Journal of Vascular Surgery
Volume 45, Issue 3 , Pages 498-504, March 2007

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

First Department of Surgery, Vascular Division, Athens University Medical School, Athens, Greece.

Received 29 September 2006; accepted 1 November 2006. published online 26 January 2007.

Article Outline

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.

 

Intravenous illicit drug abuse is a significant problem in modern societies, with continuously increasing frequency and a subsequently increasing incidence of vascular complications. Infected femoral artery pseudoaneurysms (IFAPs) are one of the most common arterial complications in intravenous drug abusers1 (Fig 1). This situation can be not only limb threatening, but also life threatening,2, 3 and poses a difficult management problem for the vascular surgeon.

Traditional treatment for IFAP secondary to intravenous drug abuse include excision and ligation of the infected artery along with local debridement.4, 5, 6 This management, however, is frequently associated with later complications such as intermittent claudication and major limb amputation.6, 7 Therefore, some authors have adopted a more aggressive approach of routine revascularization concomitantly with IFAP excision.8, 9 Various reconstruction techniques have been reported, including the use of synthetic or autogenous vein grafts sited either in situ or extra-anatomically, depending on the size of the arterial wall deficit and the presence of contamination.8, 10 However, in this patient population, autologous venous grafts are usually unavailable because of the usual coexistence of deep and superficial venous thrombosis.10 Additionally, the use of a prosthetic graft in the presence of a contaminated surgical field is not an ideal option. In this series, we present our experience in the treatment of such cases using mainly the internal iliac artery (IIA) either as a patch or interposition graft for arterial reconstruction.

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Patients and methods 

From 2001 to 2005, 14 consecutive patients were admitted to our department with IFAP due to intravenous drug abuse. Their medical records were retrospectively analyzed for this study. These included inpatient records, anesthesia records, and outpatient clinic charts. Before surgery, all hemodynamically stable patients were subjected to duplex ultrasound study, which confirmed the presence of a pseudoaneurysm. The deep veins were also examined for the presence of deep venous thrombosis (DVT), and the great saphenous veins (GSVs) were mapped bilaterally for possible use in arterial reconstruction. Patients were also subjected to contrast-enhanced computed tomographic scan of the lower abdomen and upper thigh. Additionally, intra-arterial digital subtraction angiography was performed to provide anatomic details and plan the reconstruction approach (Fig 2). Upon admission, all patients were placed on broad-spectrum antibiotics after blood cultures were drawn.

  • View full-size image.
  • Fig 2. 

    A, Intra-arterial digital subtraction angiography demonstrating a large aneurysm involving the right common femoral artery. B, Contrast-enhanced computed tomographic scan demonstrating contained retroperitoneal rupture of a large infected femoral artery pseudoaneurysm.

Surgery was performed as soon as possible after the completion of patient evaluations. All patients were operated on under general anesthesia in a supine position. Initially, a lateral abdominal pararectus incision was performed, and after retroperitoneal exposure through an uninfected field, proximal control of the external iliac artery (EIA) was obtained. Subsequently, the IIA was meticulously exposed down to its bifurcation and was controlled with vessel loops. A separate skin incision was then made to the inguinal area for exposure and adequate control of the proximal part of the common femoral artery (CFA). Whenever possible, the superficial and profunda femoral arteries (PFAs) were also controlled. Otherwise, distal control was obtained after the opening of the pseudoaneurysm sac, with insertion and inflation of No. 4 or 5 Fogarty balloon catheters in the distal CFA or separately in the PFA and superficial femoral artery.

After arterial control was obtained, extensive debridement of the suppurative surgical field was performed; the groin mass was incised, and all necrotic material was excised. The cavity was then copiously irrigated with saline. Assessment of the arterial wall defect followed, and the decision for circulation restoration was made. In the beginning of this series, if the GSV was suitable, it was used preferentially for arterial reconstruction. Later, however, as we started using the IIA either as a patch (Fig 3) or as an interposition graft, and according to our encouraging initial clinical results, we used it for arterial reconstruction even in two cases in which the GSV was available. In these cases (patients 9 and 12), instead of the GSV, we used the IIA as a conduit to bridge the arterial defect, because it offered better dimension matching with the CFA. Especially in three cases of IIA harvesting, despite angiographically documented patency of the contralateral IIA, we reconstructed the ipsilateral IIA with end-to-end anastomosis of its proximal and distal segments after adequate vessel mobilization, because such a manipulation was facilitated by local anatomic conditions (patients 8, 11, and 14). Finally, if extended destruction of the area precluded orthotopic revascularization, reconstruction was achieved with extra-anatomic obturator bypass with a synthetic polytetrafluoroethylene (PTFE) graft from the EIA to either the ipsilateral superficial femoral or the popliteal artery. After the procedure, Doppler signals were checked on all extremities treated. After surgery, all patients had in-hospital psychiatry consults and were discharged to drug abuse rehabilitation units.

