Femoral pseudoaneurysm from drugs of abuse: Ligation or reconstruction?

Abstract

A plan for management of infected arterial pseudoaneurysm has evolved from our experience with 23 such aneurysms treated between 1981 and 1989 and followed for up to 66 months. Eighteen femoral artery aneurysms are the primary focus of this report. Because we were concerned about the high probability of amputation expected from acute interruption of the femoral artery, we were reluctant to limit initial management to ligation and debridement alone. However, significant complications developed in 12 patients who underwent revascularization, requiring 3 amputations and 13 secondary arterial operations in addition to debridements and skin grafts. In contrast, no amputations were required in six patients who underwent primary arterial ligation and debridement. We recommend primary ligation that controls the septic focus, removes the danger of hemorrhage, and is not accompanied by the threat of secondary arterial infection. After ligation, limb viability is assessed during surgery by presence of an audible Doppler signal at the ankle. Revascularization is considered only when absence of a Doppler signal indicates acute limb ischemia.

Infected femoral pseudoaneurysms from intravenous drug abuse in young adults

“…A mycotic aneurysm with abscess formation develops [1]. The abscess may not be pulsating [7,13]. The growing fibrous tissue often channels the spreading of the aneurysm into the retroperitoneal space.…”

“…The growing fibrous tissue often channels the spreading of the aneurysm into the retroperitoneal space. In such cases attempted diagnostic aspirations will produce negative results [7]. In another case series of 50 patients, 17% were initially misdiagnosed as having either cellulitis or an abscess [3].…”

“…There are several reasons: physicians often do not suspect that such a dangerous route will be used for self-injection of drugs; the abscess is presenting with only one small opening at the apex, which is a typical clinical sign of matured abscesses; patients are reluctant to cooperate with physicians, trying to conceal their addiction and giving misleading answers. These patients are usually experienced drug users with an average age of about 37 years in larger series [4,5,7].…”

“…The unwary "simple" incision and drainage of a suspected groin abscess may lead to a profuse bleeding which, in cases of infected and decomposing tissue, is surgically extremely difficult to control [4]. Despite the obvious clinical picture, patients are often misdiagnosed [6,7]. There are several reasons: physicians often do not suspect that such a dangerous route will be used for self-injection of drugs; the abscess is presenting with only one small opening at the apex, which is a typical clinical sign of matured abscesses; patients are reluctant to cooperate with physicians, trying to conceal their addiction and giving misleading answers.…”

Infra-Inguinal Aneurysms – Threat to Life and Limb?

“…Padberg et al [26], in a study of 18 patients with infected femoral false aneurysms secondary to IVDA, reported on their aggressive use of limb revascularisation due to their concerns about high rates of limb loss when limiting their initial management to vessel ligation and debridement. Twelve of the 18 patients underwent revascularisation in the initial peri-operative period, resulting in 3 amputations and 13 secondary arterial operations in this re-vascularised group, in contrast to no amputations in those patients undergoing vessel ligation with no reconstruction [26]. Both Padberg and Arora et al [27], advocate a test clamp of the distal external iliac/proximal common femoral and assessing pedal doppler signals.…”