- Email: [email protected]
Treatment of Arterial Lesions in Drug Addicts
Treatment of Arterial Lesions in Drug Addicts Muhamet Devecioglu, Nicla Settembre, Zaki Samia, Mazen Elfarra, and Sergueı¨ Malikov, Vandoeuvre les Nancy, France
Background: Arterial complications among drug addicts are rare. Their appearance can engage the vital prognosis of the patient and present a major risk of amputation. The injection of products with high cellular toxicity induces septic necrosis of the arterial wall and adjacent tissues. It is frequently responsible for acute hemorrhage. The data in the literature concerning surgical treatment are discussed. The goal of our study was to analyze the immediate and midterm results of the surgical management of these arterial lesions. Methods: Between January 2005 and April 2012, 31 drug addicts (4 women; 31.4 ± 7.2 years) presenting with 33 arterial lesions were treated. They presented with a humeral (n ¼ 15), femoral (n ¼ 13), or axillar (n ¼ 3) false aneurysm. Two patients had an arterial thrombosis. The clinical manifestations were an acute hemorrhage (n ¼ 16), a septic syndrome (n ¼ 7), a pulsatile mass (n ¼ 6), and an acute ischemia (n ¼ 4). In situ revascularization was carried out in 20 cases, in 15 patients with a bypass (9 venous and 6 prosthetic), in 2 with a venous patch, in 2 by direct suture, and in 1 by transposition of the superficial femoral artery in the deep femoral artery. Extra-anatomic bypass revascularization was performed in 6 cases (4 venous and 2 prosthetic). The other techniques used were ligature (n ¼ 5) and medical care (n ¼ 2). Two patients had an additional procedure with a musculocutaneous epigastric pedicled flap in order to fill the loss of substance. Results: The early rate of reinterventions was 38.7% at 30 days (12 patients), because of a suture line hemorrhage related to sepsis (n ¼ 6), a bypass thrombosis (n ¼ 5), and of acute ischemia after a arterial ligature. These complications occurred mainly on extremities, having had an anatomic revascularization (n ¼ 9). Six extra-anatomic revascularizations had to be performed in second intention. The average follow-up was 8.6 months (range: 1e73.5 months), and 15 patients were lost to follow-up at 6 months. The patients were followed by duplex ultrasonography and/or angioscanner. Primary and secondary actuarial patencies at 1, 3, and 6 months were 61%, 46%, 46%, and 91%, 81%, and 71%, respectively. The rate of salvage of extremities was 100%. Conclusion: Our study reveals the difficulty of the management of these arterial lesions. The local and general septic process is primarily responsible for early complications. Arterial restoration with extra-anatomic bypass makes it possible to be distant from the infection. This technique can be associated with a covering flap.
INTRODUCTION Presented at the 27th Annual Meeting of the French Society for Vascular Surgery, Paris, France, June 22e25, 2012. Service de Chirurgie Vasculaire, Centre Hospitalier Universitaire Brabois, Vandoeuvre-les-Nancy, France. Correspondence to: Muhamet Devecioglu, MD, Service de Chirurgie Vasculaire, CHU Brabois, rue du Morvan, 54511 Vandoeuvre-lesNancy, France; E-mail: [email protected] Ann Vasc Surg 2014; 28: 184–191 http://dx.doi.org/10.1016/j.avsg.2012.12.010 Ó 2014 Elsevier Inc. All rights reserved. Manuscript received: June 13, 2012; manuscript accepted: December 7, 2012; published online: November 5, 2013.
184
Drug addiction is a major medicosocial problem. ‘‘Problematic users of drugs’’ are defined in Europe as users of intravenous drugs, and it is estimated that there are roughly 230,000 cases in France alone and 16e38 million cases worldwide.1 The prevalence in France is 5.9 per 1,000 inhabitants, and 10.8 per 1,000 in Lorraine.2 Vascular lesions are frequent in drug addicts, affecting primarily the veins and more rarely the arteries. Arterial lesions are the more serious of the two because they affect the patient’s prognosis and present a major risk of
Vol. 28, No. 1, January 2014
amputation. The management of these lesions is very difficult, and there is no agreement in the published literature with regard to the treatment of these lesions. The purpose of our study was to analyze the immediate and midterm results of the different modalities of treatment of these arterial lesions.
METHODS This is an observational single-center retrospective study carried out between January 1, 2005 and April 30, 2012. The criteria of inclusion were drug addiction by injectable route and the presence of an arterial lesion. The criteria of exclusion were drug addiction by injectable route without an arterial lesion, the presence of a venous lesion (i.e., thrombophlebitis, major venous thrombosis, or chronic insufficiency), and/or the presence of tissue lesions (i.e., abscess and cellulitis). Patient data were collected from the software of the cardiovascular registry (Diamm) of our institution and were cross-checked with the files of the patients in order to collect missing information. The demographic data of the patients, the clinical symptomatology, the results of the preoperative imaging studies, the results of biologic and bacteriologic sampling, the type of treatment, the early complications, the patency rate (by clinical examination or imagery), and the death and limb salvage rates were collected on a database using the Microsoft Excel software (Microsoft Corp., Redmond, WA). Therapeutic management was decided on a caseby-case basis. Thromboembolism was treated by intravenous heparin. Arterial wall lesions required a surgical procedure. The type of operation carried out was left to the surgeon’s choice according to the pre- and perioperative data. True emergencies were directly taken to the operating room. In other cases, imaging studies were conducted. The choice between ligature and arterial restoration depended on the degree of ischemia upon admission and the collateral network analyzed on the imagery. An arterial ligature was carried out when the collateral arterial network was effective. The type of arterial restoration was a function of the septic and necrotic local status, the size of the false aneurysm (FA), the degree of rupture of the arterial wall, the availability of a venous autograft, and of its length. The use of autologous material was always privileged. An in situ revascularization was carried out when the infectious signs and the arterial rupture were small. An extra-anatomic bypass was carried out when the local conditions, the size of the arterial lesion, and the septic state were serious.
