Accepted Manuscript Endovascular treatment of infected brachial pseudoaneurysm in an intravenous drug abuser: a case report Boieru Raluca, Yannick Georg, Dharmesh Ramlugun, Martin Martinot, Amelie Camin, Lucien Matysiak, Benjamin Kretz PII:
S0890-5096(15)00485-9
DOI:
10.1016/j.avsg.2015.04.061
Reference:
AVSG 2403
To appear in:
Annals of Vascular Surgery
Received Date: 17 December 2014 Revised Date:
25 March 2015
Accepted Date: 6 April 2015
Please cite this article as: Raluca B, Georg Y, Ramlugun D, Martinot M, Camin A, Matysiak L, Kretz B, Endovascular treatment of infected brachial pseudoaneurysm in an intravenous drug abuser: a case report, Annals of Vascular Surgery (2015), doi: 10.1016/j.avsg.2015.04.061. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Endovascular treatment of infected brachial pseudoaneurysm in an intravenous drug abuser: a case report Raluca Boieru1, Yannick Georg2, Dharmesh Ramlugun1, Martin Martinot3, Camin Amelie1,
RI PT
Lucien Matysiak1 and Benjamin Kretz1 1
Service de Chirurgie Vasculaire, Hôpital Pasteur, Colmar
2
Service de Chirurgie Vasculaire et de Transplantation Rénale, Nouvel Hôpital Civil,
Service des Maladies Infectieuses, Hôpital Pasteur, Colmar
M AN U
3
SC
Strasbourg
A 36-year-old male with a history of intravenous drug abuse and two surgical interventions for pseudoaneurysm in both humeral arteries (short humero-humeral bypasses with
TE D
autologous great saphenous vein at the elbow), and infected with Hepatitis C was admitted to the Emergency Room for a pulsating mass in the brachioaxillary area of the right arm. The clinical examination showed no recent acute distal ischemia, retraction of the elbow joint due
EP
to past surgery, four necrotic fingers, the thumb had already been amputated, and severely
AC C
inflamed, thick skin around the mass. The patient was hemodynamically stable, with good vital signs.
Computed Tomography Angiography showed a 3-cm pseudoaneurysm of the brachial artery. (Figure 1 and 2)
The first objective was to attempt emergency ligation of the aneurysm and revascularization of the right arm with a venous graft, as generally recommended for infected aneurysms.1
ACCEPTED MANUSCRIPT In order to check the proximal humeral artery, an axillary approach was used. It was impossible to dissect the area because of the inflammation and the poor presentation of the patient’s skin: multiple interventions in the fold of the elbow for an abscess with a poorly integrated skin graft as well as multiple puncture marks. It was thus decided to implant a
RI PT
covered stent to exclude the aneurysm. We used an infraclavicular approach so as to verify the status of the subclavian artery. After antegrade puncture of the artery, a 7F introducer was inserted. An angiogram was then performed and a 0.035 guidewire was used to cross the
SC
lesion. The distal humeral artery was subsequently catheterized. (Figure 3)
M AN U
A 6mm /120mm Fluency plus Vascular Stent Graft (C. R. Bard, Inc.) covered stent was used. It covered the leak entirely therefore excluding the pseudoaneurysm, as shown in the postoperative control angiogram. (Figure 4)
The patient was hospitalized in the Intensive Care Unit for 5 days, during which time a blood
TE D
culture became positive for Staphylococcus Aureus. The infection was treated with Ofloxacine 200mg twice a day and Rifampicine 300mg twice a day, according to the antibiogram result. The transthoracic ultrasound showed no endocarditis.
EP
After this period, the patient was transferred to the psychiatric ward for treatment of his
AC C
addictions and close surveillance by the vascular surgeon. On day 14, he was again operated on for an infected hematoma that needed debridement. At the incision the stent was visible. (figure 5) The wound was closed with only one layer, as there was almost no skin or muscle. The thrombus found in the wound was tested and was positive for Pseudomonas Aeruginosa and Staphylococcus Epidermidis. After two months of follow up, the area of the dissection looked satisfactory, there was a good distal pulse and no pulsating mass.
