|Year : 2018 | Volume
| Issue : 1 | Page : 35-39
Incidence and outcomes of infected peripheral pseudoaneurysms in drug abusers
Rami Srouji, Hanaa Dakour-Aridi, Satinderjit Locham, Besma Nejim, Mahmoud B Malas
The Johns Hopkins Bayview Vascular and Endovascular Research Center, Baltimore, MD, USA
|Date of Web Publication||10-Jul-2018|
Mahmoud B Malas
Director of the Center for Research Excellence and Surgical Trials, Johns Hopkins Hospital, The Vascular and Endovascular Research Center, Johns Hopkins Bayview Medical Center, Baltimore, MD
Source of Support: None, Conflict of Interest: None
BACKGROUND: Intravenous drug abusers (IVDA) are at an increased risk of developing infected peripheral pseudoaneurysms. The aim of this study is to describe a group of IVDA patients who present with infected peripheral pseudoaneurysms and to evaluate the outcomes of vascular surgery reconstruction in this population.
MATERIALS AND METHODS: A retrospective study of all IVDA patients presenting with peripheral pseudoaneurysms between 2009 and 2015 in the premier healthcare vascular surgery database 2009–2015 were identified. Patients' demographics, comorbidities, along with the vascular procedures performed, and in-hospital complications were reported.
RESULTS: Out of 2012 vascular surgery patients known to be opioid abusers, 71 (3.5%) presented with infected peripheral pseudoaneurysms (mean age: 44.8 years, standard deviation: 15.0). The majority of these patients were Caucasians or Whites (64.8%) and underwent resection of the upper or lower limb arteries (29.7%), clipping of aneurysm (21.9%), or bypass procedures (9.4%). Two patients (3.1%) underwent primary major amputation. In-hospital mortality was observed in 1.4% of patients, hemorrhage/shock in 12.7% and cardiac arrhythmias in 7%. Four patients (5.6%) underwent secondary major amputation during the same hospitalization. Median length of hospital stay was 8 days. Around 24% of these patients were discharged to a skilled nursing facility or a rehabilitation center. The median cost of hospitalization for these patients was 21,807 (USD) with a median fixed and variable cost of 10,392 and 9356 (USD), respectively.
CONCLUSION: IVDA patients with infected pseudoaneurysms are at high risk for postoperative complications, major morbidity, extended length of stay, and nonhome discharge destination which poses a huge medical, social, and economic burden.
Keywords: Drug abuse, infected pseudoaneurysms, outcomes, vascular surgery
|How to cite this article:|
Srouji R, Dakour-Aridi H, Locham S, Nejim B, Malas MB. Incidence and outcomes of infected peripheral pseudoaneurysms in drug abusers. Vasc Invest Ther 2018;1:35-9
|How to cite this URL:|
Srouji R, Dakour-Aridi H, Locham S, Nejim B, Malas MB. Incidence and outcomes of infected peripheral pseudoaneurysms in drug abusers. Vasc Invest Ther [serial online] 2018 [cited 2022 Jan 29];1:35-9. Available from: https://www.vitonline.org/text.asp?2018/1/1/35/236293
| Introduction|| |
Drug abuse has become one of the leading causes of health deterioration in the United States. According to the National Survey on Drug Use and Health, the number of people aged 12 and older who had substance abuse disorder reached up to 20.5 million in the year 2015, where around 600,000 Americans were shown to be addicted to heroin alone. The impact of such practices and addiction on the well-being and health status of the American population is devastating. The leading cause of infected pseudoaneurysms is intravenous drug abuse (IVDA), and the rates of this vascular complication have been on the rise in the past years.
A pseudoaneurysm is considered a pulsatile hematoma which communicates with an artery due to the disruption of the arterial wall. This disruption can be caused by the unintentional periarterial and intra-arterial injection of drugs leading to vascular trauma.,, These pseudoaneurysms can then get infected through nonsterile techniques by introducing infected material into the lesions during drug use. This in return will lead to an inflammatory process which will also add insult to the integrity of the arterial wall.,
The diagnosis of infected pseudoaneurysms is clinical, which can be confirmed by Color Doppler sonography to document blood in and outflow within the pseudoaneurysm.,, In case of a high clinical suspicion of infected pseudoaneurysm and no flow documented on Duplex Doppler sonography, computed tomography angiography can be performed. Johnson et al. showed a 20-fold increase in the frequency of patients presenting with infected pseudoaneurysms which they believed is the result of increased IV drug usage. Due to the growing impact of drug abuse and its vascular complications, we designed our study to address the characteristics and comorbidities of drug abusers presenting with infected pseudoaneurysms, along with assessing the vascular procedures they underwent and the outcomes of these procedures.
| Materials and Methods|| |
The Premier Healthcare Database was used to identify vascular surgery patients with a drug abuse history and presenting with an infected pseudoaneurysms (ICD-9 code: 442.3) between 2009 and 2015. Premier is a large, U.S. hospital-based, all-payer database containing information on inpatient discharges, from more than 700 geographically diverse nonprofit, nongovernmental, community, and teaching hospitals from rural and urban areas. The Institutional Review Board approved this study and the need for patients' informed consent was waived. ICD-9 codes were used to detect dependent and nondependent drug abuse for opioids alone or in combination with other drugs (ICD-9 codes: 304.0, 304.7, 305.5, and 305.9). The Institutional Review Board approved this study and the need for patients' informed consent was waived since the data used is de-identified and is not considered human participants research under federal guidelines.