Drug addiction and arterial lesions 185
The principal criteria of judgment were the actuarial rate of primary and secondary patency and of limb salvage. Primary patency was defined as the continuous patency of the arterial revascularization without additional procedure on the bypass or the adjacent native vessel. If a complication (e.g., thrombosis or a rupture of suture line) emerged, one spoke about secondary permeability. An arterial revascularization was considered as being in primary permeability if he(it) remained permeable without additional procedure on the bypass or on the neighboring native vessel. Any complication (thrombosis, desertion of suture) ended the primary permeability. The arterial revascularization was admitted in secondary permeability after restoration of a total or partial occlusion, either after a revision or a successful repair of anastomoses. The latter was considered after restoration of a total or partial occlusion or after a revision/repair of anastomoses. Limb salvage was defined as the absence of major amputation. An amputation above the knee was defined as being major. The secondary criteria of judgment included the frequency of infection and death rate. Each patient was reexamined 1 month after discharge from the hospital. A questionnaire, a clinical examination, and duplex ultrasonography or computed tomography angiography imaging were carried out. The patients were then reexamined after 3 and 6 months then annually thereafter in the absence of complication or of repetition. Statistical Analysis The statistical analysis was carried out with SPSS software (version 17.0; SPSS Inc., Chicago, IL). The analysis was only descriptive. Means and standard deviations were calculated for quantitative data. Frequencies and percentages were calculated for qualitative data. Variables such as survival (primary and secondary patency) were presented in KaplaneMeier actuarial survival curves.
RESULTS Thirty-three arterial lesions were treated in 31 drug addicts in our center. Two patients presented with a second localization during follow-up. The mean age of our patients was 31.4 ± 7.2 years (range: 21e49 years). Four women were in the study group. The arterial lesions were in 31 cases FAs and in 2 cases arterial thrombosis. The clinical signs (Table I) at the time of the hospitalization were a contained or active acute hemorrhage (AH) in 16 cases (Fig. 1), a septic symptoms in 7 cases, and a pulsatile mass in
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Table I. Principal clinical manifestations upon the admission of the patients Clinical manifestation
n (%)
Acute hemorrhage Septic syndrome Pulsatile mass Acute ischemia Total
16 7 6 4 33
(48.5) (21.2) (18.2) (12.1)
Fig. 2. Misuse of buprenorphine (ruptured left humeral false aneurysm).
Fig. 1. Acute hemorrhage (left humeral false aneurysm).
Table II. Injected substances Substances
n (%)
Heroin Heroin and cocaine Heroin and buprenorphine Buprenorphine No information Total
8 (25.8) 7 (22.6) 5 (16.1) 4 (12.9) 7 (22.6) 31
6 cases or acute ischiemia in 4 cases. These symptoms could accumulate among certain patients. The substance injected was mainly heroin (Table II). The intravenous misuse of buprenorphine was found among 9 patients (Fig. 2). The diagnosis could have been established by computed tomography angiography only (Fig. 3) in 7 cases (21.2%), by arterial duplex ultrasonography in 3 cases (9.1%), and by the association of these 2 techniques in 11 cases (33.3%). No preoperative imagery was realized in 12 cases (36.4%) because of need for an immediate intervention. We observed 15 humeral FAs, 13 femoral FAs, and 3 axillary FAs. Seventeen FAs were on the left side and 14 were right-sided. The biologic assessments
Fig. 3. Right common femoral artery false aneurysm and presence of foreign bodies (needles) in the area of the 2 common femoral arteries.
carried out upon admission of the patients highlighted a biologic inflammatory syndrome with elevation in the number of white cells and/or Creactive protein in 24 cases. The assessments of the 7 other cases did not show abnormalities. Serologies carried out revealed that 6 patients were carrying the hepatitis C virus. Thirty-one patients underwent surgery and 2 were medically followed-up. The first stage of the interventions consisted of a control of the arterial axes upstream and downstream from the FA in healthy zone. A broad debridement of necrotic and
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Fig. 4. Reversed venous extra-anatomic humeroradial bypass.