ACCEPTED MANUSCRIPT Six months later, the patient presented to the Emergency Room with partial exposure of the stent through the wound. An angioCT was performed and showed an asymptomatic stent thrombus. The stent was removed surgically and the axillary artery was ligated. The patient
RI PT
recovered after 5 days with no symptoms of ischemia or infection.
DISCUSSION
SC
Pseudoaneurysms after drug injection are frequently described in the literature, but as far as we know, this is the only reported case of a brachial aneurysm infected with Staphylococcus
M AN U
Aureus secondary to the intravenous injection of illegal drugs,. Several cases have been reported in the literature, but these were mostly complications of the femoral artery, treated by the gold-standard method (ligation, primary or secondary, venous or prosthetic revascularization, debridement), ultrasound-guided thrombin injection and arterial puncture
TE D
closure. 1-3 Even though the arm is the preferred injection site for most intravenous illegal drugs users, post-injection arterial complications in the brachial artery are rarely reported in
EP
the literature. 4
Around the word there are from 5 to 10 million heroin addicts, with 1 million in Europe,
AC C
among whom only 20% are treated with heroin replacement. There are 180,000 users currently living in France. Eighty-three percent of these are men with a mean age of 27 years, and 72% are unemployed. This could be considered the portrait of a typical regular heroin addict.5 The incidence of pseudoaneurysm due to the injection of drugs or substitutes is unknown. Most of these pseudoaneurysms seem to be associated with infection. The problem with managing the pseudoaneurysm in drug addicts is that there is a high degree of tissue damage in the area, because of multiple punctures, which make them very difficult to dissect. Veins are mostly unusable because of the drug injections and most of the time they
ACCEPTED MANUSCRIPT are affected by fibrosis. Due to the unsterile use of needles, drug addicts also have a permanent risk of infection. Few cases of infected aneurysms treated with stent placement have been reported, and these
RI PT
concerned the aorta, the femoral artery or the carotid artery. 6-9 We found only one article that reported the stenting of a pseudoaneurysm in the brachial artery, but the cause was extensive debridement of necrotized tissue and external lesion of the artery. 10
SC
We decided to treat this patient with a covered stent as surgical management was impossible. The best endovascular approach to the brachial artery would have been through the femoral
M AN U
artery but this would have required a long catheter, which was not available at the time. We preferred to use the subclavian approach as it allowed us to check the axillary artery, which, in the case of stent failure, could have been used for the inflow of a bypass. If we had been obliged to consider classical revascularization, a prosthetic bypass would have been necessary
TE D
as there was no suitable autologous vein. We used a covered self-expandable stent and not a balloon expandable stent because the region was too close to the elbow joint. We decided to use a long covered stent in order to encompass a large portion of the damaged artery and to
EP
prevent the eventual distal migration of the stent.
AC C
Despite the good initial results, 6 months later we found in-stent thrombosis, with no apparent underling cause. The fact that the patient presented at the emergency unit because the stent was exposed made us regret not covering the site with a free muscle flap earlier on.
Stent excision and artery ligation probably resolved the problem definitively. It is a wellknown solution for these types of pseudoaneurysm, and usually has no clinical impact, thanks to the development of collateral blood supply.
ACCEPTED MANUSCRIPT Endovascular treatment for infected pseudoaneurysm is possible, if associated with a course of appropriate antibiotics. It may be beneficial in the short term in a difficult emergent situation so as to buy time for other possible options because, as in our case, it is often just a
RI PT
temporary solution.
CONCLUSION:
SC
Pseudoaneurysms, if not treated early and appropriately, can lead to death by exsanguination or septicemia. Endovascular repair may be an alternative to open surgery for the management
M AN U
of bacterial aneurysms of the brachial artery, if classical surgery is not possible or, in emergency situations, to buy time for other possible options. Even though it is not recommended as a general treatment, it may be a good temporary alternative, as it treats the pseudoaneurysm, thus preventing it from rupture. It also enables the continuation of the
TE D
antibiotic treatment, thus saving the patients arm. However, to clearly determine whether or not stent grafting is a valid solution for infected
EP
pseudoaneurysms, both a longer follow-up and a larger group of patients treated with the
AC C
same method are needed.
1.
2.
Salimi J, Shojaeefar A and Khashayar P, Management of infected femoral pseudoaneurysms in intravenous drug abusers: a review of 57 cases. Archives of medical research 2008; 39(1): p. 120-4. Devecioglu M, Settembre N, Samia Z, et al., Treatment of arterial lesions in drug addicts. Annals of vascular surgery; 28(1): p. 184-91.