  • View full-size image.
  • Fig 3. 

    Stages of the operation. A, External iliac artery control through a separate retroperitoneal approach. B and C, Mobilization and harvesting of the internal iliac artery. D, Extensive debridement and pseudoaneurysm excision with a large arterial deficit left. E, Successful repair with an internal iliac artery patch.

Statistical analysis was performed with SPSS for Windows (version 10.0; SPSS Inc, Chicago, Ill).

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Results 

Patient characteristics are shown in Table I. Twelve patients (85.7%) were male, and two (14.3%) were female. The median age was 27 years (range, 19-42 years). Twelve IFAPs were on the right side, and two were on the left. All patients abused heroin, and three (21.4%) also abused cocaine. The duration of symptoms ranged from 5 to 31 days (median, 14 days). All patients were seen initially in the emergency department, where they had a workup and were initiated on broad-spectrum antibiotics. Afterward they were referred to our department for further evaluation and management. The median follow-up was 19 months (range, 4-52 months).

Table I. Patient demographics and clinical characteristics
Patient no.Age (y)SexPresentationDiagnosisIntraoperative culture
119MPulsatile groin mass, thigh swellingIFAPNegative
223MPulsatile groin mass, fever, leg swellingIFAPStaphylococcus aureus
327MPulsatile groin mass, signs of sepsis, thigh swellingIFAPS aureus
425MPulsatile groin mass, fever, leg swellingIFAP—contained rupture, DVT, SVTS aureus
527MPulsatile groin mass, external bleedingRuptured IFAPS aureus
635MPulsatile groin mass, feverIFAP, DVT, SVTS aureus
725MPulsatile groin mass, signs of sepsis, thigh swellingIFAP—contained ruptureS aureus, E coli
829MPulsatile groin mass, fever, thigh swellingIFAP—contained ruptureS aureus
922FPulsatile groin mass, thigh swellingIFAPStreptococcus species
1025MPulsatile groin mass, acute ipsilateral limb ischemiaProfunda femoral artery pseudoaneurysmS aureus
1127FPulsatile groin mass, fever, leg swellingIFAP, DVTStreptococcus species
1230MPulsatile groin mass, fever, thigh swellingIFAPS aureus
1342MPulsatile groin mass, fever, leg swellingIFAP, DVTS aureus
1427MPulsatile groin massIFAP, DVTS aureus

IFAP, Infected femoral artery pseudoaneurysm; DVT, deep vein thrombosis; SVT, superficial vein thrombosis.

In seven cases the pseudoaneurysm involved the distal, in two the mid, and in four the proximal CFA extending above the inferior border of the inguinal ligament. In one case, the IFAP was located in the PFA. In all 14 patients, the mass was pulsatile. Three patients (21.4%) had contained rupture of the IFAP. One patient (7%) was admitted with massive external bleeding from the right groin due to a ruptured IFAP. One patient (7%) presented with acute ipsilateral limb ischemia due to compression of the superficial femoral artery by a PFA pseudoaneurysm. Thigh or leg swelling was present in 10 patients (71.4%), whereas 9 patients (64.3%) were febrile on admission. Two patients presented in poor general condition with signs of sepsis. In 12 patients (85.7%), there were palpable pedal pulses (class 3+ or 4+). Thirteen patients had Doppler signals in both pedal arteries before the operation. Skin involvement such as erythema or induration over the IFAP was present in 11 (78.6%) patients.

