Parenteral Drug Abusers Research Articles

Defining risk factors associated with difficult peripheral venous Cannulation: A systematic review and meta-analysis

Peripheral venous catheterization is a common technique in hospitals which is not always successful, resulting in multiple punctures and degradation of the vessels. This scenario, which we have termed ‘difficult peripheral venous access’, is associated to delays in care, obtention of samples or diagnosis, as well as a higher use of central catheters.This study intends to identify risk factors associated to the incidence of ‘difficult peripheral venous access’ in adults at hospital.We designed a systematic review of published studies (protocol PROSPERO 2018 CRD42018089160). We conducted structured electronic searches using key words and specific vocabulary, as well as directed searches in several databases. After validity analysis, we selected 7 studies with observational methodology.We found great variability in the definition of ‘difficult peripheral venous access’ and in the variables proposed as risk factors. Statistically significant factors through studies include demographic and anthropometric variables (gender, Body Mass Index), as well as medical and health conditions (diabetes, renal insufficiency, parenteral drug abuse, cancer chemotherapy), together with variables related to the vein or vascular access (vein visibility and palpability, vessel diameter, previous history of difficulty). Some studies have also considered variables related to the professional performing the technique.Meta-analyses were carried out for gender and obesity as potential risk factors. Only obesity appeared as a statistically significant risk factor with OR of 1.48; 95% CI (1.03 to 1.93; p = 0.016). Methodological heterogeneity prevented the development of further meta-analyses.It is essential to design future studies with diverse hospital populations, in which a wide selection of potential risk factors can be studied in a unique analysis. Our work identifies the most relevant variables that should be included in those studies.

In Vitro Antidrug Susceptibility Testing of Candida Species Isolated from Aseptic Body Fluids

Background: Candida species are opportunistic pathogenic fungi that colonize in the human body. They may cause diseases ranging from non-life-threatening mucosal Candida infections to life-threatening invasive candidiasis among people with the aggressive use of immunosuppressive agents, cytotoxic therapies, treatment with broad-spectrum antifungal agents, prolonged central venous catheterization, total parenteral nutrition, AIDS, diabetes, and drug abuse. Objectives: The aim of this study was to describe the distribution and antifungal susceptibility of clinical Candida isolates obtained from sterile fluids of patients who suffered from candidiasis from 2008 to 2010. Methods: Vitek2 YST, CHROMagar Candida medium, and multiple PCR were used to identify the Candida species. The susceptibility testing to seven common antifungal agents, including amphotericin B, flucytosine, fluconazole, itraconazole, ketoconazole, clotrimazole, and nystatin, was performed using the methodology recommended in the M27-A3 document of the clinical and laboratory standards institute (CLSI). Results: A total of 149 clinical Candida isolates were obtained from sterile fluids at a hospital in China. Within these isolates, Candida albicans was the most predominant species (47.7%), followed by C. glabrata (26.8%) and C. tropicalis (13.4%). The sources of fungal isolates were urine (75.8%), blood (16.8%), drainage liquid (4%), hydrothorax and ascites (2%), cerebrospinal fluid (0.7%), and succus prostaticus (0.7%). All of the Candida isolates were susceptible to amphotericin B. In addition, 27.5% of the isolates were resistant to ketoconazole, 22.1% to itraconazole, and 17.4% to fluconazole. Furthermore, 16.8% (25/149) of the isolates exhibited a cross-resistance to azoles. Interestingly, we found one flucytosine-resistant C. albicans isolated from urine. Conclusions: Our findings indicate that a better preventive management and limited use of azole drugs are needed for Candida infections and further research is indispensable to identify cross-resistance mechanisms of azoles.

