- Email: [email protected]
Tolerable Hemodynamic Changes after Femoral Artery Ligation for the Treatment of Infected Femoral Artery Pseudoaneurysm
Tolerable Hemodynamic Changes after Femoral Artery Ligation for the Treatment of Infected Femoral Artery Pseudoaneurysm Zuo-Jun Hu, Shen-Ming Wang, Xiao-Xi Li, Song-qi Li, and Xue-Ling Huang, Guangzhou, China
Background: We analyzed the hemodynamic changes induced by femoral artery ligation with concomitant thrombectomy in intravenous drug abusers with infected femoral artery pseudoaneurysm (IFAP) and their clinical significance. Methods: Between January 2000 and November 2007, a total of 55 patients presented to our clinic with IFAP. Among these patients, 54 were treated by femoral artery ligation with concomitant thrombectomy. Open collateral circulations were assessed by intraoperative angiography, including detection of mean artery pressure (MAP) of back-flow from the profunda femoris artery and the superficial femoral artery after operation. Patients were followed up for 3e72 months (mean 35). The data were then subjected to statistical analysis. Results: Preoperative death occurred in one patient due to acute onset of drug addiction in the ward. Preoperatively, massive necrosis developed in the left limb of the only patient with bilateral IFAPs. All 54 patients underwent femoral artery ligation with concomitant thrombectomy, including nine cases of ligation of the external iliac artery and one case of above-knee limb amputation. All wounds were completely healed within 3 months. Six late deaths (11.1%), resulting solely from refractory drug addiction, were observed during the follow-up period, of which two occurred 2 years, one 4 years, and three 5 years postoperatively. No toe amputations were noted during the follow-up period. Fourteen patients (25.9%) developed intermittent claudication. One postoperative limb was lost. Of all 54 patients, 38 were subjected to collateral circulation assessment by intraoperative angiography. Collateral circulations were found well open in a baseline path with four stations down to the distal lower limbs of all assessed patients. Four preferred types of iliacefemoral collaterals were defined. Postoperatively, compared to the external iliac artery, the MAP levels of back-flow from the profunda femoris artery and the superficial femoral artery significantly dropped to 43.89 ± 2.75 and 18.08 ± 2.76 mm Hg, respectively. Conclusion: As a result of femoral artery ligation without reconstruction, well open collateral circulations and acceptable distal arterial runoff blood are seen, which suggests that this procedure is a reliable alternative to the emergent treatment of IFAPs in drug addicts. However, arterial reconstruction may be used as a backup approach if necessary during observation.
INTRODUCTION
Department of Vascular Surgery, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China. Correspondence to: Zuo-Jun Hu, MD, PhD, Department of Vascular Surgery, First Affiliated Hospital of Sun Yat-sen University, No. 58, Zhongshan 2nd Road, Guangzhou, China (510080), E-mail: [email protected] Ann Vasc Surg 2010; 24: 212-218 DOI: 10.1016/j.avsg.2009.06.006 Ó Annals of Vascular Surgery Inc. Published online: September 11, 2009
212
In recent years, the number of intravenous (i.v.) drug addicts visiting our clinic has shown an increasing trend. Intravenous drug abuse is more severe than traditional oral use since the former often results in local arterial and venous damage and is frequently complicated by infections, such as human immunodeficiency virus (HIV) and hepatitis B or C virus. Owing to the sudden open rupture of pseudoaneurysms and the occurrence of systemic sepsis, i.v. drug abuse is also potentially lethal. The hallmark of its diagnosis is the presence of a pulsatile
Vol. 24, No. 2, February 2010
mass in the groin full of pinholes on the skin with or without open rupture. Nowadays, it presents a unique vascular problem to our clinic. The dilemma of treatment against limb loss and the high risk of prosthetic graft infection present a practical challenge to vascular surgeons. Currently, various treatment options are available.1-6 Proximal and distal ligation of vessels and complete excision of aneurysms are frequently used for treatment. Other procedures, such as revascularization after excision of aneurysms using autogenous vein grafts or synthetic grafts, percutaneous thrombin injection,7 and endoluminal stent grafting or coil embolization, are also performed for small pseudoaneurysms without infection or with infection under good control.8 Among these procedures, ligation of vessels and excision of pseudoaneurysms along with debridement are regarded as the basic treatment, while there remains controversy over the necessity and timing of revascularization. Some researchers recommend immediate revascularization by an extra-anatomic route,9-11 whereas other researchers prefer simple ligation of the femoral artery without any reconstruction.12 Although many reports have been published on the clinical treatment of infected femoral artery pseudoaneurysm (IFAP) in drug addicts, the hemodynamic results of such approaches have not yet been conclusively determined and remain a major topic of concern. The aim of this study was to identify the hypothesis that femoral artery ligation without reconstruction can result in open collateral circulations, acceptable hemodynamic alterations in the distal lower limb, and viable presentation of the diseased limbs, which underlies the reliability of such alternative approaches to the treatment of IFAPs in drug addicts.