ACCEPTED MANUSCRIPT
9.
10.
RI PT
8.
SC
7.
M AN U
6.
TE D
5.
EP
4.
Peirce C, Coffey JC, O'Grady H, et al., The management of mycotic femoral pseudoaneurysms in intravenous drug abusers. Annals of vascular surgery 2009; 23(3): p. 345-9. Karimi M, Ghaheri H, Assari S, et al., Drug Injection to Sites other than Arm: A Study of Iranian Heroin Injectors. Frontiers in psychiatry; 5: p. 23. Mission Interministérielle de Lutte Contre les Drogues et les Conduites Addictives : Heroinomanie (www.drogues.gouv.fr). [cited; Available from: www.drogues.gouv.fr. Klonaris C, Katsargyris A, Matthaiou A, et al., Emergency stenting of a ruptured infected anastomotic femoral pseudoaneurysm. Cardiovascular and interventional radiology 2007; 30(6): p. 1238-41. Choi SY, Kim CK and Park CB, Successful management of a mycotic pseudoaneurysm involving an arch branch using an endovascular stent graft. The Thoracic and cardiovascular surgeon; 61(7): p. 600-2. Ergun O, Celtikci P, Canyigit M, et al., Covered stent-graft treatment of a postoperative common carotid artery pseudoaneurysm. Polish journal of radiology / Polish Medical Society of Radiology; 79: p. 333-6. Lupattelli T, Garaci FG, Basile A, et al., Emergency stent grafting after unsuccessful surgical repair of a mycotic common femoral artery pseudoaneurysm in a drug abuser. Cardiovascular and interventional radiology 2009; 32(2): p. 347-51. Kurimoto Y, Tsuchida Y, Saito J, et al., Emergency endovascular stent-grafting for infected pseudoaneurysm of brachial artery. Infection 2003; 31(3): p. 186-8.
AC C
3.
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
Figure 1 and 2 : pseudoaneurysm of the right brachial artery
Figure 3 : angiogram showing the pseudo aneurysm of the right brachial artery
AC C
EP
TE D
Figure 4: control angiogram
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
Figure 5. Exposure of the covered stent
S0890-5096(15)00485-9
DOI:
10.1016/j.avsg.2015.04.061
Reference:
AVSG 2403
To appear in:
Annals of Vascular Surgery
Received Date: 17 December 2014 Revised Date:
25 March 2015
Accepted Date: 6 April 2015
Please cite this article as: Raluca B, Georg Y, Ramlugun D, Martinot M, Camin A, Matysiak L, Kretz B, Endovascular treatment of infected brachial pseudoaneurysm in an intravenous drug abuser: a case report, Annals of Vascular Surgery (2015), doi: 10.1016/j.avsg.2015.04.061. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Endovascular treatment of infected brachial pseudoaneurysm in an intravenous drug abuser: a case report Raluca Boieru1, Yannick Georg2, Dharmesh Ramlugun1, Martin Martinot3, Camin Amelie1,
RI PT
Lucien Matysiak1 and Benjamin Kretz1 1
Service de Chirurgie Vasculaire, Hôpital Pasteur, Colmar
2
Service de Chirurgie Vasculaire et de Transplantation Rénale, Nouvel Hôpital Civil,
Service des Maladies Infectieuses, Hôpital Pasteur, Colmar
M AN U
3
SC
Strasbourg
A 36-year-old male with a history of intravenous drug abuse and two surgical interventions for pseudoaneurysm in both humeral arteries (short humero-humeral bypasses with
TE D
autologous great saphenous vein at the elbow), and infected with Hepatitis C was admitted to the Emergency Room for a pulsating mass in the brachioaxillary area of the right arm. The clinical examination showed no recent acute distal ischemia, retraction of the elbow joint due
EP
to past surgery, four necrotic fingers, the thumb had already been amputated, and severely
AC C
inflamed, thick skin around the mass. The patient was hemodynamically stable, with good vital signs.