Patients' demographics, medical comorbidities as well as the surgical management of the infected pseudoaneurysms (ICD-9 codes: 0.55, 0.66 38.33, 38.38, 38.43, 38.48, 38.83, 38.88, 39.25, 39.29, 39.50–39.52, 39.56–39.58, 39.79, 39.90, 84.00–84.09, 84.10–84.19, and 84.91) were described. The primary outcome in this study was in-hospital mortality. Secondary outcomes included postoperative complications, identified using ICD-9 diagnosis codes [Table 1] as well total hospitalization costs. Guidelines are provided to hospitals by the Premier Inc. regarding what expenses to place into the variable (direct-labor and supply) and fixed (Overhead-administrative, capital, and utilities) categories of cost. Cost data are reviewed and validated against the data from the hospital at the visit and total numbers within certain variances, before use within the database. Currency data were adjusted for inflation for the year 2015 using the Consumer Price Index (CPI) inflation calculator from the United States Department of Labor.
|Table 1: International Classification of Diseases, Ninth Revision codes used to identify drug abusers and peripheral revascularization procedures|
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Descriptive analysis was performed using Stata version 14.1 (Statacorp, College Station, Texas, USA). Continuous variables were reported as means with standard deviation (SD) or medians with interquartile ranges (IQRs) whereas categorical variables were reported as frequencies and percentages.
| Results|| |
A total of 2012 vascular surgery patients who are known to be opioid abusers were identified. Out of this population, 71 (3.5%) patients presented with infected peripheral pseudoaneurysms. The mean age of this population was 44.8 years (SD = 15.0). Majority of the patients were males (76.1%), were reported to be Caucasians or White (64.8%) and single (71.4%). African-Americans constituted 5.6%, Hispanics 2.8%, and other ethnicities 26.8%. This population presented mainly from the south (31%) and West (31%), followed by northeast (19.7%), and Midwest (18.3%). The majority of these patients were covered by Medicaid (47.8%) while some had Medicare coverage (14.5%) and private insurance (8.7%). Patients had several comorbidities including chronic obstructive pulmonary disease (COPD) (23.9%), liver disease (21.1%), diabetes (19.7%), peripheral vascular disease (16.9%), renal disease (14.1%), congestive heart failure (9.9%), history of cerebrovascular ischemia (9.9%), history of myocardial infarction (4.2%), and human immunodeficiency virus (1.4%) [Table 2]. The majority of admissions were emergent (63.4%) while 8.5% were urgent and 25.4% were elective. Management of the infected pseudoaneurysms was mainly through resection of the lower or upper limb arteries (29.7%), clipping of the aneurysm (21.9%), bypass surgery (9.4%), stenting (4.7%), or blood vessel repair with tissue or synthetic patch (1.6%). Two patients (3.1%) underwent primary major amputation.
|Table 2: Baseline demographics and comorbidities of intravenous drug abusers presenting with infected pseudoaneurysms|
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In-hospital mortality rate was 1.4%. Overall, 29.6% of the patients suffered from major complications during their hospital stay. Most common in-hospital complications were hemorrhagic shock and bleeding (12.7%), cardiac arrhythmia (7%), secondary/concomitant amputations (5.6%), vascular and graft-related complications (5.6%), wound complications (5.6%), respiratory failure (4.2%), pneumonia (4.2%), acute renal failure (4.2%), acute heart failure (1.4%), pulmonary embolism (1.4%), and stroke (1.4%) [Table 3]. The median length of hospital stay was 8 days (IQR: 3–14 days). Around 53% of patients were discharged home while the rest were discharged either to a skilled nursing facility or a rehabilitation center (24.3%), transferred to a general hospital (5.7%), or home under home health service organization (10%). The median cost of hospitalization for these patients was 21,807 (USD) with a median fixed cost of 10,392 (USD) and variable cost of 9.356 (USD).
|Table 3: In-hospital complications and hospitalization costs in intravenous drug abusers presenting with infected pseudoaneurysms|
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| Discussion|| |
Drug abuse rates are highly influenced by socioeconomics, which is in return affected by race, gender and demographics. Our study has managed to describe a population of drug abusers who present with infected pseudoaneurysms. Most of these patients are males, reported to be of Caucasian or white race and single and mainly come from the South and West regions of the United States. According to Martins et al., the increase in the nonmedical use of prescription opioids was much more prominent in non-Hispanic White Americans. Cicero et al. also showed that by the year 2010, almost 90% of heroin users were of White or Caucasian race and 56% were males. The population of drug abusers presenting with infected pseudoaneurysms in our study was shown to be sicker as compared to the general population. According to the Center for Disease Control and Prevalence, in 2014, the prevalence of COPD and diabetes in the general population were 6.4%, and 11.9%, respectively. In our study cohort, the prevalence of COPD and diabetes was much higher (23.9% and 19.7%, respectively).