inflammatory tissues was done. Arterial ligature without revascularization was carried out in 5 cases (4 in the superficial femoral artery and 1 in the common femoral artery). An in situ revascularization was carried out in 20 cases, including 15 bypasses (9 venous and 6 prosthetic), 2 venous patches, 2 direct sutures, and 1 transposition of the superficial femoral artery in the deep femoral artery. An ex situ revascularization by a lateral extraanatomic bypass (Fig. 4) was performed in six cases (4 venous and 2 prosthetic). The medical treatment consisted at two patients by an intravenous heparin because of ischemic signs by embolization of illicit substances residues. From a medical point of view, the patients presenting with signs of clinical sepsis or a biologic inflammatory syndrome during their admission benefitted from probabilistic intravenous antibiotics, secondarily adapted to microbiology. In 27 cases, the bacteriologic tissue cultures were positive (81.8%). Seventeen were positive for Staphylococcus aureus sensitive to methicillin (63%), 3 grew methicillin-resistant S. aureus (11.1%), 2 grew Staphylococcus epidermidis (7.4%), and in 5 cases there was a multiple colonization (18.5%). All the patients were introduced to the Welcoming and
Drug addiction and arterial lesions 187
Treatment Unit for drug addicts in order to begin or to adapt weaning. The patients benefitte then from a substitution by buprenorphine (n ¼ 17) or methadone hydrochlorate (n ¼ 10). Twelve early reinterventions (38.7%) had to be carried out because of 6 AH septic ruptures in a septic environment, 4 cases of acute ischemia by thrombosis of a bypass, 1 case of acute ischemia after arterial ligature, and 1 thrombosis of an infected bypass without downstream repercussion (Table III). The average delay before reintervention was 6.92 ± 7.53 days (range: 0e24 days). Nine of these complications occurred after an in situ revascularization, 2 after an ex situ revascularization, and 1 after a simple ligature. In second intention, we carried out 6 extra-anatomic revascularizations, 3 repairs of anastomoses, 1 replacement of an infected prosthesis by a vein, 1 thrombectomy of a bypass, and 1 arterial ligature associated with the ablation of a prosthetic bypass. Tissue loss led to the need for a directed healing with a mesh, in 3 cases with Vacuum Assisted ClosureÒ (VAC). In 2 cases, surgical covering with a pedicled epigastric flap of the contralateral rectus abdominis (Fig. 5) had to be applied thereafter in order to fill the cavity. The mean duration of hospital stay was 15.9 ± 14.7 days (range: 2e63 days). The mean duration of follow-up was 8.6 ± 14.4 months (range: 1e73.5 months). Fifteen patients were lost to follow-up after 6 months. The primary patency at 1, 3, and 6 months was of 61%, 46%, and 46%, respectively. The actuarial secondary permeability was 91%, 81%, and 71%, respectively. The rate of extremity salvage was 100% at 6 months. One transmetatarsal amputation was performed. No deaths occurred because of treatment. One patient died from suicide.
DISCUSSION The incidence of injectable drug addiction is in continuous increase. Maliphant and al.3 estimated that the average duration of time until the venous capital is exhausted before the use of intra-arterial injection is 7.7 years. Consequently, the majority of vascular surgery centers will be brought to deal with this type of pathology. The most frequent arterial lesion is infected FA. It accounts for approximately 0.14% of the complications related to the injection of intravenous drugs.4 The repeated traumatisms of the arterial wall at the time of the iterative punctures are the prevalent mechanism of these lesions. The bacterial contamination caused by the precariousness
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Table III. Early complications after surgical treatment
Ligation In situ revascularization Anatomic bypass Venous bypass Prosthetic bypass Venous patch Direct suture SFA transposition Ex situ revascularization Venous Prosthetic Total
n
Early reoperation
Acute hemorrhage
Septic thrombosis
Acute ischemia
5 20 15 9 6 2 2 1 6
1 9 8 4 4 1 d d 2
d 5 4 3 1 1 d d 1
d 4 4 1 3 d d d 1
d d d d d d d d d
4 2 31
1 1 12
1 d 6
d 1 5
d d 1
SFA, superficial femoral artery.
Fig. 5. Cover flap from the contralateral rectus abdominis muscle pedicled by the epigastric artery inferior. Result at the end of the intervention (A) and at 4 months (B).
and the defect of hygiene and asepsis has its share of responsibility in the pathophysiology of FA. We also retain the toxicity of the acid products used to dilute certain drugs, like brown heroin or crack. The lemon juice, the vinegar, or the ascorbic acid/citric present in the boxes distributed in the centers for drug addicts are also involved. These 3 factors generate a parietal destruction, a necrosis of adjacent tissues, and an inflammatory process contributing to the occurrence of a FA. Embolic complications are also possible (2 cases in our study). The emboli contained solid residues that were poorly diluted. Rare cases of embolization of needle or fragment of needle in the general circulation were also described.5
Various types of treatments have been proposed, but there is no consensus on the management. The need or not for a revascularization, the timing of revascularization, and the type of material to use in patients whose superficial venous network is faded are many elements that remain controversal. The principal studies of the literature relate to infected FA in femoral position. At the level of the upper limb, one observes primarily isolated cases or case studies. In our study, most of the FAs were located in the upper limb, 15 in the humeral artery, and 3 in the axillary artery. Angioscanner seems to us to be the most contributive imaging study. It makes it possible to affirm the positive diagnosis, to visualize the downstream arteries, and to study
Vol. 28, No. 1, January 2014
Fig. 6. False aneurysm of the right superficial femoral artery treated by ligature.
the possibility of using or not autologous material for revascularization. In one of our patients, the decision to carry out a ligature without revascularization was made before the operation thanks to the results of the angioscanner (Fig. 6). The arterial lesion was a FA located at the origin of the superficial femoral artery, followed by a short thrombosis on a few centimeters, with a downstream reentry from a well developed collateral network. In many studies,6e9 arterial ligature without revascularization is considered the best treatment to manage infected FA in drug addicts. However, the principal complications met after ligation without arterial restoration are intermittent claudication, AHs caused by the rupture of suture lines, and even amputation, with rates reaching 44.4%, 22.2%, and 18.2%, respectively.8 In our study, a patient presented with acute ischemia on the day of the intervention after ligature of the common femoral artery. An extra-anatomic bypass was carried out. The immediate revascularization is described and recommended by other researchers.10e12 The persistence of the infection or a bacterial colonization, a hemorrhage by rupture of sutures, early or late thrombosis, and amputation are also secondary complications described after revascularization.13 Indeed, the objective is to maintain the vitality of the limb in young patients, who have no atheroma and therefore no collaterality. For this reason, the need for an initial revascularization appears essential.