METHODS The protocol for the study of femoral artery ligationeinduced hemodynamic changes in i.v. drug abusers with IFAPs (see Fig. 1) and their clinical significance was approved by the research ethics committee of our institute. Consecutive IFAP patients were selected as candidates for this study. Patients reluctant to abide by the study protocol (including regular follow-up) were excluded. Informed consent was obtained from all enrolled IFAP patients. Data collection and definition of the study were performed according to the recommendations of the Ad Hoc Committee for Standardized Reporting Practice.13,14 These demographic data, perioperative details, and follow-up data were
Hemodynamic changes after femoral artery ligation
213
Fig. 1. Preoperative photo showing the infected left femoral pseudoaneurysm with thrombus in a drug addict.
prospectively collected. Each patient underwent serological testing for HIV and hepatitis virus infections. Digital subtraction angiography (anteroposterior and oblique views) was also performed using a catheter to further define the collateral circulations during the operation, including detection of mean arterial pressure (MAP) of back-flow from the profunda femoris artery (PFA) and superficial femoral artery (SFA) after operation using a transducer connecting to the arterial pressure monitor. Femoral artery ligation and debridement was performed under general or epidural anesthesia according to previously described techniques.12 Briefly, the common femoral artery (CFA) proximal to the aneurysm was first exposed. If the CFA was found to be unhealthy, suprainguinal control was taken by exposing the external iliac artery (EIA). After that, the pseudoaneurysm cavity was opened and excised. Subsequently, both the proximal SFA and the PFA were controlled. Patients with evidence of proximal or distal thrombosis underwent thrombectomy through the arterial stumps until forward and back-flow showed satisfactory performance during the operation. The choice of bipolar or triple ligations was tailored to the individual situation. Complete debridement was then undertaken. The groin wound was left open, filled with iodoform gauze, and dressed until healing. After the operation, all patients were given oral aspirin (an antiplatelet agent) at a dose of 100 mg/day for 3 months. Clinical follow-up examinations were conducted at 30 days, 3 months, and 6 months postoperatively and then annually thereafter. Continuous data were expressed as mean ± standard deviation. Statistical tests were performed using SPSS software (version 14.0; SPSS, Inc.,
214 Hu et al.
Annals of Vascular Surgery
Table I. Patient demographics (n ¼ 55) Characteristic
Patients (%)
Age (mean, years) Male sex Symptomatic History of drug usage (mean, years) Experience with i.v. drugs (mean, years) Aneurysm diameter (mean, cm) Comorbid Type of groin bleeding Contained Free HIV infection Hepatitis C infection Arterial thrombosis of lower limb Proximal DVT Ischemia of lower limb Viable Marginally threatened Irreversible Abscess involved iliac fossa Abscess in groin Anemia Malnutrition Death before operation
31.7 ± 6.7 54 (98) 55 (100) 6.0 ± 3.6 1.7 ± 1.1 10.4 ± 4.0
33 22 1 12 50 26
(60) (40) (2) (22) (91) (47)
31 23 1 10 55 55 55 1
(56) (42) (2) (18) (100) (100) (100) (2)
Chicago, IL). The t-test was used for data analysis. Statistical significance was set at p < 0.05.
RESULTS During the period between January 2000 and November 2007, a total of 55 consecutive patients presented to our clinic with IFAP from i.v. drug abuse. Of these patients, 54 were subjected to simple femoral artery ligation without revascularization. One patient died of acute onset of drug addiction in the ward before operation. Preoperatively, massive necrosis developed in the left lower limb of the only patient with bilateral IFAPs. All these patients had a confidently established diagnosis of IFAP. Their conditions are listed in Table I. Nearly all patients were male (n ¼ 54, 98%). All patients, aged between 15 and 45 years (mean 31.7), were symptomatic. Pseudoaneurysm occurred in the left groin in 25 patients, in the right groin in 29, and bilaterally in one, with a mean diameter of 10.4 cm and a maximum value of 20 cm. All patients had a history of groin injection and bleeding. The mean duration of groin injection was 1.7 years (range 0.3-4). The mean duration of drug abuse was 6 years (range 1-13). All patients abused heroin. Ninety-one percent (n ¼ 50) of the patients developed incomplete femoral artery
thrombosis in the lower limb, and 26 of these simultaneously developed proximal deep venous thrombosis (DVT). Nearly half (n ¼ 23, 42%) of patients showed marginally threatened lower limb ischemia. All patients had groin abscess, and 10 patients developed iliac fossa. Twelve patients (22%) had hepatitis C, while one patient was positive for HIV. All patients presented with anemia (mean hemoglobin value 79.1 g/L, range 55.2-92.6) and malnutrition (mean weight loss 40%, range 30-55%). Operative and Clinical Results All 54 patients underwent femoral artery ligation with concomitant thrombectomy through the vessel stumps, including ligation of the EIA in nine patients and above-knee amputation of the left lower limb of the patient with bilateral IFAPs. Both bipolar (n ¼ 12, 22%) and triple (CFA, SFA, and PFA; n ¼ 42, 78%) ligations were used. The mean volume of hematoma inside the aneurysm was 235 mL (range 100-450). Thrombus was removed by thrombectomy from the distal and proximal artery of all diseased limbs, with a maximum length up to 20 cm (mean 8, range 2-20). Nine patients received a blood transfusion. No operative death or perioperative wound complication was observed. All patients were discharged with viable limbs. All patients were followed up for a mean period of 35 months (range 3-72). During the follow-up period, all wounds were completely healed within 3 months. Six late deaths (11.1%), resulting from refractory drug addiction, were observed: two at 2 years, one at 4 years, and three at 5 years postoperatively. No toe amputations were noted during the follow-up period. Fourteen patients (25.9%) developed intermittent claudication. One postoperative limb was lost. Open Collateral Circulations Open collateral circulations were assessed by intraoperative angiography in 38 (70.4%) patients. Collateral circulations were found well open in a baseline path with four stations down to the distal lower limbs of all assessed patients. At the first station, it was noted that the ipsilateral internal iliac artery (IIA) and its branches became compensatorily enlarged, and blood flow first went through the enlarged IIA and its branches when the EIA or CFA was blocked (Fig. 2). The second station showed extensive openness in the collaterals between the IIA and the PFA (Fig. 3). At the third station, blood flow went through the branches of the PFA and the genicular artery around the knee
Vol. 24, No. 2, February 2010
Hemodynamic changes after femoral artery ligation
215
Fig. 2. The first station: compensatory enlargement of the left IIA. Fig. 4. The third station: branches of the PFA bridged to the SFA and PA.