Recurrent Infective Endocarditis in a Drug Addict: A Case Report

Infective endocarditis is a disease with a high mortality rate; mortality increases with the number of new episodes. Patients with relapsing endocarditis have a higher mortality rate per year (20%) than patients with a single episode (9%); moreover, the episodes of infective endocarditis on the prosthetic valve have a worse prognosis, with a mortality rate of 45% for each episode. In relapsing endocarditis, the following are distinguished: the relapses, characterized by the same germ, less than six months after the previous episode, and the reinfections, which may be caused by a different germ, or by the same germ, more than six months after previous episode. A recent analysis of the risk factors of recurrent bacterial endocarditis showed that the use of intravenous drugs, hemodialysis, immunosuppression and previous episodes of infective endocarditis played a major role, especially if they occurred on the prosthetic valve and if caused by S. aureus. Recurrent infectious endocarditis occurs more frequently in young male patients with HIV seropositivity, who routinely use intravenous drugs. We have analyzed the clinical case of a 36-year-old immunocompetent man with a long history of parenteral drug abuse, who has presented 6 new episodes of relapsing infective endocarditis on mitral valve and 2 reinfections since 2013. Between 2013 and 2016, the patient underwent two mitral valve replacements with a biological prosthesis implant and a mitral valve replacement with a mechanical prosthesis implant and a tricuspid annuloplasty. The remaining episodes were treated with medical therapy only. Currently in the literature 6 episodes of relapsing infective endocarditis and 1 reinfection in a single patient is the highest number of reported events.

Adverse childhood experiences and their effect on the orthopaedic surgery patient

The Adverse Childhood Experiences (ACE) study sought to determine if a relationship between adverse childhood experiences and long-term medical and public health problems exist. Ten risk factors that contribute to the leading cause of mortality in the United States were chosen for further analysis in the ACE study. The ten risk factors chosen were smoking, severe obesity, physical inactivity, depressed mood, suicide attempts, alcoholism, drug abuse, parenteral drug abuse, a high number of sexual partners, and history of sexually transmitted infections. The patients identified with one or more of these risk factors noted in the ACE study may present to an orthopaedic surgeon more frequently, with more severe injuries, reporting a decreased quality of life and increased pain when compared to those not falling into one of these risk categories. This patient population may also undergo more procedures and may suffer an increase in postoperative complications and a decrease in overall improvement after recovery. The goal of this literature review was to examine the ten risk factors suggested to be more prevalent in patients who have suffered from a greater number of adverse childhood experiences, and determine their potential effect on the management, treatment, and outcome for orthopaedic conditions. Available literature supports that the presentation and management of orthopaedic surgical cases may be more challenging in patients who fall into one of the above-discussed risk categories. Based on the results of ACE, this information can be inferred, although not conclusively, to mean that patients with a high ACE score may require the use of additional resources to provide the best outcome when being treated by the orthopaedic surgical team. This review is unable to conclude that using an ACE score in patients presenting for treatment by an orthopaedic surgeon would be beneficial. However, it may highlight the importance of the history, including the social history, to better determine what effect psychosocial factors may have in the assessment, management, and potential benefit of treatment for a patient.

Tumefactive multiple sclerosis and hepatitis C virus 2a/2C infection: Dual benefit of long-term interferon beta-1a therapy?

Hepatitis C virus (HCV) infection has been implicated in triggering acute disseminated encephalomyelitis but not tumefactive multiple sclerosis. We report the case of a 17-year-old female who presented with a 5-day history of left hemiparesis and hemisensory loss followed by a right third nerve palsy. Tumefactive multiple sclerosis was diagnosed based on the absence of encephalopathic signs, the presence of tumefactive brain lesions, the exclusion of neoplastic and infectious causes of the lesions by biopsy, and the occurrence of relapse after a period of remission. The patient was at risk for HCV infection due to parenteral drug abuse and multiple sexual partners. Serial HCV antibody tests and RNA polymerase chain reaction assays revealed acute HCV infection and genotyping showed HCV genotype 2a/2c. She was treated with high-dose methylprednisolone and discharged with only mild left hand weakness. Interferon beta-1a 30mcg was administered intramuscularly once a week. Remission from HCV infection was achieved in three years without standard anti-HCV therapy. This case suggests that CNS myelin is a potential target of the immune response to HCV 2a/2c infection, the HCV 2a/2c virus may be involved in triggering autoimmune tumefactive brain lesions, and interferon beta-1a is effective against HCV 2a/2c infection. We recommend serial HCV antibody testing and HCV RNA PCR assay, preferably with HCV genotyping, in all patients with acute inflammatory demyelinating diseases of the CNS.

