The main goals for management  of IFFA are to eliminate sepsis, preserve the life and the limb viability and vitality (functionality), so management method should be tailored to individual requirements.

Adequate local debridement of infected tissues and ensuring healthy arterial margins is the primary non-debatable treatment.

To   preserve     a   functional    limb   it   is

recommended   that   in  the   absence   of   a distal Doppler signal intraoperatively after clamping of CFA or EIA, revascularization should be elected, the extra-anatomical  route is a reasonable approach.

Large multicenter  prospective  trials  with

longer follow-up should be performed so as to  elucidate  the  best  surgical  methods  for IFFA.

Reference:

1-   Maltezos    C,   Kopadis    G,   Tzortzis   EA, Pappas            Th,    Marakis    J,    Hatzigakis    P, Dayantas J: Management  of femoral artery pseudoaneurysm secondary to drug abuse. Euro]  f-asc Endovasc Surg Extra 2004; 7:

26-29.

2-    Chan  YC,  Bumand   KG:  Management   of septic  groin  complications  and infected femoral false aneurysms in intravenous drug abusers.  Br] Surg2006; 93: 781-782.

3-    Huebl HC,  Read  RC: Aneurysmal  abscess.

Minn Med 1966; 49: 11-16.

4-    Georgiadis  GS, LazaridesPolychronidis

KA, Simopoulos C: Surgical treatment of femoral   artery   infected   false   aneurysms in  drug  abusers.   ANZ  ] Surg  2005;  75:

1005-1010.

5-    Gan JP, Leiberman DP, Pollock JG: Outcome after ligation of infected false femoral aneurysms  in intravenous  drug abusers.  Eur

] f-asc Endovasc Surg2000; 19: 158-161.

6-    Patel  KR,  Semel  L,  Clauss  RH:  Routine revascularisation with resection of infected femoral pseudoaneurysms from substance abuse.] f-asc Surg 1988; 8: 321-328.

7-    Reddy DJ, Smith RF, Elliot JP, Haddad GK, Wanek EA: Infected femoral artery false aneurysms in drug addicts: Evolution of selective  reconstruction.   ] Vase Surg 1986;

3: 718-724.

8-    Ting       AC,       Cheng        SW:       Femoral pseudoaneurysms  in  drug  addicts.   World] Surg 1997; 21: 783-786.

9-    Arora  S,  Weber  MA,  Fox  CJ,  Neville  R, Lidor  A,   Sidawy  AN:  Common   femoral artery   ligation   and  local  debridement:   A safe treatment for infected femoral artery pseudoaneurysms.   ]  f-asc  Surg  2001;  33:

990-993.

10-  Behera A, Menakuru  SR, Jindal R: Vascular complications of drug abuse: An Indian experience. ANZ]Surg2003; 73:1004--1007.

11-  Li JW, Wang SChen  XD:  Management

of  femoral  artery  pseudoaneurysm   due  to addictive  drug  injection.  Chin ] Traumata]

2004; 7: 244-246.

12-  Kozvelj  M,  Kobilica   N,  Flis  V:  Infected femoral pseudoaneurysms from intravenous drug abuse in young adults. Mid Euro] Med

2006; 118: 71 -75.

13-  Naqi  SA,  Khan  HAkhtar  S, Shah  TA: Femoral  pseudoaneurysm   in  drug  addicts­ Excision without revascularization is a viable option.  Eur] f-asc Endovase Surg 2006; 31:

Am-Shams] Surg 2014; 7(4):1-10