collateral consisting of the superior gluteal artery (SGA), inferior epigastric artery (IGA), and OA. All these types of collaterals were connected subsequently to the ascending branches of the medial or lateral circumflex femoral artery (ACFA) originating from the PFA. Among these 38 patients, 11 (28.9%) showed type I collateral, eight (21.1%) type II, seven (18.4%) type III, and 12 (31.6%) type IV (Figs. 6e9). Measurement of MAP in the PFA, SFA, and EIA after Ligation Fig. 3. The second station: extensively open collaterals from the IIA to the PFA.
until it reached back to the SFA and the popliteal artery (PA) (Fig. 4). Lastly, blood flow was supplied to the distal limb via the normal pathway, including the posterior and anterior tibial arteries as well as the fibular artery (Fig. 5). Based on intraoperative angiographic observations, we also found that there were different predominant collaterals between the iliac and femoral arteries. We defined them as four preferred types. Type I was noted as a dominant bridge originating from the inferior gluteal artery (IGA), type II was defined as a dominant bridge from the obturator artery (OA), type III represented a dominant collateral from the inferior epigastric artery (IEGA), and type IV showed a mixed-mode
MAP measurement was achieved in 38 (70.4%) patients during operation. Considerable impairment of postoperative hemodynamic performance was observed (see Table II) since MAP dropped from 65.03 ± 3.15 to 18.08 ± 2.76 mm Hg ( p < 0.001).
DISCUSSION Femoral artery pseudoaneurysms resulting from drug addiction are a special kind of false aneurysm often complicated with infection and arterial wall damage. The pathogenesis of femoral artery pseudoaneurysms is associated with the introduction of infected material due to nonsterile manipulations and the trauma resulting from inadvertent or deliberate puncture of femoral vessels. In recent years, groin injection appears to be one of the preferred routes for drug abuse in our local region. Intravenous drug abuse frequently results in many complications, such as local and systemic sepsis, distal
216 Hu et al.
Annals of Vascular Surgery
Table II. Postoperative MAP changes (n ¼ 38)
MAP* (mm Hg)
EIA
PFA
SFA
65.03 ± 3.15
43.89 ± 2.75 ( p < 0.001)
18.08 ± 2.76 ( p < 0.001)
*Significant differences among the EIA, PFA, and SFA values (t values were 32.126 and 69.919, respectively). Significant difference between PFA and SFA values (t value was 34.846, p < 0.001).
Fig. 5. The fourth station: blood flow supplied to the distal limb.
Fig. 6. Type I: dominated by the IGA.
ischemia, and aneurysmal rupture.15 Subsequent bleeding and hematoma may cause breakdown and rupture of the vessel wall or even local skin, which is partly responsible for the lethality of i.v. drug abuse. Staphylococcus aureus is the predominant infective organism, observed in 71% and 76% of blood and local wound cultures, respectively.16 Ting and Cheng17 found that blood and tissue cultures mostly showed pure growth of methicillin-sensitive S. aureus and partly showed mixed growth of this bacterium with other ones. In our series, all groins showed extensive abscess, while 18% of them exhibited iliac fossa and locally disorganized vessels and tissues. Additionally, 47% of the patients developed proximal DVT. These results suggested a high possibility of infection and occlusion of prosthetic grafts, which is greatly unfavorable to revascularization. Therefore, the clinical manifestations, such as infections, disorganized tissues, and poor deep venous back-flow, should be weighed when considering treatment options. Although many reports have been published on the clinical treatment of femoral pseudoaneurysm in drug addicts and satisfactory results have been achieved, the related hemodynamic results of such approaches have not yet been conclusively
determined and remain a major topic of concern. Theoretically, the widespread availability of potential collaterals between the iliac and femoral arteries provides a collateral reserve, which has been verified anatomically. Once the main trunks of the iliac or femoral arteries are blocked, these collaterals will possibly function as a compensatory system. Furthermore, most of these drug addicts are young and, therefore, have little opportunity for developing arterial atherosclerosis. Thus, their collateral conditions are always fairly good. Consequently, it is very possible that the iliacefemoral collateral circulations may afford sufficient blood compensations to maintain the viability of the distal lower limbs. In our series, it was interesting that arterial thrombosis was present in the diseased lower limbs of 91% (n ¼ 50) of the patients. Only 42% of these patients showed marginally threatened lower limb ischemia, and 56% had viable limbs on admission. Irreversible ischemia was noted in one case. That is, the potential collaterals might begin to function when occlusive factors were present in the main arterial trunks during the course of disease. During the operation, the mean volume of hematoma, mixed with abscess, inside the aneurysm was
Vol. 24, No. 2, February 2010
Hemodynamic changes after femoral artery ligation
217
Fig. 8. Type III: dominated by the IGA. Fig. 7. Type II: dominated by the OA.
235 mL (range 100-450). Thrombus was removed by thrombectomy from the distal and proximal artery of all diseased limbs, with the maximum length up to 20 cm (mean 8, range 2-20). Thrombus in the main trunks may occlude the reentry of blood flow from the collaterals to the lower limb. In this regard, concomitant thrombectomy will be helpful to open the reentry orifice and establish more extensive collaterals to the lower limb. Thus, we think that thrombectomy should be performed concomitantly with ligation of the femoral artery. Due to these procedures, the distal blood supply may be improved, which was observed in this study. Open collateral circulations were assessed by intraoperative angiography in our series. Collateral circulations were found well open in a baseline path with four stations down to the distal lower limbs of all assessed patients. Firstly, the ipsilateral IIA and its branches became compensatorily enlarged, and blood flow went through the enlarged IIA and its branches when the EIA or CFA was blocked. Secondly, that was connected to extensive open collaterals between the IIA and PFA. Thirdly, blood flow reentered into the SFA and PA via the branches of the PFA and the genicular artery around the knee. Lastly, blood flow continued to be supplied to the distal limb via the normal pathway, including the posterior and anterior tibial arteries as well as the fibular artery. Based on intraoperative angiographic observations, we also found that there were different predominant collaterals between the iliac and femoral arteries. Four preferred types were noted.