English

Drug abuse is a worldwide problem with disastrous consequences for the patient, family and society at large. The case of injection drug abusers seems a little different as cutaneous complications may occur. Considering these complications the present article attempts to review the adverse effects of parenteral drug abuse on the skin including the common skin and soft tissue infections secondary to the drug abuse.

Barriers to care and treatment for patients with chronic viral hepatitis in Europe: a systematic review.

Despite the availability of effective therapies for hepatitis B (HBV) and C virus (HCV), only a minority of these patients receive treatment. We systematically reviewed published data on barriers to management for chronic HBV/HCV patients in Europe. Literature search to identify studies including adult patients with chronic HBV/HCV infection from European countries and data on barriers to treatment. Twenty-five studies including 6253 chronic HBV and 19,014 HCV patients were identified, of which only two were from Eastern Europe. The mean rate of no treatment in HBV patients was 42% being higher in North-Western European countries than Italy (56% vs. 39%, P < 0.001). Immigrants represented the most common barrier to HBV treatment. The mean rate of no treatment in HCV RNA-positive patients was 57%, being highest in Romania (89%), intermediate in France (79%) and lower though still high in other European countries (52%, P < 0.001). The predominant barriers to HCV treatment were lack of financial resources in Romania and direct/indirect limitations of interferon-alfa and/or parenteral drug and alcohol abuse in other countries. The mean rate of no treatment was highest in HCV RNA-positive parenteral drug users (72%) and intermediate in those with HCV-HIV co-infection (64%). A substantial proportion of diagnosed chronic HBV and the majority of diagnosed HCV patients remain untreated. The rates and most importantly the reasons of barriers to treatment in chronic HBV/HCV patients vary widely among European countries supporting the need for country-specific national strategies, resource allocation and implementation of global management policies.

Infected femoral false aneurysm in drug abusers: Tailoring management to individual requirements

Background: Thereismuch controversy regarding the best management of infected femoral false aneurysm (IFFA), with advocates of mere arterial ligation or reconstruction either routine or selective. Aim of the work: To assess the outcome of surgical management of (IFFA) due to local injury in parenteral drug abusers. Patients and methods: Eighteen male patients with IFFA were surgically managed and retrospectively reviewed from October 2009 until October 2013. Data analyzed included demographic characteristics, modes of presentation, side and site of involvement, management and outcome. Arterial ligation with excision ofpseudoaneurysm was done in (6) cases whereas vascular reconstruction was done in (12) cases. Results: Overall amputation rate was 1118 (5.5%). All patients who had no revascularization experienced late claudications and/or rest pain. Limb salvage without critical ischemia was achieved in all cases having vascular reconstruction. Hemorrhage followed primary CFA repair in one case (1112,8.3%) and infection occurred in 216 {33.3%) cases of ligation versus 3/12 (25%) cases ofreconstruction. Conclusion: Revascularization should be selected if pedal Doppler signals are absent after excision ofpseudoaneurysm and ligation of the involved arteries, the extra anatomic route is a reasonable approach.

