Outcomes of femoral artery ligation for treatment of infected femoral pseudoaneurysms due to drug injection

J Vasc Surg. 2021 Feb;73(2):635-640. doi: 10.1016/j.jvs.2020.05.074. Epub 2020 Jul 3.


Objective: Infected femoral artery pseudoaneurysms (IFAPs) are a known complication of illicit intravenous drug injection. As the opioid crisis in our country continues to worsen, we will likely see more IFAPs and algorithms for management of these patients will need to be elucidated. The aim of this study was to describe the surgical management and outcomes of patients presenting with IFAPs treated with femoral artery ligation.

Methods: This is a single-center, retrospective study of consecutive patients presenting to our institution with IFAPs associated with illicit drug injection between 2004 and 2017 and treated with primary ligation. Primary end points included major adverse limb events (MALE) and death. Baseline demographics, clinical features, and long-term outcomes were recorded.

Results: Over the study period, 60 IFAPs were managed with arterial ligation in 58 patients. Fifty-two percent of patients underwent common femoral artery ligation, 30% of patients underwent a triple ligation (ligation of the common femoral artery, profunda femoris artery, and superficial femoral artery), and 18% of patients underwent ligation of the superficial femoral artery only. The average postoperative ankle-brachial index was 0.47. None of the patients underwent revascularization at the index procedure. In our early experience, four patients (6.6%) underwent delayed revascularization with a prosthetic bypass. Two of the patients subsequently re-presented with infected bypass grafts and required the only major amputations in our series. The mean follow-up was 51.3 months and four patients were lost to follow-up. No differences were identified in MALE between patients undergoing a femoral artery ligation vs a triple ligation. Nine patients (15%) died during the follow-up period and all deaths were unrelated to IFAP treatment; the mean survival from procedure to death was 28 months.

Conclusions: We describe the largest series in the United States of IFAP related to illicit drug use treated with femoral artery ligation and found it is a safe procedure associated with low MALE. Reconstruction is not recommended and is associated with graft infection. Although the mortality rate in these patients was high, it was not related to the ligation procedure.

Keywords: Arterial ligation; Black tar heroin; IVDU; Infected femoral pseudoaneurysm; Injection drug use; Mycotic aneurysm.

MeSH terms

  • Adult
  • Amputation
  • Aneurysm, False / diagnostic imaging
  • Aneurysm, False / mortality
  • Aneurysm, False / surgery*
  • Aneurysm, Infected / diagnostic imaging
  • Aneurysm, Infected / mortality
  • Aneurysm, Infected / surgery*
  • Blood Vessel Prosthesis Implantation
  • Female
  • Femoral Artery / diagnostic imaging
  • Femoral Artery / injuries
  • Femoral Artery / surgery*
  • Humans
  • Ligation
  • Limb Salvage
  • Male
  • Middle Aged
  • Reoperation
  • Retrospective Studies
  • Risk Assessment
  • Risk Factors
  • Substance Abuse, Intravenous / complications*
  • Substance Abuse, Intravenous / mortality
  • Time Factors
  • Treatment Outcome
  • Vascular Surgical Procedures* / adverse effects
  • Vascular Surgical Procedures* / mortality
  • Vascular System Injuries / diagnostic imaging
  • Vascular System Injuries / mortality
  • Vascular System Injuries / surgery*