The white cell count ranged between 8.2 × 109/L and 24.8 × 109/L, with a median value of 13.0 × 109/L. Five patients (35.7%) had DVT: one patient at the ipsilateral popliteal vein, three at the ipsilateral femoral vein, and one at the contralateral femoral vein. Two of these patients also had ipsilateral GSV thrombosis. Seven patients (50%) had a damaged ipsilateral GSV due to previous superficial venous thrombosis. Thirteen patients (92.9%) underwent imaging studies before surgery. These included color duplex ultrasonography (12 patients), lower abdomen and upper thigh contrast-enhanced computed tomographic scan (9 patients), and digital subtraction angiography (7 patients). In the seven patients who underwent digital subtraction angiography, we confirmed patency of the contralateral IIA before harvesting the ipsilateral IIA to ensure adequate pelvic perfusion.

The median length of the arterial defect was 1.8 cm (range, 0.8-2.9 cm), which is larger than that usually seen after femoral artery puncture for endoluminal procedures. In seven patients we were able to repair the deficit with a patch (five arterial and two venous). In four patients we performed a reconstruction with an interposition graft by using the IIA. In two patients a prosthetic extra-anatomic obturator expanded PTFE bypass graft was performed. In one of these cases, the arterial destruction was so extensive that it precluded orthotopic repair with a patch or a short conduit, whereas in the second case, no specific reason for expanded PTFE use was mentioned in the intraoperative notes. In the remaining case, the pseudoaneurysm involved the PFA and was treated with excision and proximal and distal ligation of the PFA (Table II).

Table II. Surgical procedure and outcomes
Patient no.Operation30-d Morbidity/ mortalityFollow-up (mo)ClaudicationAmputation
1Iliopopliteal bypass (synthetic graft)—52NoNo
2GSV patch—13NoNo
3GSV patchMultiorgan failure, death———
4IIA patch—35NoNo
5IIA patch—36NoNo
6IIA interposition graft—21NoNo
7Iliofemoral bypass (synthetic graft)Rupture of proximal anastomosis; graft excision and external iliac artery ligation20YesTrans-metatarsal
8IIA patch⁎—32NoNo
9IIA interposition graft 19NoNo
10Ligation of profunda femoral artery—15NoNo
11IIA patch⁎—13NoNo
12IIA interposition graft—11NoNo
13IIA interposition graft—12NoNo
14IIA patch⁎—4NoNo

GSV, Great saphenous vein; IIA, internal iliac artery.

⁎Primary reconstruction of the IIA.

There was one death (7%) in this series. The patient was admitted in poor general condition with findings of sepsis and was human immunodeficiency virus positive. He underwent a GSV patch reconstruction but died 25 days after surgery in the intensive care unit from multiorgan failure. One patient (7%) had a rupture of the proximal anastomosis of the iliofemoral synthetic graft on the sixth postoperative day, and he was treated with graft excision and EIA ligation. This patient was septic on admission and had a large contained retroperitoneal rupture. Intraoperative cultures were positive for Staphylococcus aureus and Escherichia coli. He had a long postoperative course, with an open groin wound left to heal secondarily and a transmetatarsal amputation. He was finally discharged 42 days after surgery. The remaining 12 patients did not experience any minor or major surgery complication.

One patient (7%) was human immunodeficiency virus positive, and 12 patients (85.7%) were hepatitis C virus positive. Wound cultures grew S aureus in 11 (78.6%) patients (4 methicillin-resistant) and Streptococcus species in 2 patients (14.3%). One patient with Staphylococcus aureus had also E coli grown (7%). No organisms were grown in one patient’s culture (7%). All patients were given intravenous antibiotics according to the antibiogram for 4 to 6 weeks.

After surgery, all 14 patients (100%) had Doppler signals over both pedal arteries, whereas 13 (92.9%) had also pedal pulses. The median length of hospital stay was 14.5 days (range, 7-42 days). All 13 patients were discharged to rehabilitation units, where they continued their intravenous antibiotic treatment and received rehabilitation for drug abuse. All 13 patients were ambulatory, and 12 were free of claudication symptoms during the long-term follow-up period (median, 19 months; range, 4-52 months). None of the nine patients who underwent revascularization with the use of IIA experienced any perioperative complication or required limb amputation. All nine patients (100%) were free of claudication symptoms, and no graft reinfection was observed in long-term follow-up.