Global Eradication of Hepatitis C Virus: A Herculean Task

Once dubbed under the entity of Non A-Non B (NANB) hepatitis agents, Hepatitis C Virus (HCV) was finally discovered and named in 1989 [1,2]. HCV is an enveloped single stranded positive sense 9.6 kb RNA virus about 50 nm in diameter under the hepacivirus genus within the Flaviviridae family. Approximately 200 million people (about 3% of the world population) are currently infected with HCV including about 4 million in USA itself. The virus has 6 major genotypes and over 50 subtypes based on the genomic heterogeneity. Some experts recognize even more genotypes but it remains debatable until major genomic variability is authentically demonstrated in the new genotypes. While genotypes 1-3 have a worldwide distribution, some types are predominantly confined to certain geographical regions. Whereas type 1 is most prevalent in USA and Europe, type 3 in Southeast Asia, type 4 principally in Middle East, Egypt and Central Africa, the type 5 is almost exclusively encountered in South Africa. The prevalence rates of HCV infection vary from <1.5% in USA to 10% or more in Egypt. For reasons largely unknown, the baby boomers (people born between 1945 to1964) account for nearly three fourths of cases in most parts of the world. The major mode of HCV transmission has been variable over time. The main determinants had been the practice of parenteral drug abuse which was uncommon before 1960 and the development of HCV screening kits for blood, tissue or organ donors which became available only in early 1990s. Though globally, the major mode of transmission has usually remained unscreened blood/tissue/organ donors, the parenteral infective drug abuse may presently be the leading mode in most parts of the world including the developed countries. The other modes of transmission include the widespread practice of tattooing, use of unsterilized injection needles, vertical transmission from mother to child and the sexual contact. The incubation period is variable but on an average it is about 8 weeks. Only 15-25% individuals are able to clear the HCV infection spontaneously. Up to 85% infections may be asymptomatic. Majority of those infected develop chronic infection which runs for decades. The symptomatic HCV infection usually presents as mild disease with jaundice in less than 50% cases in whom the liver enzymes are either slightly elevated or even within normal range. If untreated chronic liver disease, cirrhosis and hepatocellular carcinoma may develop after twenty to thirty years in majority of the cases. Co-morbidity with Hepatitis A, Hepatitis B, HIV and chronic alcoholism leads to increased mortality and also affects the treatment schedule. HCV culture in the standard cell lines has always been difficult. Given the fact that the virus undergoes frequent mutations, the precise identification of the genotype has often been questionable. Moreover, a patient may sometimes be infected with more than one genotype at the same time. Because of these above inherent limitations, the availability of reliable diagnostic kits and the development of an effective vaccine as equally the therapy for HCV infection have all been formidable challenges. Despite the various modalities of the virus culture and efforts to develop HCV vaccines using helper adenovirus and baculovirus vectors during the last over two decades, the research in this context has still to go a long journey through as the task is yet unfinished [3-7].

Acute critical hand ischemia secondary to iatrogenic intrarterial injection of dexchlorfeniramine and prednisone

IntroductionAccidental intraarterial injection is a serious condition which, if unattended, can compromise the viability of a limb within a few hours. ReportA 97-year-old woman developed acute critical left hand ischemia secondary to iatrogenic intrarterial injection of dexchlorfeniramine and prednisone. The initial angiogram showed the complete occlusion of the ulnar artery and the superficial palmar arch. She underwent successful thrombectomy of the ulnar artery and thrombolysis of the palmar arch, which achieved complete digital reperfusion. DiscussionMost previously published cases report accidental arterial injections in parenteral drug abusers. There is no consensus about the ideal treatment for these events.