Drug addiction and arterial lesions 189
The therapeutic sequence is to be chosen between the initial control of the infected area and the realization of the revascularization in aseptic zone as a first stage. Because of the late presentation of the drug addicts, generally at the instant of the hemorrhagic rupture of an infected FA (16 patients in our study), we initially carried out the control of the pathologic zone followed by revascularization. In our study, we carried out 26 immediate revascularizations. The 2 principal types of complications met were AHs and septic thrombosis. Nine of these complications occurred after an in situ revascularization, including 5 AHs (25%). Our results are close to those (23.8%) in a literature review by Georgiadis et al.14 It should be noted that 4 of these AHs occurred after the use of autologous material. This complication is explained by the progression of the infection and tissue erosion responsible for the anastomotic rupture. Some studies15,16 show that the frequency of anastomotic dehiscence is more important with the use of a vein than with the use of prosthetic material, in particular cases of S. aureus infection. Septic thrombosis was present in 5 cases, in 4 cases at the time of the implantation of a prosthetic material. The use of prosthetic material appears unsuited in this context of necrotic and inflammatory lesions of soft tissues. However, when revascularization is needed, in the absence of autologous material, our choice was for the use of silver impregnated grafts. Insufficient debridement of infected tissues, contamination by an adjacent infection, or hematogenous seeding are certainly possible causes of prosthetic septic thrombosis. A biologic inflammatory syndrome was present in 10 of 12 cases at the time of early reintervention, of which 6 had a C-reactive protein level >100 mg/L. These values reveal intense inflammatory activity. The severity of the tissue and biologic septic attack is responsible for the early complications at the time of the immediate arterial restorations. This is why, in order to be remote from infection, we carried out second intention arterial restorations with extra-anatomic bypasses when the primary revascularization was in situ. Patel et al.10 reported good results with extra-anatomic obturator bypasses, with a rate of 7% of septic thromboses among 15 patients. No bypass through the obturator hole was carried out in our study. Any traumatism at the time of the tunnelization can induce hemorrhage by vascular wound of the obturator pedicle, which is difficult to control in the pelvis, nervous trauma with anesthesia of the anterior face of the thigh and deficit of the adduction, or pelvic visceral lesions. We carried out bypasses through a lateral approach at the
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Fig. 7. Actuarial primary and secondary patencies. Permeabilite IIR, Secondary patency; permeabilite IR,
primary patency; temps (mois), time (months); exposes au risque, exposed to risk; taux de permeabilite, patency rate.
femoral level as described by Leather and Karmody.17 Secondary actuarial patencies (Fig. 7), the limb salvage rate, and the rates of morbidity and mortality in our study were acceptable in spite of an important rate of reinterventions. The number of patients recruited in our study is too small to allow a subgroup analysis of the various methods of arterial restoration. We think that an extra-anatomic revascularization, preferably with autologous material, is the technique of choice in order to be remote infected tissues and to decrease the frequency of the early complications. The essential stage of the management of drug addicts is a broad debridement of necrotic and inflammatory tissues, associated with a treatment adapted to the infection with intravenous broad spectrum antibiotics. In order to fill the loss of substance, we had to carry out 2 pedicled flaps from the rectus abdominis muscle, whose evolution was favorable (Fig. 5B) and without complication. We should underscore that among drug addicts, therapeutic follow-up is very difficult. The rupture of care and the number lost to follow-up are extremely important in many studies. Georgiadis et al.15 conclude that no management proved its effectiveness in terms of total surgical complications
at the time of the surgical management of infected FA. A longer duration of follow-up would be necessary to provide more precise results. The risk among these patients is the continuation of their addiction and the appearance of new sites of arterial lesions. In our study, we observed 2 patients with 1 second arterial localization. The average follow-up in our study was of 8.6 months, and the number of lost to follow-up was 15 at 6 months. This is why our choice was to apply a strategy of aggressive revascularization under sometimes difficult conditions.
CONCLUSION The arterial lesions among drug addicts are an entity made of chemical burns inducing inflammation and necrosis in contact with and in the wall of the arteries. The difficulty lies in the combined management of vascularization, of loss of substance of the soft tissues, and of infection. Arterial restoration with extra-anatomic bypasses makes it possible to be remote from infection and seems to have better results in the short- and midterm in our study. This technique can be associated with a pedicled flap with the contralateral rectus abdominis muscle.
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Drug addiction and arterial lesions 191
REFERENCES 1. World Drug Report 2010. United Nations Office on Drugs and Crime (UNODC). United Nations Publication Sales No. E.10.XI.13. 2. Costes JM, Vaissade L, Colasante E, et al. Prevalence de l’usage problematique de drogues en France - estimations 2006. Observatoire Franc¸ais des Drogues et des Toxicomanes. Available from: http://www.ofdt.fr/ofdtdev/live/publi/ rapports/rap09/epfxjcp6.html. Accessed August 12, 2013. 3. Maliphant J, Scott J. Use of the femoral vein (‘groin injecting’) by a sample of needle exchange clients in Bristol, UK. Harm Reduct J 2005;2:6. 4. Tsao JW, Marder SR, Goldstone J, et al. Presentation, diagnosis, and management of arterial mycotic pseudoaneurysms in injection drug users. Ann Vasc Surg 2002;16:652e62. 5. Norfolk GA, Gray SF. Intravenous drug users and broken needles-a hidden risk? Addiction 2003;98:1163e6. 6. Yegane RA, Salehi NA, Ghaseminegad A, et al. Surgical approach to vascular complications of intravenous drug abuse. Eur J Vasc Endovasc Surg 2006;32:397e401. 7. Salimi J, Shojaeefar A, Khashayar P. Management of infected femoral pseudoaneurysms in intravenous drug abusers: a review of 57 cases. Arch Med Res 2008;39:120e4. 8. Peirce C, Coffey JC, O’Grady H, et al. The management of mycotic femoral pseudoaneurysms in intravenous drug abusers. Ann Vasc Surg 2009;23:345e9. 9. Hu ZJ, Wang SM, Li XX, et al. Tolerable hemodynamic changes after femoral artery ligation for the treatment of
10.