In drug abusers, the femoral artery is the most common site for infected pseudoaneurysms due to the fact that the groin area is easily accessible, especially when other peripheral vessels are thrombosed due to continuous injections ,,, Due to the use of ICD-9 codes in our study, the exact location of these aneurysms cannot be defined. Johnson et al. have shown that 80% of their drug abusers presenting with infected pseudoaneurysms have femoral artery involvement. Coughlin and Mavor also showed that upper limb vessels are also affected by mycotic aneurysms especially the brachial, axillary, and subclavian arteries. The hallmark for the diagnosis of infected pseudoaneurysms, according to Ting and Cheng is a painful pulsatile groin swelling (if femoral artery is involved) where only 36% of these patients will present with fever. Some of the patients can also present with signs of extremity ischemia such as absent or diminished pulses, decreased temperature or pallor. Pseudoaneurysms and abscesses can have similar clinical presentation; therefore, differentiating them is of great importance to avoid significant hemorrhage.
In our study, most patients underwent resection of the artery that was affected by the infected pseudoaneurysm. Saini et al. discussed two major approaches for the management of infected pseudoaneurysms. The first being simple ligation without vascular reconstruction and the second being early vascular reconstruction with autogenous or prosthetic grafts. Some of the patients who underwent simple ligation without vascular reconstruction may present later with chronic extremity ischemia and disabling claudication., In our study, 4.6% of patients suffered secondary amputation possibly due to extremity ischemia during their hospital stay.
Klonaris et al. analyzed the data of 14 patients between 2001 and 2005 where they highlighted a new approach in treating infected pseudoaneurysms using the internal iliac artery. This artery can be used as a tissue patch or interposition for arterial reconstruction instead of veins. The authors showed that this approach improves resistance to infection and reduces susceptibility to aneurysm or pseudoaneurysm formation. Yegane et al. and Gan et al. addressed the same topic and concluded that the most appropriate treatment for this condition would be ligation without reconstruction., The scarcity of healthy autologous veins in drug abusers makes simultaneous vascular reconstruction of the infected pseudoaneurysms very difficult. Despite immediate revascularization, the rates of amputation are comparable to those of primary ligation reaching up to 33%. In our study, patients were also at a high risk of undergoing major extremity amputations with 3.1% and 5.6% of patients undergoing primary and secondary amputations, respectively. Tan et al. have shown that when patients present with a nonviable affected limb, primary amputation becomes inevitable, especially in the presence of necrotizing fasciitis or extensive tissue necrosis.
The majority of patients included in our study presented as emergency cases (63.4%) as compared to urgent (within 14 days of symptom onset) (8.5%) and elective cases (25.4%), putting them under a higher risk for worse surgical outcome and complications. Not only do these patients present acutely, but are also reluctant to be admitted to the hospital. Moreover, they often received antibiotics before presentation which alters the signs of systemic infection required for the diagnosis of infected pseudoaneurysm. This means these patients will be harder to detect and will have much more complex delayed presentation.
According to the National Institute on Drug Abuse, healthcare expenditure due to illicit drug abuse is around 11 billion dollars per year. The majority of our patients were covered by either Medicaid or Medicare, which highlights the increased financial burden of IVDA vascular complications on the US government. The prolonged length of stay (median [IQR], 8 days) in addition to the fact that the treatment requires surgery and entails high risk of complications, make the cost of hospitalization a major concern. The median cost in our study was around $22,000, with 25% of patients paying more than $38,000. When comparing hospitalization costs between patients presenting with infected peripheral pseudoaneurysms and presenting for regular lower extremity bypass secondary to peripheral arterial disease, the former were shown to pose a greater financial burden ($22,000 vs. $13,259). Moreover, only 52.9% of patients were discharged home after their hospitalization. The rest were more likely to be discharged to a rehabilitation center, transferred to a general hospital, or home under home health service organization, which consequently adds to the overall healthcare costs of these patients.
| Conclusion|| |
The present study describes the management of infected pseudoaneurysms in a cohort of IVDA. Significant racial and demographic disparities exist in this patient population which also has more prevalent comorbidities. Since the majority of cases requires emergent and complex vascular repair, they are more likely to have poor surgical outcomes which increases the healthcare, economic, and societal burdens associated with IVDA.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]