English

Hepatitis C virus (HCV) continues to be a major disease burden affecting about 200 million people in world. Using blood donors as a prevalence source may underestimate the real prevalence of the virus because the donors are highly selected population. Presently more evidences support intravenous drug use as leading risk factor for the spread of virus. OBJECTIVES: The study aims at finding out the seroprevelance of Hepatitis C virus in high risk individuals as well as healthy blood donors. SETTINGS AND DESIGN: The study group comprise of 350 subjects which included 150 healthy voluntary donors as control group and 200 subjects taken from different high risk population like intravenous drug abuser (50), patients on long term haemodialysis (40), patients with chronic liver disease (50), HIV positive cases (30), health care workers (30). STATISTICAL ANALYSIS USED: Percentage. RESULTS: Seropositivity for anti HCV antibody was found to be 12% (24/200) among high risk population and 0.66 % (1/150) in healthy voluntary blood donors. Among different high risk groups, maximum prevalence rate 28% (14/50) was found in I.V drug abusers. Fifty percent (7/14) of the seropositive parenteral drug abusers were male in the age group of 21-30 years followed by 35.7% (5/14) in 31-40 years of age group. Only one female (7.14%) between 21-30 years was found to be sero-reactive for antiHCV antibody. In HIV co-infected cases 13.33 % (4/30) were seropositive for antiHCV antibody. In chronic liver disease (two hepatocellular carcinoma, one cirrhosis and one chronic hepatitis) and long standing haemodialysis, the prevalence rate for anti HCV was found to be 8% (4/50) and 5% (2/40) respectively. None of the health workers (0/30) found to be sero-reactive for antiHCV antibody. CONCLUSIONS: HCV poses a serious worldwide health problem affecting people from all walks of life in every country. In the present study 12% and 0.66% HCV prevalence was noticed in high risk group and healthy blood donors respectively. Among high risk group maximum prevalence (58.33%) was found in IV drug abusers. Prevention should target the reduction of virus transmission by health education, risk reduction counseling and thorough HCV screening following the suggestion of CDC, Atlanta, USA.

Spontaneous External Rupture of Femoral Pseudoaneurysm

Drug abuse can lead to many life-threatening complications, the most frequent of which are overdoses and infections.We report here the case of a 38-year-old long-term drug abuser found dead in a near-sitting position on his bed at home, by his roommate. A pillow imbued with blood was recovered on his right groin region. At autopsy, we observed a ruptured pseudoaneurysm (false aneurysm) of the right common femoral artery. No obvious signs of infection were present. This article focuses the attention of the reader on an unusual complication of parenteral drug abuse with a rare but potentially lethal outcome; to the best of our knowledge, this is the first report of a fatal hemorrhage from a ruptured arterial femoral pseudoaneurysm as a complication of drug injection in the forensic literature.

Risky Sexual Behavior among Patients in Turkey with Bipolar Disorder, Schizophrenia, and Heroin Addiction

Risky sexual behavior associated with such sexually transmitted infections (STIs) as hepatitis B and C, herpes, Treponema pallidum, and Neisseria gonorrhoeae, is more frequent among psychiatric patients and parenteral drug abusers than the general population. The aim of this study was to investigate risky sexual behavior in psychiatric outpatients diagnosed with schizophrenia (SCH), bipolar disorder, and heroin addiction (HA), and to compare them with those observed in healthy controls. The study group (N = 485; 234 females and 251 males) consisted of patients that consecutively presented to Bakırkoy State and Training Hospital for Psychiatric and Neurological Diseases in Istanbul and normal healthy controls. The chi-squared test was used for comparisons between groups and categorical variables. One-way analysis of variance (post-hoc Bonferroni test) was used for demographic data. A 22-item questionnaire for collecting demographic, illness history, and sexual activity data, and a structured 23-item form for collecting data on risky sexually behavior were administered to the participants. In all, 10% of the participants had a positive history for STIs. The majority of risky sexual behaviors was observed among the HA patients. The frequency of being sexually assaulted and having homosexual acts among the SCH group were higher. None of the patients had a positive human immunodeficiency virus (HIV) test result. The frequency of positivity for hepatitis B and C markers was highest among the HA patients. The provision of information and training about all STIs and risky sexual behavior should become routine in the treatment of mentally ill patients, especially those that abuse drugs.

Infective Endocarditis

Infective endocarditis is a microbial infection of a cardiac valve or the mural endocardium caused by bacteria or fungi. Forms of this infection include subacute bacterial endocarditis (SBE) and acute bacterial endocarditis (ABE). Etiology and epidemiology are discussed. There is a section on pathogenesis followed by specific clinical presentations, including endocarditis associated with parenteral drug abuse as well as prosthetic valve endocarditis (PVE). Diagnosis and cardiac complications of endocarditis, treatment, recommendations for prophylaxis, and prognosis are addressed. There are several figures showing manifestations and anatomic relations from the infection. Tables describe microorganisms that cause native valve endocarditis, the etiology of PVE, the Duke criteria for diagnosis of infective endocarditis, antimicrobial therapy for endocarditis in adults, guidelines to prevent endocarditis, and recommendations and regimens for endocarditis prophylaxis. This chapter contains 99 references.