11.
12.
13.
14.
15.
16.
17.
infected femoral artery pseudoaneurysm. Ann Vasc Surg 2010;24:212e8. Patel KR, Semel L, Clauss RH, et al. Routine revascularization with resection of infected femoral pseudoaneurysms from substance abuse. J Vasc Surg 1988;8:321e8. Levi N, Rordam P, Jensen LP, Schroeder TV. Femoral pseudoaneurysm in drug addicts. Eur J Vasc Endovasc Surg 1997;13:361e2. Li Q, Shu C, Jiang X, et al. Surgical management of infected pseudoaneurysms of femoral artery caused by narcotics injection. Zhong Nan Da Xue Xue Bao Yi Xue Ban 2009;34:476e80. Coughlin PA, Mavor AI. Arterial consequences of recreational drug use. Eur J Vasc Endovasc Surg 2006;32: 389e96. Georgiadis GS, Lazarides MK, Polychronidis A, et al. Surgical treatment of femoral artery infected false aneurysms in drug abusers. ANZ J Surg 2005;75:1005e10. Stone KS, Walshaw R, Sugiyama GT, et al. Polytetrafluoroethylene versus autogenous vein grafts for vascular reconstruction in contaminated wounds. Am J Surg 1984;147: 692e5. Shah PM, Katsuki I, Clauss RH, et al. Expanded microporous polytetrafluoroethylene (PTFE) grafts in contaminated wounds: experimental and clinical study. J Trauma 1983;23:1030e3. Leather RP, Karmody AM. A lateral route for extraanatomical bypass of the femoral artery. Surgery 1977;81: 307e9.
Background: Arterial complications among drug addicts are rare. Their appearance can engage the vital prognosis of the patient and present a major risk of amputation. The injection of products with high cellular toxicity induces septic necrosis of the arterial wall and adjacent tissues. It is frequently responsible for acute hemorrhage. The data in the literature concerning surgical treatment are discussed. The goal of our study was to analyze the immediate and midterm results of the surgical management of these arterial lesions. Methods: Between January 2005 and April 2012, 31 drug addicts (4 women; 31.4 ± 7.2 years) presenting with 33 arterial lesions were treated. They presented with a humeral (n ¼ 15), femoral (n ¼ 13), or axillar (n ¼ 3) false aneurysm. Two patients had an arterial thrombosis. The clinical manifestations were an acute hemorrhage (n ¼ 16), a septic syndrome (n ¼ 7), a pulsatile mass (n ¼ 6), and an acute ischemia (n ¼ 4). In situ revascularization was carried out in 20 cases, in 15 patients with a bypass (9 venous and 6 prosthetic), in 2 with a venous patch, in 2 by direct suture, and in 1 by transposition of the superficial femoral artery in the deep femoral artery. Extra-anatomic bypass revascularization was performed in 6 cases (4 venous and 2 prosthetic). The other techniques used were ligature (n ¼ 5) and medical care (n ¼ 2). Two patients had an additional procedure with a musculocutaneous epigastric pedicled flap in order to fill the loss of substance. Results: The early rate of reinterventions was 38.7% at 30 days (12 patients), because of a suture line hemorrhage related to sepsis (n ¼ 6), a bypass thrombosis (n ¼ 5), and of acute ischemia after a arterial ligature. These complications occurred mainly on extremities, having had an anatomic revascularization (n ¼ 9). Six extra-anatomic revascularizations had to be performed in second intention. The average follow-up was 8.6 months (range: 1e73.5 months), and 15 patients were lost to follow-up at 6 months. The patients were followed by duplex ultrasonography and/or angioscanner. Primary and secondary actuarial patencies at 1, 3, and 6 months were 61%, 46%, 46%, and 91%, 81%, and 71%, respectively. The rate of salvage of extremities was 100%. Conclusion: Our study reveals the difficulty of the management of these arterial lesions. The local and general septic process is primarily responsible for early complications. Arterial restoration with extra-anatomic bypass makes it possible to be distant from the infection. This technique can be associated with a covering flap.
INTRODUCTION Presented at the 27th Annual Meeting of the French Society for Vascular Surgery, Paris, France, June 22e25, 2012. Service de Chirurgie Vasculaire, Centre Hospitalier Universitaire Brabois, Vandoeuvre-les-Nancy, France. Correspondence to: Muhamet Devecioglu, MD, Service de Chirurgie Vasculaire, CHU Brabois, rue du Morvan, 54511 Vandoeuvre-lesNancy, France; E-mail: [email protected] Ann Vasc Surg 2014; 28: 184–191 http://dx.doi.org/10.1016/j.avsg.2012.12.010 Ó 2014 Elsevier Inc. All rights reserved. Manuscript received: June 13, 2012; manuscript accepted: December 7, 2012; published online: November 5, 2013.
184
Drug addiction is a major medicosocial problem. ‘‘Problematic users of drugs’’ are defined in Europe as users of intravenous drugs, and it is estimated that there are roughly 230,000 cases in France alone and 16e38 million cases worldwide.1 The prevalence in France is 5.9 per 1,000 inhabitants, and 10.8 per 1,000 in Lorraine.2 Vascular lesions are frequent in drug addicts, affecting primarily the veins and more rarely the arteries. Arterial lesions are the more serious of the two because they affect the patient’s prognosis and present a major risk of
Vol. 28, No. 1, January 2014
amputation. The management of these lesions is very difficult, and there is no agreement in the published literature with regard to the treatment of these lesions. The purpose of our study was to analyze the immediate and midterm results of the different modalities of treatment of these arterial lesions.
