Drug misuse is now a significant problem in western society; many different pharmaceuticals are administered by drug abusers as intravenous preparations. This has resulted in an increasing number of complications associated with prolonged intravascular and perivascular injection of abused substances. These complications of intravenous drug abuse may lead to limb-threatening arterial injuries that present a considerable management problem in patients who often have significant comorbidity. This article provides a comprehensive review of the vascular complications that result from drug misuse by injection. It discusses the aetiology and clinical features of these complications and highlights the limited role of both the general surgeon and specialist vascular surgeon in the management of these patients.