Infective Endocarditis

Infective endocarditis is a microbial infection of a cardiac valve or the mural endocardium caused by bacteria or fungi. Forms of this infection include subacute bacterial endocarditis (SBE) and acute bacterial endocarditis (ABE). Etiology and epidemiology are discussed. There is a section on pathogenesis followed by specific clinical presentations, including endocarditis associated with parenteral drug abuse as well as prosthetic valve endocarditis (PVE). Diagnosis and cardiac complications of endocarditis, treatment, recommendations for prophylaxis, and prognosis are addressed. There are several figures showing manifestations and anatomic relations from the infection. Tables describe microorganisms that cause native valve endocarditis, the etiology of PVE, the Duke criteria for diagnosis of infective endocarditis, antimicrobial therapy for endocarditis in adults, guidelines to prevent endocarditis, and recommendations and regimens for endocarditis prophylaxis. This chapter contains 99 references.

Infective Endocarditis

Infective endocarditis is a microbial infection of a cardiac valve or the mural endocardium caused by bacteria or fungi. Forms of this infection include subacute bacterial endocarditis (SBE) and acute bacterial endocarditis (ABE). Etiology and epidemiology are discussed. There is a section on pathogenesis followed by specific clinical presentations, including endocarditis associated with parenteral drug abuse as well as prosthetic valve endocarditis (PVE). Diagnosis and cardiac complications of endocarditis, treatment, recommendations for prophylaxis, and prognosis are addressed. There are several figures showing manifestations and anatomic relations from the infection. Tables describe microorganisms that cause native valve endocarditis, the etiology of PVE, the Duke criteria for diagnosis of infective endocarditis, antimicrobial therapy for endocarditis in adults, guidelines to prevent endocarditis, and recommendations and regimens for endocarditis prophylaxis. This chapter contains 99 references.

Revascularization for Iliac-femoral Artery Pseudoaneurysm with Greater Saphenous Vein

To investigate the role of revascularization procedures with autologous greater saphenous vein in surgical management of iliac-femoral artery pseudoaneurysm in parenteral drug abusers. Twenty-one patients with iliac-femoral artery pseudoaneurysm caused by parenteral drug abuse from 2004 to 2007 were enrolled. Among them, 15 patients were male and 6 were female; their average age was 31.3 years. The size of pseudoaneurysms ranged from 3.0 cm to 7.5 cm. Common femoral artery and distal external iliac artery were often involved. We performed arterial reconstruction on these patients with autologous greater saphenous vein as a graft after excising iliac-femoral artery pseudoaneurysm through a single curved inguinal incision. All patients were followed up, and the complications were recorded. The surgical procedures were finished without intraoperative mortality or perioperative complications. All patients were free of claudication symptoms after the surgery except one case with preoperative popliteal artery stenosis. One case of infection and wound tissue fistula was found later. One case had inguinal incisional hematoma and another complained of numbness in thigh skin. The use of autologous greater saphenous venous grafts for arterial reconstruction after pseudoaneurysm excision in drug abusers is safe and effective. This technique offers more advantages than arterial ligation alone without revascularization. An optimal greater saphenous venous graft is a prerequisite for revascularization.