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Discussion 

IFAP is a well-known complication among parenteral drug abusers that is due to accidental or intentional intra-arterial drug injection.11, 12, 13, 14, 15, 16 The pathogenesis of IFAP in drug addicts consists of introduction of infected material by nonsterile techniques combined with arterial trauma from inadvertent or even intentional arterial puncture when access to peripheral veins is impossible because of thrombosis.11 If left untreated, IFAP can lead to hemorrhage, sepsis, limb loss, and death.5

The optimal management of IFAPs in drug abusers remains debatable, because these lesions are not very common and because results in most published series5, 6, 8, 17, 18 are based on small numbers of patients. Current treatment options include (1) excision and debridement of the IFAP with ligation of the CFA without revascularization5, 6, 15, 18, 19, 20 and (2) excision and debridement of the IFAP with routine or selective revascularization.7, 10, 11, 17, 20 The latter requires arterial reconstruction, which is achieved with an autogenous or synthetic graft sited either in situ or extra-anatomically, depending on the size of the arterial wall deficit and the presence of contamination.8, 11 The GSV has been the most commonly used autogenous graft in these circumstances, although some authors also report the successful use of the femoral and popliteal veins.10, 21

Ligation of the involved vessels alone, without arterial reconstruction, has been reported by several authors as a viable option.4, 5, 6, 18, 22 Padberg et al,18 in a review of 18 patients with IFAPs due to drug abuse, concluded that ligation alone was preferable to either selective or routine arterial reconstruction. This conclusion, however, may be due to the fact that 50% of the patients who underwent ligation had pseudoaneurysms that did not involve the femoral artery bifurcation. Indeed, it has been reported that ligation of infected pseudoaneurysms that do not involve the femoral bifurcation8, 19, 23 carries less risk for limb loss than those extending to the bifurcation. Reddy et al,23 in a study of 54 cases of femoral artery pseudoaneurysms in drug addicts, classified the patients into 2 groups: patients with false aneurysms isolated to the common, superficial, or deep femoral artery were classified as group A, whereas the remaining patients with lesions of the common femoral bifurcation were classified as group B. Group A patients were treated by aneurysm ligation and excision, whereas group B patients underwent excision and triple arterial ligation or vascular reconstruction. In group A, no amputation was performed. However, in group B, with bifurcation involvement, 33% of patients who underwent ligation alone without revascularization finally required limb amputation. Naqi et al,6 in a recent study, also reported a high amputation rate of 23% after vessel ligation alone without immediate revascularization. Thus, ligation alone without revascularization is frequently complicated with limb amputation, especially in cases in which the pseudoaneurysm extends to the femoral bifurcation.

Even when arterial ligation does not lead to major amputation, a considerable number of patients will experience intermittent claudication; these patients are usually young, without advanced atherosclerotic lesions, and thus they lack significant collateral circulation. Indeed, Cheng et al4 observed a claudication rate of 14 (73.7%) in 19 among patients who underwent ligation without arterial reconstruction for the management of groin IFAP. Additionally, Naqi et al6 and Arora et al,5 who both favor ligation alone without reconstruction, report considerable rates of claudication (23% and 33%, respectively). Stable claudication may be relatively innocent in the general population, but this may not be the rule in drug abusers; these patients usually have poor personal hygiene and are at risk for skin and soft tissue infection, as well as wounds due to trauma that may not heal as a result of diminished arterial blood flow. Although such lesions would be relatively easily discovered and treated in the general population, they can progress and have devastating results in drug addicts, because these patients often have poor medical care and follow-up.24

When arterial revascularization is decided in these cases, the choice of graft is another challenging issue regarding this patient group. Although the GSV is generally the favored conduit for lower extremity arterial reconstruction, its availability is restricted in such patients, because superficial veins are commonly damaged by the prolonged direct injections10; in our series, 9 of 14 patients had no usable GSV. Consequently, the use of prosthetic grafts for delayed or immediate arterial reconstruction seems unavoidable. However, these grafts have been associated with a high reinfection risk even when placed in extra-anatomic routes, such as through the obturator foramen.23 The latter is attributed to transient bacteremias that may occur with continued intravenous drug use by these patients.10

