Management and Outcomes of Infected Arterial Pseudoaneurysms Secondary to Groin Injecting Drug Use: A Systematic Review and Meta-analysis.

Abstract

Objective: Infected arterial pseudoaneurysms secondary to groin injecting drug use are challenging, and surgical strategies are controversial. This review evaluated existing evidence on their management and outcomes.

Data sources: Embase, MEDLINE, and Scopus from inception to 10 March 2024.

Review methods: Systematic review and meta-analysis. Study quality assessment involved the Joanna Briggs Institute critical appraisal tool and Grading of Recommendations Assessment, Development, and Evaluation (GRADE). Outcomes, stratified by ligation and debridement alone and immediate arterial reconstruction (at the initial intervention), were pooled and analysed using random effects models.

Results: Fifty six observational studies were included, with 1783 ligation and debridement alone and 414 immediate arterial reconstructions (open and endovascular) undertaken. The major limb amputation rate was 4.36% (95% confidence interval [CI] 2.56 - 7.34%) following ligation and debridement alone and 3.53% (95% CI 1.59 - 7.66%) for immediate arterial reconstruction, with no statistically significant difference between strategies (p=.59; GRADE, very low). Ligation and debridement alone resulted in lower re-intervention rates (7.04%, 95% CI 4.38 - 11.13%) vs. immediate arterial reconstruction (19.85%, 95% CI 12.19 - 30.63%; p<.001; GRADE, low). Re-bleeding rates were reduced for ligation and debridement alone (0.63%, 95% CI 0.17 - 2.29%) vs. immediate arterial reconstruction (4.05%, 95% CI 1.57 - 10.04%; p<.001; GRADE, low). Chronic limb threatening ischaemia (0.29%, 95% CI 0.05 - 1.85% vs. 0.04%, 95% CI 0 - 0.79%, p=.65; GRADE, very low) and 30 day mortality (0.86%, 95% CI 0.35 - 2.09% vs. 1.45%, 95% CI 0.64 - 3.27%, p=.42; GRADE, very low) did not statistically significantly differ between groups. Claudication was higher for ligation and debridement alone (25.75%, 95% CI 17.08 - 36.88% vs. 5.38%, 95% CI 2.71 - 10.39%, p<.001; GRADE, low). Subgroup analysis demonstrated fewer major limb amputations for endovascular immediate arterial reconstruction compared with ligation and debridement alone (p=.048). There was no statistically significant difference in re-intervention rates (p=.89); however, re-bleeding for endovascular immediate arterial reconstruction remained higher than ligation and debridement alone (p=.048).

Conclusion: Surgical strategies should be individualised for patients presenting with infected arterial pseudoaneurysms secondary to groin injecting drug use, with demonstrable safety of ligation and debridement alone balanced against the re-intervention risk for immediate arterial reconstruction for potential functional gain.