Fig. 9. Type IV: mixed mode consisting of the SGA, IGA, and OA.
Type I was noted as a dominant bridge originating from the IGA, type II was a dominant bridge from the OA, type III represented a dominant collateral from the IEGA, and type IV showed a mixed-mode collateral consisting of the SGA and IGA and the OA. All these types of collaterals were connected subsequently to the ACFA originating from the PFA. In our study, 28.9% of the patients showed type I collateral, 21.1% type II, 18.4% type III, and 31.6% type IV. These results revealed unique and multiple modes of the development of iliacefemoral
218 Hu et al.
collaterals in drug addicts, representing another major finding of this study since no similar results have been reported in the relevant literature. Associated significant impairment, however, was also noted in the assessment of MAP. Interestingly, MAP levels did not drop to zero but were maintained at around 18.08 mm Hg, which was enough to keep most limbs alive. Some studies18,19 have reported limb amputation rates of 11-33% and frequent intermittent claudication when femoral pseudoaneurysms were treated by simple ligation. In our study, no toe amputations were noted during the follow-up period. Only 25.9% of patients developed intermittent claudication, and one postoperative limb was lost. The good clinical results achieved in this study may be mainly due to the well open collaterals and the reversed blood flow reentry by concomitant thrombectomy. In addition, the fact that the young patients included in the study had no apparent atherosclerosis in the lower limb can partly explain our results. Furthermore, in additional to the well open collaterals, a fair survival was noted during the follow-up period since only six late deaths were observed. All these deaths resulted solely from refractory drug abuse that caused damage to systemic functions. Therefore, in view of our emergent surgical treatment, the results were quite acceptable, though the special drug addiction of these patients may mainly influence their longterm survival. A psychiatric regimen without interruption should be pursued in these patients as a lifelong task.
CONCLUSION Since femoral artery ligation with concomitant thrombectory can result in effectively open collateral circulations, acceptable distal arterial runoff, as well as viable presentation of the diseased limbs, this procedure may be a substantially reliable alternative approach to the emergent treatment of IFAPs in drug addicts. However, arterial reconstruction may be used as a backup approach if necessary during observation. A further prospective randomized trial with a large cohort will be necessary to verify these outcomes.
Annals of Vascular Surgery
REFERENCES 1. Levi N, Rordam P, Jensen LP, Schroeder TV. Femoral pseudoaneurysm in drug addicts. Eur J Vasc Endovasc Surg 1997;13:361-362. 2. Patel KR, Semel L, Clauss RH. Routine revascularization with resection of infected femoral pseudoaneurysms from substance abuse. J Vasc Surg 1988;8:321-328. 3. Reddy DJ, Smith RF, Elliott JP, et al. Infected femoral artery false aneurysms in drug addicts: evolution of selective vascular reconstruction. J Vasc Surg 1986;3:718-724. 4. Welch GH, Reid DB, Pollock JG. Infected false aneurysm in the groin of intravenous drug abusers. Br J Surg 1990;77: 330-333. 5. Naqi SA, Khan HM, Akhtar S, Shah TA. Femoral pseudoaneurysm in drug addictsdexcision without revascularization is a viable option. Eur J Vasc Endovasc Surg 2006;31: 585-587. 6. Behera A, Menakuru SR, Jindal R. Vascular complications of drug abuse: an Indian experience. Aust N Z J Surg 2003;73: 1004-1007. 7. Goel PK, Modi N, Baijal SS, Kathuria M, Agrawal SK. Sonographically guided thrombin injection for the treatment of femoral artery pseudoaneurysm. Indian Heart J 2003;55:365-367. 8. Righini M, Quere I, Laroche JP. Treatment of postcatheterization femoral false aneurysms. J Mal Vasc 2004;29:63-72. 9. Bell CL, Ali AT, Brawley JG, et al. Arterial reconstruction of infected femoral artery pseudoaneurysms using superficial femoral-popliteal vein. J Am Coll Surg 2005;200:831-836. 10. Matoussevitch V, Aleksic M, Gawenda M, Brunkwall J. Primary extraanatomical revascularization for groin infections in drug addicts. Vasa 2007;36:210-214. 11. Klonaris C, Katsargyris A, Papapetrou A, et al. Infected femoral artery pseudoaneurysm in drug addicts: the beneficial use of the internal iliac artery for arterial reconstruction. J Vasc Surg 2007;45:498-504. 12. Arora S, Weber MA, Fox CJ, et al. Common femoral artery ligation and local debridement: a safe treatment for infected femoral artery pseudoaneurysms. J Vasc Surg 2001;33: 990-993. 13. Johnston KW, Rutherford RB, Tilson MD, et al. Suggested standards for reporting on arterial aneurysms. J Vasc Surg 1991;13:444-450. 14. Rutherford RB, Baker JD, Ernst C, et al. Recommended standards for reports dealing with extremity ischemia: revised version. J Vasc Surg 1997;26:517-538. 15. Schulz S, Beckenbach C, Philipp M, Hengstmann J. Color coded duplex sonography of inguinal vessels in i.v. drug addicts. Vasa 2002;31:7-13. 16. Johnson JR, Ledgerwood AM, Lucas CE. Mycotic aneurysm. Arch Surg 1983;118:577-582. 17. Ting ACW, Cheng SWK. Femoral pseudoaneurysms in drug addicts. World J Surg 1997;21:783-787. 18. Benjamin ME, Cohn EJ, Purtill WA, et al. Arterial reconstruction with deep leg veins for the treatment of mycotic aneurysms. J Vasc Surg 1999;30:1004-1015. 19. Padberg F, Hobson R, Lee B, et al. Femoral pseudoaneurysm from drugs of abuse: ligation or reconstruction? J Vasc Surg 1992;15:642-648.