Therefore, it seems reasonable that the ideal material for arterial reconstruction in drug abusers would be an autogenous conduit of adequate artery size match, other than the often-unavailable GSV, that could provide resistance to reinfection. The IIA fits these prerequisites. The IIA has been successfully used for blood flow restoration in several vascular sites. Ritchey et al25 have used the IIA as an interposition graft for the repair of superior mesenteric artery injury. Furthermore, the IIA has been used successfully for renal artery (RA) reconstruction after the repair of lesions such as RA dysplasia, RA hypoplasia, midaortic syndrome, RA aneurysm, dissection, and arteritis.26, 27, 28 Other authors have also documented the use of the IIA either as an interposition or a bypass graft in the pediatric population for reconstruction after arterial injury.29, 30 Finally, the use of the IIA has been described in the treatment of iatrogenic trauma during pelvic lymph node dissection,31 in radical resection of a malignancy of the pelvis including the EIA,32 or, rarely, in the treatment of the iliac vein compression syndrome (Cockett or May-Thurner syndrome).33

In this series, we used the ipsilateral IIA successfully for arterial reconstruction in nine patients. The use of the IIA for arterial reconstruction after IFAP excision in intravenous drug abusers has not been documented before, to our knowledge. However, this technique provides several advantages:

1.It offers a revascularization treatment that is physiologically superior to the viable, but less than ideal, ligation option.

2.The IIA as an autologous conduit offers increased resistance to infections.

3.The IIA as an arterial graft may be less prone to late aneurysm or pseudoaneurysm formation compared with vein.34, 35, 36

4.The IIA can be applied in cases in which the GSV is not available so that the use of a synthetic graft is avoided.

5.The IIA is harvested from an originally uninfected field; in contrast, femoral vein or GSV harvesting may be compromised by the existence of overlying chronic leg ulcers that result from “skin popping,” the subdermal injection of illicit drugs when vascular access cannot be obtained.37

6.The use of the IIA requires no extra incisions and time, in contrast with superficial vein harvesting; the IIA lies in proximity to the ipsilateral EIA, which usually has to be exposed to gain proximal control.

7.In case of small arterial deficits, in which only a short IIA graft is required, the IIA can be primarily reconstructed with adequate mobilization and end-to-end anastomosis of its proximal and distal segments.

8.The IIA offers good dimension matching with the CFA.

The short length of the IIA could be considered as one of the limitations of this technique. However, in all nine cases for which we used the IIA, its proximal part until the first branch was at least 4 cm long, which was proven adequate for repair of the arterial deficit in all patients. Buttock ischemia is another possible issue associated with IIA ligation. None of the patients in this series developed buttock claudication or other signs of immediate or later buttock ischemia. This is reasonable, because these patients are usually young, with no severe atherosclerotic lesions, and thus the remaining contralateral IIA can compensate for the ligated one. Additionally, there are also several ipsilateral collateral branches from the femoral and EIAs that can provide adequate flow. Because of this collateral circulation, patients can tolerate even bilateral IIA interruption, as sometimes happens during open or endovascular aortoiliac aneurysm repair.38

Some authors advocate the use of the popliteal or femoral vein as a conduit for extra-anatomic bypass.10, 21 This technique has been reported to be safe and effective; however, its application can be limited because of the unavailability of suitable lower extremity deep veins and because of the potential for further compromising the likely already-defective venous outflow system in this group of patients. Indeed, Arora et al5 reported a DVT rate of 50% in a drug addict population.

In the setting of complex infected femoral pseudoaneurysms in patients prone to substance abuse, the ideal conduit for replacement of the excised infected arterial segment should be of autologous origin and of adequate caliber for direct reconstruction of the native artery involved. Our work demonstrates that the IIA can meet both goals with excellent limb salvage and functional integrity, diminished rates of reinfection, and low patient morbidity. Our data indicate that the IIA may be the preferred conduit in patients with retroperitoneal exposure (simplifies access to ipsilateral IIA) to obtain proximal EIA control, especially when autologous GSV is not available. In all other cases, additional experience and direct comparison with methods using superficial or deep vein for reconstruction would be needed to establish the role and relative merit of each approach in the care of these very challenging patients.

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Author contributions 


Conception and design: CK

Analysis and interpretation: CK, AK, AP, ST

Data collection: AP, GV, SG, AG, EB

Writing the article: CK, AK, GV, AP

Critical revision of the article: CK, AK, AP, GV, ST, SG, AG, EB

Final approval of the article: CK, AK, AP, GV, ST, SG, AG, EB

Statistical analysis: AK

Overall responsibility: CK, EB

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 Competition of interest: none.

PII: S0741-5214(06)02030-1

doi:10.1016/j.jvs.2006.11.014

Journal of Vascular Surgery
Volume 45, Issue 3 , Pages 498-504, March 2007

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