Successful treatment of a giant isolated cerebral mucormycotic (zygomycotic) abscess using endoscopic debridement: case report and therapeutic considerations

Background Cerebral mucormycosis without rhino-orbital or systemic involvement is an extremely rare condition mostly associated with parenteral drug abuse. Case description We report the case of a 42-year-old woman who presented with hemiparesis of the left side and altered mental status. Neuroradiologic workup demonstrated an inflammatory lesion involving the right basal ganglia. Proton magnetic resonance spectroscopy demonstrated features consistent with a pyogenic abscess. Computed tomography–guided stereotactic biopsy led to the diagnosis of cerebral mucormycosis. Parenteral AMB-L treatment was conducted, but the patient worsened clinically, presenting with a complete hemiplegia, and cerebral magnetic resonance imaging (MRI) scans demonstrated a voluminous abscess formation. Then, under stereotactic guidance, a surgical endoscopic debridement of the abscess cavity associated with the placement of an Ommaya reservoir was performed. Systemic and intralesional treatment with AmB associated with an adjunctive immune therapy was conducted. At 3-year follow-up, the patient had recovered partially from her left hemiplegia, allowing her to walk without help, and cerebral MRI scans showed complete resorption of the abscess. Conclusion Our good results suggest that surgical endoscopic debridement associated with intravenous and intracavitary antifungal therapy might be valuable in treating voluminous deep-seated mucormycotic lesions.

Infected femoral artery pseudoaneurysm in drug addicts: The beneficial use of the internal iliac artery for arterial reconstruction

Infected femoral artery pseudoaneurysm (IFAP) is a severe complication in parenteral drug abusers, with difficult and controversial management. Ligation alone without revascularization is frequently associated with later intermittent claudication and limb amputation. Furthermore, arterial reconstruction with a synthetic or venous conduit is limited because of a contaminated field and, often, unavailability of autologous venous grafts. In this study, we present our experience with the internal iliac artery (IIA) as a graft for arterial reconstruction after IFAP excision in these patients. Data of 14 consecutive patients who presented with IFAP secondary to parenteral drug abuse from 2001 to 2005 were analyzed. Twelve patients (85.7%) were male. The median age was 27 years (range, 19-42 years). In 13 cases, the IFAP involved the common femoral artery, and in 1 case it involved the profunda femoris artery (PFA). In nine patients, we used the IIA for arterial reconstruction (five as a patch and four as an interposition graft), whereas in two patients the arterial deficit was repaired with a great saphenous vein patch. In two cases, an extra-anatomic bypass with a synthetic polytetrafluoroethylene graft was performed. In one patient, the pseudoaneurysm involved the PFA and was treated with excision and ligation of the PFA. All nine patients who underwent revascularization with the use of IIA were free of claudication symptoms. None of them experienced any perioperative complications, had signs of reinfection, or required limb amputation during the follow-up period (median, 19 months; range, 4-52 months). Regarding the remaining five patients, one died 25 days after surgery because of multiorgan failure, and one underwent reoperation because of proximal anastomotic rupture of a synthetic graft. The latter patient finally underwent a transmetatarsal amputation. The use of IIA for arterial reconstruction after IFAP excision in drug abusers is safe and effective. These preliminary results indicate that the implementation of this technique offers many advantages compared with traditional treatment options.

Infected femoral pseudoaneurysms from intravenous drug abuse in young adults

Intravenous or parenteral drug abuse is the most common cause of infected femoral artery pseudoaneurysms (IFAP). This complication of intravenous drug abuse is not only limb threatening but can also be life threatening. The management of IFAP is difficult and controversial. Generally speaking, ligation and excision of the pseudoaneurysm without revascularization is accepted procedure in the majority of patients, with acceptable morbidity and low rate of limb loss. However, it is not an appropriate procedure for cases of acute interruption of the femoral artery flow, where a high probability of amputation is expected. We present four cases of young patients (average 19.5 years, range 17-24) with IFAP, where primary reconstruction was performed due to the absence of a Doppler signal over the pedal arteries after ligation of the common femoral artery. In two cases complications in the form of hemorrhage and repeated infection developed in the late postoperative period; in one case excision and ligation was performed, and in the last case reconstruction with a silver-impregnated dacron prosthesis. None of the patients required an amputation. Overall prognosis is uncertain because of the high incidence of postoperative drug injection despite aggressive drug rehabilitation.