Background: We analyzed the hemodynamic changes induced by femoral artery ligation with concomitant thrombectomy in intravenous drug abusers with infected femoral artery pseudoaneurysm (IFAP) and their clinical significance. Methods: Between January 2000 and November 2007, a total of 55 patients presented to our clinic with IFAP. Among these patients, 54 were treated by femoral artery ligation with concomitant thrombectomy. Open collateral circulations were assessed by intraoperative angiography, including detection of mean artery pressure (MAP) of back-flow from the profunda femoris artery and the superficial femoral artery after operation. Patients were followed up for 3e72 months (mean 35). The data were then subjected to statistical analysis. Results: Preoperative death occurred in one patient due to acute onset of drug addiction in the ward. Preoperatively, massive necrosis developed in the left limb of the only patient with bilateral IFAPs. All 54 patients underwent femoral artery ligation with concomitant thrombectomy, including nine cases of ligation of the external iliac artery and one case of above-knee limb amputation. All wounds were completely healed within 3 months. Six late deaths (11.1%), resulting solely from refractory drug addiction, were observed during the follow-up period, of which two occurred 2 years, one 4 years, and three 5 years postoperatively. No toe amputations were noted during the follow-up period. Fourteen patients (25.9%) developed intermittent claudication. One postoperative limb was lost. Of all 54 patients, 38 were subjected to collateral circulation assessment by intraoperative angiography. Collateral circulations were found well open in a baseline path with four stations down to the distal lower limbs of all assessed patients. Four preferred types of iliacefemoral collaterals were defined. Postoperatively, compared to the external iliac artery, the MAP levels of back-flow from the profunda femoris artery and the superficial femoral artery significantly dropped to 43.89 ± 2.75 and 18.08 ± 2.76 mm Hg, respectively. Conclusion: As a result of femoral artery ligation without reconstruction, well open collateral circulations and acceptable distal arterial runoff blood are seen, which suggests that this procedure is a reliable alternative to the emergent treatment of IFAPs in drug addicts. However, arterial reconstruction may be used as a backup approach if necessary during observation.
INTRODUCTION
Department of Vascular Surgery, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China. Correspondence to: Zuo-Jun Hu, MD, PhD, Department of Vascular Surgery, First Affiliated Hospital of Sun Yat-sen University, No. 58, Zhongshan 2nd Road, Guangzhou, China (510080), E-mail: [email protected] Ann Vasc Surg 2010; 24: 212-218 DOI: 10.1016/j.avsg.2009.06.006 Ó Annals of Vascular Surgery Inc. Published online: September 11, 2009
212
In recent years, the number of intravenous (i.v.) drug addicts visiting our clinic has shown an increasing trend. Intravenous drug abuse is more severe than traditional oral use since the former often results in local arterial and venous damage and is frequently complicated by infections, such as human immunodeficiency virus (HIV) and hepatitis B or C virus. Owing to the sudden open rupture of pseudoaneurysms and the occurrence of systemic sepsis, i.v. drug abuse is also potentially lethal. The hallmark of its diagnosis is the presence of a pulsatile
Vol. 24, No. 2, February 2010
mass in the groin full of pinholes on the skin with or without open rupture. Nowadays, it presents a unique vascular problem to our clinic. The dilemma of treatment against limb loss and the high risk of prosthetic graft infection present a practical challenge to vascular surgeons. Currently, various treatment options are available.1-6 Proximal and distal ligation of vessels and complete excision of aneurysms are frequently used for treatment. Other procedures, such as revascularization after excision of aneurysms using autogenous vein grafts or synthetic grafts, percutaneous thrombin injection,7 and endoluminal stent grafting or coil embolization, are also performed for small pseudoaneurysms without infection or with infection under good control.8 Among these procedures, ligation of vessels and excision of pseudoaneurysms along with debridement are regarded as the basic treatment, while there remains controversy over the necessity and timing of revascularization. Some researchers recommend immediate revascularization by an extra-anatomic route,9-11 whereas other researchers prefer simple ligation of the femoral artery without any reconstruction.12 Although many reports have been published on the clinical treatment of infected femoral artery pseudoaneurysm (IFAP) in drug addicts, the hemodynamic results of such approaches have not yet been conclusively determined and remain a major topic of concern. The aim of this study was to identify the hypothesis that femoral artery ligation without reconstruction can result in open collateral circulations, acceptable hemodynamic alterations in the distal lower limb, and viable presentation of the diseased limbs, which underlies the reliability of such alternative approaches to the treatment of IFAPs in drug addicts.
METHODS The protocol for the study of femoral artery ligationeinduced hemodynamic changes in i.v. drug abusers with IFAPs (see Fig. 1) and their clinical significance was approved by the research ethics committee of our institute. Consecutive IFAP patients were selected as candidates for this study. Patients reluctant to abide by the study protocol (including regular follow-up) were excluded. Informed consent was obtained from all enrolled IFAP patients. Data collection and definition of the study were performed according to the recommendations of the Ad Hoc Committee for Standardized Reporting Practice.13,14 These demographic data, perioperative details, and follow-up data were
Hemodynamic changes after femoral artery ligation
213
Fig. 1. Preoperative photo showing the infected left femoral pseudoaneurysm with thrombus in a drug addict.