METHODS This is an observational single-center retrospective study carried out between January 1, 2005 and April 30, 2012. The criteria of inclusion were drug addiction by injectable route and the presence of an arterial lesion. The criteria of exclusion were drug addiction by injectable route without an arterial lesion, the presence of a venous lesion (i.e., thrombophlebitis, major venous thrombosis, or chronic insufficiency), and/or the presence of tissue lesions (i.e., abscess and cellulitis). Patient data were collected from the software of the cardiovascular registry (Diamm) of our institution and were cross-checked with the files of the patients in order to collect missing information. The demographic data of the patients, the clinical symptomatology, the results of the preoperative imaging studies, the results of biologic and bacteriologic sampling, the type of treatment, the early complications, the patency rate (by clinical examination or imagery), and the death and limb salvage rates were collected on a database using the Microsoft Excel software (Microsoft Corp., Redmond, WA). Therapeutic management was decided on a caseby-case basis. Thromboembolism was treated by intravenous heparin. Arterial wall lesions required a surgical procedure. The type of operation carried out was left to the surgeon’s choice according to the pre- and perioperative data. True emergencies were directly taken to the operating room. In other cases, imaging studies were conducted. The choice between ligature and arterial restoration depended on the degree of ischemia upon admission and the collateral network analyzed on the imagery. An arterial ligature was carried out when the collateral arterial network was effective. The type of arterial restoration was a function of the septic and necrotic local status, the size of the false aneurysm (FA), the degree of rupture of the arterial wall, the availability of a venous autograft, and of its length. The use of autologous material was always privileged. An in situ revascularization was carried out when the infectious signs and the arterial rupture were small. An extra-anatomic bypass was carried out when the local conditions, the size of the arterial lesion, and the septic state were serious.
Drug addiction and arterial lesions 185
The principal criteria of judgment were the actuarial rate of primary and secondary patency and of limb salvage. Primary patency was defined as the continuous patency of the arterial revascularization without additional procedure on the bypass or the adjacent native vessel. If a complication (e.g., thrombosis or a rupture of suture line) emerged, one spoke about secondary permeability. An arterial revascularization was considered as being in primary permeability if he(it) remained permeable without additional procedure on the bypass or on the neighboring native vessel. Any complication (thrombosis, desertion of suture) ended the primary permeability. The arterial revascularization was admitted in secondary permeability after restoration of a total or partial occlusion, either after a revision or a successful repair of anastomoses. The latter was considered after restoration of a total or partial occlusion or after a revision/repair of anastomoses. Limb salvage was defined as the absence of major amputation. An amputation above the knee was defined as being major. The secondary criteria of judgment included the frequency of infection and death rate. Each patient was reexamined 1 month after discharge from the hospital. A questionnaire, a clinical examination, and duplex ultrasonography or computed tomography angiography imaging were carried out. The patients were then reexamined after 3 and 6 months then annually thereafter in the absence of complication or of repetition. Statistical Analysis The statistical analysis was carried out with SPSS software (version 17.0; SPSS Inc., Chicago, IL). The analysis was only descriptive. Means and standard deviations were calculated for quantitative data. Frequencies and percentages were calculated for qualitative data. Variables such as survival (primary and secondary patency) were presented in KaplaneMeier actuarial survival curves.
RESULTS Thirty-three arterial lesions were treated in 31 drug addicts in our center. Two patients presented with a second localization during follow-up. The mean age of our patients was 31.4 ± 7.2 years (range: 21e49 years). Four women were in the study group. The arterial lesions were in 31 cases FAs and in 2 cases arterial thrombosis. The clinical signs (Table I) at the time of the hospitalization were a contained or active acute hemorrhage (AH) in 16 cases (Fig. 1), a septic symptoms in 7 cases, and a pulsatile mass in
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Table I. Principal clinical manifestations upon the admission of the patients Clinical manifestation
n (%)
Acute hemorrhage Septic syndrome Pulsatile mass Acute ischemia Total
16 7 6 4 33
(48.5) (21.2) (18.2) (12.1)
Fig. 2. Misuse of buprenorphine (ruptured left humeral false aneurysm).
Fig. 1. Acute hemorrhage (left humeral false aneurysm).
Table II. Injected substances Substances
n (%)
Heroin Heroin and cocaine Heroin and buprenorphine Buprenorphine No information Total
8 (25.8) 7 (22.6) 5 (16.1) 4 (12.9) 7 (22.6) 31
6 cases or acute ischiemia in 4 cases. These symptoms could accumulate among certain patients. The substance injected was mainly heroin (Table II). The intravenous misuse of buprenorphine was found among 9 patients (Fig. 2). The diagnosis could have been established by computed tomography angiography only (Fig. 3) in 7 cases (21.2%), by arterial duplex ultrasonography in 3 cases (9.1%), and by the association of these 2 techniques in 11 cases (33.3%). No preoperative imagery was realized in 12 cases (36.4%) because of need for an immediate intervention. We observed 15 humeral FAs, 13 femoral FAs, and 3 axillary FAs. Seventeen FAs were on the left side and 14 were right-sided. The biologic assessments
Fig. 3. Right common femoral artery false aneurysm and presence of foreign bodies (needles) in the area of the 2 common femoral arteries.
carried out upon admission of the patients highlighted a biologic inflammatory syndrome with elevation in the number of white cells and/or Creactive protein in 24 cases. The assessments of the 7 other cases did not show abnormalities. Serologies carried out revealed that 6 patients were carrying the hepatitis C virus. Thirty-one patients underwent surgery and 2 were medically followed-up. The first stage of the interventions consisted of a control of the arterial axes upstream and downstream from the FA in healthy zone. A broad debridement of necrotic and
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Fig. 4. Reversed venous extra-anatomic humeroradial bypass.
