Infected femoral pseudoaneurysms in intravenous drug abusers: a decade of experience from a Singapore tertiary centre.

INTRODUCTION: A pseudoaneurysm (or false aneurysm) is a haematoma that communicates with an artery through a disruption in the arterial wall. The femoral artery is the most common injection site among drug users, and infected femoral pseudoaneurysms are the most common vascular complications. METHODS: A retrospective review of medical records of intravenous drug abusers (IVDAs) who presented with infected femoral pseudoaneurysms from January 2006 to December 2016 was carried out. Patients who had pseudoaneurysms due to other aetiologies or trauma were excluded. RESULTS: A total of 27 patients with infected femoral pseudoaneurysms were identified. The majority were male (92.6%) and of Malay ethnicity (55.6%). Median age was 50 (range 31-62) years. Commonly abused drugs were buprenorphine (or Subutex; 59.3%) and midazolam (or Dormicum; 51.9%). Groin pain and swelling (100.0%), fever (66.7%) and presence of a pulsatile mass (51.9%) were the most common presenting symptoms. Diagnosis was confirmed via computed tomography angiography in all patients. 25 patients underwent upfront arterial ligation with debridement, among whom three patients required concurrent surgical revascularisation. Only two patients underwent ultrasonography-guided thrombin injection - one eventually required surgery and the other was lost to follow-up. Postoperative complications included wound infection (42.3%), bleeding (11.5%) and necrotising fasciitis eventually resulting in limb loss (3.8%). There were no associated mortalities. CONCLUSION: Infected pseudoaneurysms in IVDAs pose a unique challenge to vascular surgeons. We found that simple ligation and debridement was a safe and effective option for such patients.

Endovascular retrograde recanalization in Asian critical limb ischaemia patients.

BACKGROUND: To evaluate endovascular retrograde recanalization of critical limb ischaemia (CLI) patients with chronic total occlusions (CTOs) in an Asian population. METHODS: We conducted a single centre-based retrospective review of CLI patients with CTOs who had undergone endovascular retrograde recanalization using the subintimal arterial flossing with antegrade-retrograde intervention technique. RESULTS: A total of 40 CLI patients with CTOs underwent endovascular intervention. The median age was 71 years; 67.5% were males and Chinese accounted for 65% of the patients, of which 55% were in Rutherford category 6, 37.5% in category 5 and 7.5% in category 4. Antegrade-retrograde access was performed via the femoral artery in 39 cases and the brachial artery in one case for the proximal puncture, and the following arteries for the distal puncture: superficial femoral, n = 4 (10%); popliteal, n = 4 (10%); anterior tibial, n = 12 (30%); dorsalis pedis, n = 9 (22.5%); peroneal, n = 4 (10%) and posterior tibial, n = 7 (17.5%). Technical success was high at 92.5% (n = 37). After intervention, 25% (n = 10) had below-knee triple vessel runoff, 52.5% (n = 21) had double vessel runoff and 15.0% (n = 6) had single vessel runoff. Stenting for target vessel dissections was required in 12 patients. There were two cases of significant bleeding; one common femoral artery pseudoaneurysm was treated with ultrasound-guided thrombin injection and another case of distal puncture site bleeding only required compression. Limb salvage at 1 year was 92.5% (n = 37). CONCLUSION: The subintimal arterial flossing with antegrade-retrograde intervention technique is safe with high technical success rates and acceptable outcomes in Asian CLI patients with CTOs.