prospectively collected. Each patient underwent serological testing for HIV and hepatitis virus infections. Digital subtraction angiography (anteroposterior and oblique views) was also performed using a catheter to further define the collateral circulations during the operation, including detection of mean arterial pressure (MAP) of back-flow from the profunda femoris artery (PFA) and superficial femoral artery (SFA) after operation using a transducer connecting to the arterial pressure monitor. Femoral artery ligation and debridement was performed under general or epidural anesthesia according to previously described techniques.12 Briefly, the common femoral artery (CFA) proximal to the aneurysm was first exposed. If the CFA was found to be unhealthy, suprainguinal control was taken by exposing the external iliac artery (EIA). After that, the pseudoaneurysm cavity was opened and excised. Subsequently, both the proximal SFA and the PFA were controlled. Patients with evidence of proximal or distal thrombosis underwent thrombectomy through the arterial stumps until forward and back-flow showed satisfactory performance during the operation. The choice of bipolar or triple ligations was tailored to the individual situation. Complete debridement was then undertaken. The groin wound was left open, filled with iodoform gauze, and dressed until healing. After the operation, all patients were given oral aspirin (an antiplatelet agent) at a dose of 100 mg/day for 3 months. Clinical follow-up examinations were conducted at 30 days, 3 months, and 6 months postoperatively and then annually thereafter. Continuous data were expressed as mean ± standard deviation. Statistical tests were performed using SPSS software (version 14.0; SPSS, Inc.,
214 Hu et al.
Annals of Vascular Surgery
Table I. Patient demographics (n ¼ 55) Characteristic
Patients (%)
Age (mean, years) Male sex Symptomatic History of drug usage (mean, years) Experience with i.v. drugs (mean, years) Aneurysm diameter (mean, cm) Comorbid Type of groin bleeding Contained Free HIV infection Hepatitis C infection Arterial thrombosis of lower limb Proximal DVT Ischemia of lower limb Viable Marginally threatened Irreversible Abscess involved iliac fossa Abscess in groin Anemia Malnutrition Death before operation
31.7 ± 6.7 54 (98) 55 (100) 6.0 ± 3.6 1.7 ± 1.1 10.4 ± 4.0
33 22 1 12 50 26
(60) (40) (2) (22) (91) (47)
31 23 1 10 55 55 55 1
(56) (42) (2) (18) (100) (100) (100) (2)
Chicago, IL). The t-test was used for data analysis. Statistical significance was set at p < 0.05.
RESULTS During the period between January 2000 and November 2007, a total of 55 consecutive patients presented to our clinic with IFAP from i.v. drug abuse. Of these patients, 54 were subjected to simple femoral artery ligation without revascularization. One patient died of acute onset of drug addiction in the ward before operation. Preoperatively, massive necrosis developed in the left lower limb of the only patient with bilateral IFAPs. All these patients had a confidently established diagnosis of IFAP. Their conditions are listed in Table I. Nearly all patients were male (n ¼ 54, 98%). All patients, aged between 15 and 45 years (mean 31.7), were symptomatic. Pseudoaneurysm occurred in the left groin in 25 patients, in the right groin in 29, and bilaterally in one, with a mean diameter of 10.4 cm and a maximum value of 20 cm. All patients had a history of groin injection and bleeding. The mean duration of groin injection was 1.7 years (range 0.3-4). The mean duration of drug abuse was 6 years (range 1-13). All patients abused heroin. Ninety-one percent (n ¼ 50) of the patients developed incomplete femoral artery
thrombosis in the lower limb, and 26 of these simultaneously developed proximal deep venous thrombosis (DVT). Nearly half (n ¼ 23, 42%) of patients showed marginally threatened lower limb ischemia. All patients had groin abscess, and 10 patients developed iliac fossa. Twelve patients (22%) had hepatitis C, while one patient was positive for HIV. All patients presented with anemia (mean hemoglobin value 79.1 g/L, range 55.2-92.6) and malnutrition (mean weight loss 40%, range 30-55%). Operative and Clinical Results All 54 patients underwent femoral artery ligation with concomitant thrombectomy through the vessel stumps, including ligation of the EIA in nine patients and above-knee amputation of the left lower limb of the patient with bilateral IFAPs. Both bipolar (n ¼ 12, 22%) and triple (CFA, SFA, and PFA; n ¼ 42, 78%) ligations were used. The mean volume of hematoma inside the aneurysm was 235 mL (range 100-450). Thrombus was removed by thrombectomy from the distal and proximal artery of all diseased limbs, with a maximum length up to 20 cm (mean 8, range 2-20). Nine patients received a blood transfusion. No operative death or perioperative wound complication was observed. All patients were discharged with viable limbs. All patients were followed up for a mean period of 35 months (range 3-72). During the follow-up period, all wounds were completely healed within 3 months. Six late deaths (11.1%), resulting from refractory drug addiction, were observed: two at 2 years, one at 4 years, and three at 5 years postoperatively. No toe amputations were noted during the follow-up period. Fourteen patients (25.9%) developed intermittent claudication. One postoperative limb was lost. Open Collateral Circulations Open collateral circulations were assessed by intraoperative angiography in 38 (70.4%) patients. Collateral circulations were found well open in a baseline path with four stations down to the distal lower limbs of all assessed patients. At the first station, it was noted that the ipsilateral internal iliac artery (IIA) and its branches became compensatorily enlarged, and blood flow first went through the enlarged IIA and its branches when the EIA or CFA was blocked (Fig. 2). The second station showed extensive openness in the collaterals between the IIA and the PFA (Fig. 3). At the third station, blood flow went through the branches of the PFA and the genicular artery around the knee
Vol. 24, No. 2, February 2010
Hemodynamic changes after femoral artery ligation
215
Fig. 2. The first station: compensatory enlargement of the left IIA. Fig. 4. The third station: branches of the PFA bridged to the SFA and PA.