inflammatory tissues was done. Arterial ligature without revascularization was carried out in 5 cases (4 in the superficial femoral artery and 1 in the common femoral artery). An in situ revascularization was carried out in 20 cases, including 15 bypasses (9 venous and 6 prosthetic), 2 venous patches, 2 direct sutures, and 1 transposition of the superficial femoral artery in the deep femoral artery. An ex situ revascularization by a lateral extraanatomic bypass (Fig. 4) was performed in six cases (4 venous and 2 prosthetic). The medical treatment consisted at two patients by an intravenous heparin because of ischemic signs by embolization of illicit substances residues. From a medical point of view, the patients presenting with signs of clinical sepsis or a biologic inflammatory syndrome during their admission benefitted from probabilistic intravenous antibiotics, secondarily adapted to microbiology. In 27 cases, the bacteriologic tissue cultures were positive (81.8%). Seventeen were positive for Staphylococcus aureus sensitive to methicillin (63%), 3 grew methicillin-resistant S. aureus (11.1%), 2 grew Staphylococcus epidermidis (7.4%), and in 5 cases there was a multiple colonization (18.5%). All the patients were introduced to the Welcoming and
Drug addiction and arterial lesions 187
Treatment Unit for drug addicts in order to begin or to adapt weaning. The patients benefitte then from a substitution by buprenorphine (n ¼ 17) or methadone hydrochlorate (n ¼ 10). Twelve early reinterventions (38.7%) had to be carried out because of 6 AH septic ruptures in a septic environment, 4 cases of acute ischemia by thrombosis of a bypass, 1 case of acute ischemia after arterial ligature, and 1 thrombosis of an infected bypass without downstream repercussion (Table III). The average delay before reintervention was 6.92 ± 7.53 days (range: 0e24 days). Nine of these complications occurred after an in situ revascularization, 2 after an ex situ revascularization, and 1 after a simple ligature. In second intention, we carried out 6 extra-anatomic revascularizations, 3 repairs of anastomoses, 1 replacement of an infected prosthesis by a vein, 1 thrombectomy of a bypass, and 1 arterial ligature associated with the ablation of a prosthetic bypass. Tissue loss led to the need for a directed healing with a mesh, in 3 cases with Vacuum Assisted ClosureÒ (VAC). In 2 cases, surgical covering with a pedicled epigastric flap of the contralateral rectus abdominis (Fig. 5) had to be applied thereafter in order to fill the cavity. The mean duration of hospital stay was 15.9 ± 14.7 days (range: 2e63 days). The mean duration of follow-up was 8.6 ± 14.4 months (range: 1e73.5 months). Fifteen patients were lost to follow-up after 6 months. The primary patency at 1, 3, and 6 months was of 61%, 46%, and 46%, respectively. The actuarial secondary permeability was 91%, 81%, and 71%, respectively. The rate of extremity salvage was 100% at 6 months. One transmetatarsal amputation was performed. No deaths occurred because of treatment. One patient died from suicide.
DISCUSSION The incidence of injectable drug addiction is in continuous increase. Maliphant and al.3 estimated that the average duration of time until the venous capital is exhausted before the use of intra-arterial injection is 7.7 years. Consequently, the majority of vascular surgery centers will be brought to deal with this type of pathology. The most frequent arterial lesion is infected FA. It accounts for approximately 0.14% of the complications related to the injection of intravenous drugs.4 The repeated traumatisms of the arterial wall at the time of the iterative punctures are the prevalent mechanism of these lesions. The bacterial contamination caused by the precariousness
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Table III. Early complications after surgical treatment
Ligation In situ revascularization Anatomic bypass Venous bypass Prosthetic bypass Venous patch Direct suture SFA transposition Ex situ revascularization Venous Prosthetic Total
n
Early reoperation
Acute hemorrhage
Septic thrombosis
Acute ischemia
5 20 15 9 6 2 2 1 6
1 9 8 4 4 1 d d 2
d 5 4 3 1 1 d d 1
d 4 4 1 3 d d d 1
d d d d d d d d d
4 2 31
1 1 12
1 d 6
d 1 5
d d 1
SFA, superficial femoral artery.
Fig. 5. Cover flap from the contralateral rectus abdominis muscle pedicled by the epigastric artery inferior. Result at the end of the intervention (A) and at 4 months (B).
and the defect of hygiene and asepsis has its share of responsibility in the pathophysiology of FA. We also retain the toxicity of the acid products used to dilute certain drugs, like brown heroin or crack. The lemon juice, the vinegar, or the ascorbic acid/citric present in the boxes distributed in the centers for drug addicts are also involved. These 3 factors generate a parietal destruction, a necrosis of adjacent tissues, and an inflammatory process contributing to the occurrence of a FA. Embolic complications are also possible (2 cases in our study). The emboli contained solid residues that were poorly diluted. Rare cases of embolization of needle or fragment of needle in the general circulation were also described.5
Various types of treatments have been proposed, but there is no consensus on the management. The need or not for a revascularization, the timing of revascularization, and the type of material to use in patients whose superficial venous network is faded are many elements that remain controversal. The principal studies of the literature relate to infected FA in femoral position. At the level of the upper limb, one observes primarily isolated cases or case studies. In our study, most of the FAs were located in the upper limb, 15 in the humeral artery, and 3 in the axillary artery. Angioscanner seems to us to be the most contributive imaging study. It makes it possible to affirm the positive diagnosis, to visualize the downstream arteries, and to study
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Fig. 6. False aneurysm of the right superficial femoral artery treated by ligature.
