Surgical management of infected pseudoaneurysms in intravenous drug abusers: single institution experience and a proposed algorithm.
BACKGROUND
Vascular complications from intravenous drug abuse pose significant challenges to vascular surgeons. No formalized policies have been reached on surgical management of the resultant infected pseudoaneurysm.


METHODS
A retrospective review of all patients who underwent surgery for pseudoaneurysms due to chronic intravenous drug abuse from July 2005 to February 2008 was performed.


RESULTS
A total of 15 patients with infected pseudoaneurysms from chronic intravenous drug abuse were operated on during the study period. The sites of involvement were restricted to the femoral (86.7%) and brachial (13.3%) areas. The drug involved was buprenorphine (Subutex) in all cases. Pain over the limb swelling (100%), pulsatility (60%), and symptoms suggestive of septicemia (46.7%) were the most common symptoms. Staphylococcus aureus was present in 93.3%. Diagnosis was achieved clinically in 26.7%, by duplex ultrasonography in 60.0%, and by computed tomography (CT) angiography in 13.3%. In the two patients with brachial pseudoaneurysms, the brachial artery was ligated in one, and a basilic vein patch was used in the other. In the 13 patients with femoral pseudoaneurysms, the pseudoaneurysm was ligated and excised in 8 (61.5%), and immediate reconstructive bypass surgery was performed in 5 (38.5%). Two patients had critical ischemia after ligation and required reconstructive bypass surgery a few weeks later. Postoperative complications included claudication, digital gangrene, localized wound infection, and rebleeding. There was no associated mortality.


CONCLUSIONS
Pseudoaneurysm from intravenous drug abuse continues to pose significant challenges to surgeons worldwide, ranging from an accurate diagnosis to the choice of surgery. The aims of surgery must be to achieve adequate débridement and control infection and hemorrhage. Any associated postoperative complications must be identified and dealt with.
Tan
Ker-Kan
KK
Department of General Surgery, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore. kerkan@gmail.com
Chen
Kenneth
K
Chia
Kok-Hoong
KH
Lee
Chee-Wei
CW
Nalachandran
Sanjay
S
D000328:Adult; D000465:Algorithms; D017541:Aneurysm, False / Q000000981:diagnostic imaging / Q000209:etiology / Q000601:surgery*; D000785:Aneurysm, Infected / Q000209:etiology / Q000601:surgery*; D001916:Brachial Artery / Q000000981:diagnostic imaging / Q000601:surgery; D002047:Buprenorphine / Q000009:adverse effects; D005260:Female; D005263:Femoral Artery / Q000000981:diagnostic imaging / Q000601:surgery; D006801:Humans; D008297:Male; D008875:Middle Aged; D009294:Narcotics / Q000009:adverse effects; D012189:Retrospective Studies; D015819:Substance Abuse, Intravenous / Q000150:complications*; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome
D009294:Narcotics; D002047:Buprenorphine