collateral consisting of the superior gluteal artery (SGA), inferior epigastric artery (IGA), and OA. All these types of collaterals were connected subsequently to the ascending branches of the medial or lateral circumflex femoral artery (ACFA) originating from the PFA. Among these 38 patients, 11 (28.9%) showed type I collateral, eight (21.1%) type II, seven (18.4%) type III, and 12 (31.6%) type IV (Figs. 6e9). Measurement of MAP in the PFA, SFA, and EIA after Ligation Fig. 3. The second station: extensively open collaterals from the IIA to the PFA.
until it reached back to the SFA and the popliteal artery (PA) (Fig. 4). Lastly, blood flow was supplied to the distal limb via the normal pathway, including the posterior and anterior tibial arteries as well as the fibular artery (Fig. 5). Based on intraoperative angiographic observations, we also found that there were different predominant collaterals between the iliac and femoral arteries. We defined them as four preferred types. Type I was noted as a dominant bridge originating from the inferior gluteal artery (IGA), type II was defined as a dominant bridge from the obturator artery (OA), type III represented a dominant collateral from the inferior epigastric artery (IEGA), and type IV showed a mixed-mode
MAP measurement was achieved in 38 (70.4%) patients during operation. Considerable impairment of postoperative hemodynamic performance was observed (see Table II) since MAP dropped from 65.03 ± 3.15 to 18.08 ± 2.76 mm Hg ( p < 0.001).
DISCUSSION Femoral artery pseudoaneurysms resulting from drug addiction are a special kind of false aneurysm often complicated with infection and arterial wall damage. The pathogenesis of femoral artery pseudoaneurysms is associated with the introduction of infected material due to nonsterile manipulations and the trauma resulting from inadvertent or deliberate puncture of femoral vessels. In recent years, groin injection appears to be one of the preferred routes for drug abuse in our local region. Intravenous drug abuse frequently results in many complications, such as local and systemic sepsis, distal
216 Hu et al.
Annals of Vascular Surgery
Table II. Postoperative MAP changes (n ¼ 38)
MAP* (mm Hg)
EIA
PFA
SFA
65.03 ± 3.15
43.89 ± 2.75 ( p < 0.001)
18.08 ± 2.76 ( p < 0.001)
*Significant differences among the EIA, PFA, and SFA values (t values were 32.126 and 69.919, respectively). Significant difference between PFA and SFA values (t value was 34.846, p < 0.001).
Fig. 5. The fourth station: blood flow supplied to the distal limb.
Fig. 6. Type I: dominated by the IGA.
ischemia, and aneurysmal rupture.15 Subsequent bleeding and hematoma may cause breakdown and rupture of the vessel wall or even local skin, which is partly responsible for the lethality of i.v. drug abuse. Staphylococcus aureus is the predominant infective organism, observed in 71% and 76% of blood and local wound cultures, respectively.16 Ting and Cheng17 found that blood and tissue cultures mostly showed pure growth of methicillin-sensitive S. aureus and partly showed mixed growth of this bacterium with other ones. In our series, all groins showed extensive abscess, while 18% of them exhibited iliac fossa and locally disorganized vessels and tissues. Additionally, 47% of the patients developed proximal DVT. These results suggested a high possibility of infection and occlusion of prosthetic grafts, which is greatly unfavorable to revascularization. Therefore, the clinical manifestations, such as infections, disorganized tissues, and poor deep venous back-flow, should be weighed when considering treatment options. Although many reports have been published on the clinical treatment of femoral pseudoaneurysm in drug addicts and satisfactory results have been achieved, the related hemodynamic results of such approaches have not yet been conclusively
determined and remain a major topic of concern. Theoretically, the widespread availability of potential collaterals between the iliac and femoral arteries provides a collateral reserve, which has been verified anatomically. Once the main trunks of the iliac or femoral arteries are blocked, these collaterals will possibly function as a compensatory system. Furthermore, most of these drug addicts are young and, therefore, have little opportunity for developing arterial atherosclerosis. Thus, their collateral conditions are always fairly good. Consequently, it is very possible that the iliacefemoral collateral circulations may afford sufficient blood compensations to maintain the viability of the distal lower limbs. In our series, it was interesting that arterial thrombosis was present in the diseased lower limbs of 91% (n ¼ 50) of the patients. Only 42% of these patients showed marginally threatened lower limb ischemia, and 56% had viable limbs on admission. Irreversible ischemia was noted in one case. That is, the potential collaterals might begin to function when occlusive factors were present in the main arterial trunks during the course of disease. During the operation, the mean volume of hematoma, mixed with abscess, inside the aneurysm was
Vol. 24, No. 2, February 2010
Hemodynamic changes after femoral artery ligation
217
Fig. 8. Type III: dominated by the IGA. Fig. 7. Type II: dominated by the OA.
235 mL (range 100-450). Thrombus was removed by thrombectomy from the distal and proximal artery of all diseased limbs, with the maximum length up to 20 cm (mean 8, range 2-20). Thrombus in the main trunks may occlude the reentry of blood flow from the collaterals to the lower limb. In this regard, concomitant thrombectomy will be helpful to open the reentry orifice and establish more extensive collaterals to the lower limb. Thus, we think that thrombectomy should be performed concomitantly with ligation of the femoral artery. Due to these procedures, the distal blood supply may be improved, which was observed in this study. Open collateral circulations were assessed by intraoperative angiography in our series. Collateral circulations were found well open in a baseline path with four stations down to the distal lower limbs of all assessed patients. Firstly, the ipsilateral IIA and its branches became compensatorily enlarged, and blood flow went through the enlarged IIA and its branches when the EIA or CFA was blocked. Secondly, that was connected to extensive open collaterals between the IIA and PFA. Thirdly, blood flow reentered into the SFA and PA via the branches of the PFA and the genicular artery around the knee. Lastly, blood flow continued to be supplied to the distal limb via the normal pathway, including the posterior and anterior tibial arteries as well as the fibular artery. Based on intraoperative angiographic observations, we also found that there were different predominant collaterals between the iliac and femoral arteries. Four preferred types were noted.
