J Milburn, J
Brittenden
Correspondence
to:
Email: j.brittenden@arh.grampian.scot.nhs.uk
SMJ 2006 52(1): 55
Introduction
This case report
describes two referrals to our department in a single day.
In both cases the failure to consider the diagnosis of an arterial
pseudoaneurysm by junior and senior medical staff may have delayed appropriate
treatment. The rising prevalence of
intravenous drug abuse has led to an increased awareness of the vascular
complications which can arise. In
the case of arterial pseudo-aneurysms this can be life and limb threatening.
Case One
A
male Intravenous Drug Abuser (IVDA) self-referred to Accident and Emergency with
a swelling in his right groin resulting from attempted groin injection.
The patient was afebrile with a 6 by 4cm hot, red swelling arising over
the area of a puncture wound. The
initial diagnosis was of a groin abscess and he was discharged with a course of
oral antibiotics and instructed to return fasted in two days for possible
incision and drainage in the department. During
the next 48 hours he injected into his left groin and represented with a similar
swelling in his left groin. The
patient provided a history of “blood
spurting” from the puncture site in his left groin.
A general surgical opinion suggested bilateral groin abscesses and due to
their position a referral was made to Orthopaedics.
He was admitted and consented for incision and drainage of bilateral
groin abscesses under general anaesthetic. Whilst anaesthetised the swellings
were noticed to be pulsatile, and on table ultrasound and vascular opinion
sought. (Fig 1) Bilateral false aneurysms were diagnosed and the decision to
operate urgently was taken and both groins explored. On both sides grossly infected tissue was found surrounding
large false aneurysms with disintegration of the common femoral artery on the
right and the superficial femoral artery on the left. Due to the extensive involvement of the major vessels
bilateral ligation of the common femoral artery was the only surgical option.
Both wounds were left open and the patient observed.
The patient made a slow recovery being able to mobilise freely and denies
symptoms of claudication. He was
subsequently discharged to the community, and has not attended follow-up
appointments.
Figure
1:
Duplex
image of the right SFA highlighting arterial flow into a large false aneurysm
cavity.
Case
Two
A
twenty one year old female IVDA was referred to accident and emergency with a
painful right thigh following groin injection.
The patient was afebrile with a swollen, tense hard swollen thigh.
A separate swelling was noticed in her groin at an inflamed puncture
site. The initial diagnosis was of
thrombosis of the femoral vein. The
patient was initially treated with a therapeutic dose of low molecular weight
heparin and antibiotics with a routine request for ultrasound organised.
The ultrasound revealed a 2.7cm false aneurysm in the common femoral
artery with thrombus in the common femoral vein.
The current management plan was continued and she was referred to the
vascular team three days following false aneurysm diagnosis and five days from
admission. At operation extensive infection was evident surrounding a 10cm false
aneurysm involving the common femoral and superficial femoral arteries.
The common femoral artery required ligation due severe disease of the
vessel wall. Despite social
problems she was discharged fully mobile to the community walking. She also has
failed to attend subsequent clinic appointments.
Discussion
An
arterial pseudoaneurysm is an uncommon but one of the most serious sequelae of
intravenous drug abuse. It results from inadvertent puncture of arteries in an
attempt to access the deep veins when superficial options are exhausted.
Previously it has been suggested that the triad of pus, blood and
pulsatile groin mass is an unmistakeable triad.1
However, some series have reported that up to 23% may not have a
pulsatile swelling due to overlying soft tissue masking the clinical sign.2
The differential diagnosis is usually one of a groin abscess although
cellulites and lympadenitis may also be considered.3 Great improvements in the accuracy and reliability of
ultrasonography have made this the investigative modality of choice in the
current era. This should be
performed urgently once there is clinical suspicion and should not be delayed
until after a surgical review. Preoperative
angiography may allow improved assessment of the extent of the aneurysm but may
lead to unnecessary delays and be of limited benefit.
A
background of HIV or viral hepatitis, uncooperative patients and lack of
superficial veins for direct access or reconstruction often complicate
management of these patients. Increasingly
the use of primary ligation of vessels is being advocated with revascularisation
only reserved for those at risk of acute limb loss.4
The most common procedure is to bypass the groin via the obturator route2,
thus avoiding the affected area so as to reduce the risk of subsequent graft
infection. Some centres use the presence or absence of a Doppler signal at pedal
vessels after ligation of the groin vessels to determine limb viability5
In both these cases Doppler signals were present and the viability of the limbs
were carefully assessed for 48 hours following the initial surgery. In these
young patients without peripheral atheromatous change the development of an
adequate collateral circulation allows distal perfusion.6 In line with published series5,6,7 both our
patients retain viable limbs but are likely to experience claudication symptoms.
If the common femoral artery alone
is ligated the risk of subsequent limb loss is low although this may rise to 33%
if all three vessels are ligated.2
This is particular fortunate in case 1, where there was no opportunity
for informed consent or a pre-operative discussion about the likelihood of limb
loss and the need for surgery in order to avoid catastrophic haemorrhage.
In
our second case despite knowledge of the ultrasonic findings of a false aneurysm
there was an unacceptable delay until referral whilst the patient was treated
with high dose heparin. These cases
highlight the need for vigilance of all drug abusers presenting with groin
swellings by all members of staff.
With
the spiralling social epidemic of intravenous drug abuse affecting many
populations worldwide, more patients with false aneurysms will present to
primary care physicians and hospital staff.
There is a need for improved awareness of this condition among junior and
senior medical staff to prevent further attempts at blind exploration and
inappropriate delayed referral.
References
1.
Zahrani HA. Vascular complications following intravascular self-injection of
addictive drugs. J R Coll Surg Edinb.1997; 42: 50-55
2.
Woodburn KR, Murie JA. Vascular Complications of injecting drug misuse. Br J
Surgery. 1996; 83(10): 1329-1334
3.
Welch GH, Reid DB, Pollock JG. Infected false aneurysms in the groin of
intravenous drug abusers. Br J Surg. 1990; 77(3): 330-333
4.
Arora S, Weber MA, Fox CJ, Neville R, Lidor A, Sidaway AN. Common femoral artery
ligation and local debridement: A safe treatment for infected
femoral artery pseudoaneurysms. J Vasc Surg. 2001; 33(5): 990-993
5.
Behera A, Menakuru SR, Jindal R. Vascular complications of drug abuse: an Indian
experience. ANZ J Surg. 2003; 73: 1004-1007
6.
Gan JP, Leiberman DP, Pollock JG. Outcome
after ligation for Infected false femoral aneurysms in intravenous drug abusers.
Eur J Vasc Endovasc surg. 2000; 19: 158-161
7. Ting ACW, Cheng SWK. Femoral Pseudoaneurysms in drug addicts World Journal of Surgery. 1997; 21: 783-787