Computed Tomography Angiography showed a 3-cm pseudoaneurysm of the brachial artery. (Figure 1 and 2)
The first objective was to attempt emergency ligation of the aneurysm and revascularization of the right arm with a venous graft, as generally recommended for infected aneurysms.1
ACCEPTED MANUSCRIPT In order to check the proximal humeral artery, an axillary approach was used. It was impossible to dissect the area because of the inflammation and the poor presentation of the patient’s skin: multiple interventions in the fold of the elbow for an abscess with a poorly integrated skin graft as well as multiple puncture marks. It was thus decided to implant a
RI PT
covered stent to exclude the aneurysm. We used an infraclavicular approach so as to verify the status of the subclavian artery. After antegrade puncture of the artery, a 7F introducer was inserted. An angiogram was then performed and a 0.035 guidewire was used to cross the
SC
lesion. The distal humeral artery was subsequently catheterized. (Figure 3)
M AN U
A 6mm /120mm Fluency plus Vascular Stent Graft (C. R. Bard, Inc.) covered stent was used. It covered the leak entirely therefore excluding the pseudoaneurysm, as shown in the postoperative control angiogram. (Figure 4)
The patient was hospitalized in the Intensive Care Unit for 5 days, during which time a blood
TE D
culture became positive for Staphylococcus Aureus. The infection was treated with Ofloxacine 200mg twice a day and Rifampicine 300mg twice a day, according to the antibiogram result. The transthoracic ultrasound showed no endocarditis.
EP
After this period, the patient was transferred to the psychiatric ward for treatment of his
AC C
addictions and close surveillance by the vascular surgeon. On day 14, he was again operated on for an infected hematoma that needed debridement. At the incision the stent was visible. (figure 5) The wound was closed with only one layer, as there was almost no skin or muscle. The thrombus found in the wound was tested and was positive for Pseudomonas Aeruginosa and Staphylococcus Epidermidis. After two months of follow up, the area of the dissection looked satisfactory, there was a good distal pulse and no pulsating mass.
ACCEPTED MANUSCRIPT Six months later, the patient presented to the Emergency Room with partial exposure of the stent through the wound. An angioCT was performed and showed an asymptomatic stent thrombus. The stent was removed surgically and the axillary artery was ligated. The patient
RI PT
recovered after 5 days with no symptoms of ischemia or infection.
DISCUSSION
SC
Pseudoaneurysms after drug injection are frequently described in the literature, but as far as we know, this is the only reported case of a brachial aneurysm infected with Staphylococcus
M AN U
Aureus secondary to the intravenous injection of illegal drugs,. Several cases have been reported in the literature, but these were mostly complications of the femoral artery, treated by the gold-standard method (ligation, primary or secondary, venous or prosthetic revascularization, debridement), ultrasound-guided thrombin injection and arterial puncture
TE D
closure. 1-3 Even though the arm is the preferred injection site for most intravenous illegal drugs users, post-injection arterial complications in the brachial artery are rarely reported in
EP
the literature. 4
Around the word there are from 5 to 10 million heroin addicts, with 1 million in Europe,
AC C
among whom only 20% are treated with heroin replacement. There are 180,000 users currently living in France. Eighty-three percent of these are men with a mean age of 27 years, and 72% are unemployed. This could be considered the portrait of a typical regular heroin addict.5 The incidence of pseudoaneurysm due to the injection of drugs or substitutes is unknown. Most of these pseudoaneurysms seem to be associated with infection. The problem with managing the pseudoaneurysm in drug addicts is that there is a high degree of tissue damage in the area, because of multiple punctures, which make them very difficult to dissect. Veins are mostly unusable because of the drug injections and most of the time they
ACCEPTED MANUSCRIPT are affected by fibrosis. Due to the unsterile use of needles, drug addicts also have a permanent risk of infection. Few cases of infected aneurysms treated with stent placement have been reported, and these
RI PT
concerned the aorta, the femoral artery or the carotid artery. 6-9 We found only one article that reported the stenting of a pseudoaneurysm in the brachial artery, but the cause was extensive debridement of necrotized tissue and external lesion of the artery. 10
SC
We decided to treat this patient with a covered stent as surgical management was impossible. The best endovascular approach to the brachial artery would have been through the femoral
M AN U
artery but this would have required a long catheter, which was not available at the time. We preferred to use the subclavian approach as it allowed us to check the axillary artery, which, in the case of stent failure, could have been used for the inflow of a bypass. If we had been obliged to consider classical revascularization, a prosthetic bypass would have been necessary
TE D
as there was no suitable autologous vein. We used a covered self-expandable stent and not a balloon expandable stent because the region was too close to the elbow joint. We decided to use a long covered stent in order to encompass a large portion of the damaged artery and to
EP
prevent the eventual distal migration of the stent.