Fig. 9. Type IV: mixed mode consisting of the SGA, IGA, and OA.
Type I was noted as a dominant bridge originating from the IGA, type II was a dominant bridge from the OA, type III represented a dominant collateral from the IEGA, and type IV showed a mixed-mode collateral consisting of the SGA and IGA and the OA. All these types of collaterals were connected subsequently to the ACFA originating from the PFA. In our study, 28.9% of the patients showed type I collateral, 21.1% type II, 18.4% type III, and 31.6% type IV. These results revealed unique and multiple modes of the development of iliacefemoral
218 Hu et al.
collaterals in drug addicts, representing another major finding of this study since no similar results have been reported in the relevant literature. Associated significant impairment, however, was also noted in the assessment of MAP. Interestingly, MAP levels did not drop to zero but were maintained at around 18.08 mm Hg, which was enough to keep most limbs alive. Some studies18,19 have reported limb amputation rates of 11-33% and frequent intermittent claudication when femoral pseudoaneurysms were treated by simple ligation. In our study, no toe amputations were noted during the follow-up period. Only 25.9% of patients developed intermittent claudication, and one postoperative limb was lost. The good clinical results achieved in this study may be mainly due to the well open collaterals and the reversed blood flow reentry by concomitant thrombectomy. In addition, the fact that the young patients included in the study had no apparent atherosclerosis in the lower limb can partly explain our results. Furthermore, in additional to the well open collaterals, a fair survival was noted during the follow-up period since only six late deaths were observed. All these deaths resulted solely from refractory drug abuse that caused damage to systemic functions. Therefore, in view of our emergent surgical treatment, the results were quite acceptable, though the special drug addiction of these patients may mainly influence their longterm survival. A psychiatric regimen without interruption should be pursued in these patients as a lifelong task.
CONCLUSION Since femoral artery ligation with concomitant thrombectory can result in effectively open collateral circulations, acceptable distal arterial runoff, as well as viable presentation of the diseased limbs, this procedure may be a substantially reliable alternative approach to the emergent treatment of IFAPs in drug addicts. However, arterial reconstruction may be used as a backup approach if necessary during observation. A further prospective randomized trial with a large cohort will be necessary to verify these outcomes.
Annals of Vascular Surgery
REFERENCES 1. Levi N, Rordam P, Jensen LP, Schroeder TV. Femoral pseudoaneurysm in drug addicts. Eur J Vasc Endovasc Surg 1997;13:361-362. 2. Patel KR, Semel L, Clauss RH. Routine revascularization with resection of infected femoral pseudoaneurysms from substance abuse. J Vasc Surg 1988;8:321-328. 3. Reddy DJ, Smith RF, Elliott JP, et al. Infected femoral artery false aneurysms in drug addicts: evolution of selective vascular reconstruction. J Vasc Surg 1986;3:718-724. 4. Welch GH, Reid DB, Pollock JG. Infected false aneurysm in the groin of intravenous drug abusers. Br J Surg 1990;77: 330-333. 5. Naqi SA, Khan HM, Akhtar S, Shah TA. Femoral pseudoaneurysm in drug addictsdexcision without revascularization is a viable option. Eur J Vasc Endovasc Surg 2006;31: 585-587. 6. Behera A, Menakuru SR, Jindal R. Vascular complications of drug abuse: an Indian experience. Aust N Z J Surg 2003;73: 1004-1007. 7. Goel PK, Modi N, Baijal SS, Kathuria M, Agrawal SK. Sonographically guided thrombin injection for the treatment of femoral artery pseudoaneurysm. Indian Heart J 2003;55:365-367. 8. Righini M, Quere I, Laroche JP. Treatment of postcatheterization femoral false aneurysms. J Mal Vasc 2004;29:63-72. 9. Bell CL, Ali AT, Brawley JG, et al. Arterial reconstruction of infected femoral artery pseudoaneurysms using superficial femoral-popliteal vein. J Am Coll Surg 2005;200:831-836. 10. Matoussevitch V, Aleksic M, Gawenda M, Brunkwall J. Primary extraanatomical revascularization for groin infections in drug addicts. Vasa 2007;36:210-214. 11. Klonaris C, Katsargyris A, Papapetrou A, et al. Infected femoral artery pseudoaneurysm in drug addicts: the beneficial use of the internal iliac artery for arterial reconstruction. J Vasc Surg 2007;45:498-504. 12. Arora S, Weber MA, Fox CJ, et al. Common femoral artery ligation and local debridement: a safe treatment for infected femoral artery pseudoaneurysms. J Vasc Surg 2001;33: 990-993. 13. Johnston KW, Rutherford RB, Tilson MD, et al. Suggested standards for reporting on arterial aneurysms. J Vasc Surg 1991;13:444-450. 14. Rutherford RB, Baker JD, Ernst C, et al. Recommended standards for reports dealing with extremity ischemia: revised version. J Vasc Surg 1997;26:517-538. 15. Schulz S, Beckenbach C, Philipp M, Hengstmann J. Color coded duplex sonography of inguinal vessels in i.v. drug addicts. Vasa 2002;31:7-13. 16. Johnson JR, Ledgerwood AM, Lucas CE. Mycotic aneurysm. Arch Surg 1983;118:577-582. 17. Ting ACW, Cheng SWK. Femoral pseudoaneurysms in drug addicts. World J Surg 1997;21:783-787. 18. Benjamin ME, Cohn EJ, Purtill WA, et al. Arterial reconstruction with deep leg veins for the treatment of mycotic aneurysms. J Vasc Surg 1999;30:1004-1015. 19. Padberg F, Hobson R, Lee B, et al. Femoral pseudoaneurysm from drugs of abuse: ligation or reconstruction? J Vasc Surg 1992;15:642-648.