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

Abstract

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. Embase, MEDLINE, and Scopus from inception to 10 March 2024. 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. Fifty-six observational studies were included, with 1 783 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 rates (0.86%, 95% CI 0.35 - 2.09% vs. 1.45%, 95% CI 0.64 - 3.27%, p = .42; GRADE, very low) did not differ statistically significantly between groups. Claudication incidence 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). 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 of immediate arterial reconstruction for potential functional gain.