AC C
Despite the good initial results, 6 months later we found in-stent thrombosis, with no apparent underling cause. The fact that the patient presented at the emergency unit because the stent was exposed made us regret not covering the site with a free muscle flap earlier on.
Stent excision and artery ligation probably resolved the problem definitively. It is a wellknown solution for these types of pseudoaneurysm, and usually has no clinical impact, thanks to the development of collateral blood supply.
ACCEPTED MANUSCRIPT Endovascular treatment for infected pseudoaneurysm is possible, if associated with a course of appropriate antibiotics. It may be beneficial in the short term in a difficult emergent situation so as to buy time for other possible options because, as in our case, it is often just a
RI PT
temporary solution.
CONCLUSION:
SC
Pseudoaneurysms, if not treated early and appropriately, can lead to death by exsanguination or septicemia. Endovascular repair may be an alternative to open surgery for the management
M AN U
of bacterial aneurysms of the brachial artery, if classical surgery is not possible or, in emergency situations, to buy time for other possible options. Even though it is not recommended as a general treatment, it may be a good temporary alternative, as it treats the pseudoaneurysm, thus preventing it from rupture. It also enables the continuation of the
TE D
antibiotic treatment, thus saving the patients arm. However, to clearly determine whether or not stent grafting is a valid solution for infected
EP
pseudoaneurysms, both a longer follow-up and a larger group of patients treated with the
AC C
same method are needed.
1.
2.
Salimi J, Shojaeefar A and Khashayar P, Management of infected femoral pseudoaneurysms in intravenous drug abusers: a review of 57 cases. Archives of medical research 2008; 39(1): p. 120-4. Devecioglu M, Settembre N, Samia Z, et al., Treatment of arterial lesions in drug addicts. Annals of vascular surgery; 28(1): p. 184-91.
ACCEPTED MANUSCRIPT
9.
10.
RI PT
8.
SC
7.
M AN U
6.
TE D
5.
EP
4.
Peirce C, Coffey JC, O'Grady H, et al., The management of mycotic femoral pseudoaneurysms in intravenous drug abusers. Annals of vascular surgery 2009; 23(3): p. 345-9. Karimi M, Ghaheri H, Assari S, et al., Drug Injection to Sites other than Arm: A Study of Iranian Heroin Injectors. Frontiers in psychiatry; 5: p. 23. Mission Interministérielle de Lutte Contre les Drogues et les Conduites Addictives : Heroinomanie (www.drogues.gouv.fr). [cited; Available from: www.drogues.gouv.fr. Klonaris C, Katsargyris A, Matthaiou A, et al., Emergency stenting of a ruptured infected anastomotic femoral pseudoaneurysm. Cardiovascular and interventional radiology 2007; 30(6): p. 1238-41. Choi SY, Kim CK and Park CB, Successful management of a mycotic pseudoaneurysm involving an arch branch using an endovascular stent graft. The Thoracic and cardiovascular surgeon; 61(7): p. 600-2. Ergun O, Celtikci P, Canyigit M, et al., Covered stent-graft treatment of a postoperative common carotid artery pseudoaneurysm. Polish journal of radiology / Polish Medical Society of Radiology; 79: p. 333-6. Lupattelli T, Garaci FG, Basile A, et al., Emergency stent grafting after unsuccessful surgical repair of a mycotic common femoral artery pseudoaneurysm in a drug abuser. Cardiovascular and interventional radiology 2009; 32(2): p. 347-51. Kurimoto Y, Tsuchida Y, Saito J, et al., Emergency endovascular stent-grafting for infected pseudoaneurysm of brachial artery. Infection 2003; 31(3): p. 186-8.
AC C
3.
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
Figure 1 and 2 : pseudoaneurysm of the right brachial artery
Figure 3 : angiogram showing the pseudo aneurysm of the right brachial artery
AC C
EP
TE D
Figure 4: control angiogram
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
Figure 5. Exposure of the covered stent