the possibility of using or not autologous material for revascularization. In one of our patients, the decision to carry out a ligature without revascularization was made before the operation thanks to the results of the angioscanner (Fig. 6). The arterial lesion was a FA located at the origin of the superficial femoral artery, followed by a short thrombosis on a few centimeters, with a downstream reentry from a well developed collateral network. In many studies,6e9 arterial ligature without revascularization is considered the best treatment to manage infected FA in drug addicts. However, the principal complications met after ligation without arterial restoration are intermittent claudication, AHs caused by the rupture of suture lines, and even amputation, with rates reaching 44.4%, 22.2%, and 18.2%, respectively.8 In our study, a patient presented with acute ischemia on the day of the intervention after ligature of the common femoral artery. An extra-anatomic bypass was carried out. The immediate revascularization is described and recommended by other researchers.10e12 The persistence of the infection or a bacterial colonization, a hemorrhage by rupture of sutures, early or late thrombosis, and amputation are also secondary complications described after revascularization.13 Indeed, the objective is to maintain the vitality of the limb in young patients, who have no atheroma and therefore no collaterality. For this reason, the need for an initial revascularization appears essential.
Drug addiction and arterial lesions 189
The therapeutic sequence is to be chosen between the initial control of the infected area and the realization of the revascularization in aseptic zone as a first stage. Because of the late presentation of the drug addicts, generally at the instant of the hemorrhagic rupture of an infected FA (16 patients in our study), we initially carried out the control of the pathologic zone followed by revascularization. In our study, we carried out 26 immediate revascularizations. The 2 principal types of complications met were AHs and septic thrombosis. Nine of these complications occurred after an in situ revascularization, including 5 AHs (25%). Our results are close to those (23.8%) in a literature review by Georgiadis et al.14 It should be noted that 4 of these AHs occurred after the use of autologous material. This complication is explained by the progression of the infection and tissue erosion responsible for the anastomotic rupture. Some studies15,16 show that the frequency of anastomotic dehiscence is more important with the use of a vein than with the use of prosthetic material, in particular cases of S. aureus infection. Septic thrombosis was present in 5 cases, in 4 cases at the time of the implantation of a prosthetic material. The use of prosthetic material appears unsuited in this context of necrotic and inflammatory lesions of soft tissues. However, when revascularization is needed, in the absence of autologous material, our choice was for the use of silver impregnated grafts. Insufficient debridement of infected tissues, contamination by an adjacent infection, or hematogenous seeding are certainly possible causes of prosthetic septic thrombosis. A biologic inflammatory syndrome was present in 10 of 12 cases at the time of early reintervention, of which 6 had a C-reactive protein level >100 mg/L. These values reveal intense inflammatory activity. The severity of the tissue and biologic septic attack is responsible for the early complications at the time of the immediate arterial restorations. This is why, in order to be remote from infection, we carried out second intention arterial restorations with extra-anatomic bypasses when the primary revascularization was in situ. Patel et al.10 reported good results with extra-anatomic obturator bypasses, with a rate of 7% of septic thromboses among 15 patients. No bypass through the obturator hole was carried out in our study. Any traumatism at the time of the tunnelization can induce hemorrhage by vascular wound of the obturator pedicle, which is difficult to control in the pelvis, nervous trauma with anesthesia of the anterior face of the thigh and deficit of the adduction, or pelvic visceral lesions. We carried out bypasses through a lateral approach at the
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Fig. 7. Actuarial primary and secondary patencies. Permeabilite IIR, Secondary patency; permeabilite IR,
primary patency; temps (mois), time (months); exposes au risque, exposed to risk; taux de permeabilite, patency rate.
femoral level as described by Leather and Karmody.17 Secondary actuarial patencies (Fig. 7), the limb salvage rate, and the rates of morbidity and mortality in our study were acceptable in spite of an important rate of reinterventions. The number of patients recruited in our study is too small to allow a subgroup analysis of the various methods of arterial restoration. We think that an extra-anatomic revascularization, preferably with autologous material, is the technique of choice in order to be remote infected tissues and to decrease the frequency of the early complications. The essential stage of the management of drug addicts is a broad debridement of necrotic and inflammatory tissues, associated with a treatment adapted to the infection with intravenous broad spectrum antibiotics. In order to fill the loss of substance, we had to carry out 2 pedicled flaps from the rectus abdominis muscle, whose evolution was favorable (Fig. 5B) and without complication. We should underscore that among drug addicts, therapeutic follow-up is very difficult. The rupture of care and the number lost to follow-up are extremely important in many studies. Georgiadis et al.15 conclude that no management proved its effectiveness in terms of total surgical complications
at the time of the surgical management of infected FA. A longer duration of follow-up would be necessary to provide more precise results. The risk among these patients is the continuation of their addiction and the appearance of new sites of arterial lesions. In our study, we observed 2 patients with 1 second arterial localization. The average follow-up in our study was of 8.6 months, and the number of lost to follow-up was 15 at 6 months. This is why our choice was to apply a strategy of aggressive revascularization under sometimes difficult conditions.
CONCLUSION The arterial lesions among drug addicts are an entity made of chemical burns inducing inflammation and necrosis in contact with and in the wall of the arteries. The difficulty lies in the combined management of vascularization, of loss of substance of the soft tissues, and of infection. Arterial restoration with extra-anatomic bypasses makes it possible to be remote from infection and seems to have better results in the short- and midterm in our study. This technique can be associated with a pedicled flap with the contralateral rectus abdominis muscle.
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Drug addiction and arterial lesions 191
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