Infectious femoral artery pseudoaneurysm (fa-IPA) is a both common and severe complication of intravenous drug administration by repeated nonsterile groin punctures, and the treatment remains controversial. The early clinical manifestation in most cases is local swelling or palpable pulsatile lump at the affected groin area, with or without subtle pain. With these minor symptoms at the early stage, together with insufficient disease cognition and inferior socioeconomic conditions, a significant proportion of patients are not sufficiently motivated to seek medical assistance. This may explain why the unusual long interval between aneurysm formation and hospital arrival was observed in this study. The aneurysm gradually enlarges as the disease progresses, with the aggravation of local tissue infection and eventually leading to sudden sac rupture and massive hemorrhage, which often place patients under life/limb-threatening circumstances. According to our experiences, approximately 75% of cases are urgently transported to the emergency room with varied bleeding due to a ruptured aneurysm sac, and more than one-third are hemodynamically unstable at arrival. The high proportion of cases with active bleeding at admission is in accordance with that reported by Becker et al. (68%) and Xu Jian et al. (72.4). The latter also observed nearly 1/3 of cases to be faint due to hemodynamic instability. Due to massive hemorrhage and an unstable general condition, these patients are typically at high risk of death or limb loss, the management is quite challenging, and the overall prognosis remains unsatisfactory.
The optimal management of ruptured I-FAP is not yet universally accepted. However, arguments are mainly concentrated on some hot topics, including the chief surgical strategy (ligation without bypass/with bypass/in situ repair)[5,6,7], specific bypass indication (all/none/selective)[8,9], the type of graft conduit (autologous/synthetic/biological)[3,10], or the intervention methods (open surgery/endovascular/hybrid technology)[4,11,12]. However, there are few discussions on surgical operation timing. Emergent or urgent surgical intervention is generally claimed in almost all vascular centers in treating ruptured I-FAP with the primary objective of reliable hemostasis and life savings[3,4]. We also admit that kind of strategy is both reasonable and practical under most circumstances, as surgical intervention remains the first choice of bleeding due to any large artery rupture.
Therefore, the most important question is as follows: Do we need any discussion on operation timing, if urgent surgery, as the only choice in such a critical situation, is universally believed and practiced? Does it make any sense?
We believe it is still of some significance to discuss the feasibility of a delayed, nonemergent surgical intervention and the possibility of rendering a practical alternative. We based this argument on two main considerations. The first is that discreetly delayed surgical interference timing is not necessarily impractical, as we thought, and it might be safe enough if well conducted. The second is an ideal emergent operation modality that is not universally practical in every area or every time in the real world.
On Medical quality and security
We believe all urgent operations are by principle the last resort, in circumstance of compelling emergency without other effectual alternatives. Due to the lack of more comprehensive preoperative preparation and evaluation, urgent operations are basically inferior in every aspect compared to selective operations. The long-term chaotic lifestyle makes drug abusers commonly present with impaired immune function, lower nutritive conditions, chronic organ dysfunction, and infection of the groin area. Sudden rupture and massive hemorrhage always bring about severe hemodynamic instability and internal environmental disorders. Performing a complicated surgical procedure under such urgent circumstances actually places patients under typically higher risk both for anesthesia and the procedure itself. According to this study and our experiences, temporarily satisfactory hemostasis could be achieved by local compression and other techniques, even for those with massive bleeding. The overall condition can be significantly improved after 24-48 h fluid resuscitation and blood transfusion, thus providing a better preoperative condition.
Moreover, with the restrictions of medical resources and conditions, a definitive operational strategy sometimes cannot be perfectly implemented in an urgent situation. All related resources might be immediately mobilized in developed medical institutions; however, in some less developed areas or in particular periods (e.g., the COVID-19 pandemic), this availability is quite questionable. When autogenous veins are not suitable and biological grafts are not available, prosthetic grafts might be the only alternative when reconstruction is considered. If even prosthetic grafts were not available, compelled sole ligation is most likely to be the only choice. The nature of an urgent operation might justify any possible procedure but at the same time means a sacrifice of better solutions. In contrast, an appropriately delayed operation timing may be better and safer, which allows more preoperative evaluation, preparation and communication.
On practical feasibility of urgent operation
An urgent operation requires medical management of all respects to be efficiently carried out in a quite short time, which imposes a great challenge and pressure on the vascular team and multidisciplinary team cooperation. This kind of cooperation can be carried out in advanced institutions with satisfactory efficiency and quality. Nevertheless, in the real world, there might be some impediments. For some areas of the world, medical financing still remains a major consideration for patients, which cannot be fully raised in the short term and subsequently affects strategy making. In some cultural backgrounds, patient consent and informed choice could not be achieved before time-consuming communication and discussion. In some areas of tension physician–patientpatient relationships, without the participation and endorsements of related family members, urgent medical interference might incur possible medical conflicts, especially when the outcome is not satisfactory. Last, for the area of medical source scarcity, preoperative examination and evaluation might also need more time to be accomplished. For example, contagious disease screening might not be finished within several hours in many centers, which may put surgeons under extra exposure risks. Under such circumstances as discussed above, a delayed operation, if feasible, may be more appropriate than an urgent hasty operation.
Another important question also worth debating is whether life-threatening hemorrhage in this situation can be safely controlled by local compression and bandages until planned operation.
All of the above discussion and claims should be based on a fundamental fact: the feasibility and safety of bleeding control via local bandages until delayed operation, which is the main aim of this research. There are several important results we observed from this study.
First, for the rupture of femoral artery pseudoaneurym and the consequent mass bleeding, unlike mostly assumed, it proved to be both feasible and reliable to achieve satisfactory hemostasis by some nonoperational measures. No preoperative death was observed in this study, and none of the cases with observed lift-threatened bleeding necessitated an urgent operation after proper local bandage compression. Although the incidence of interval bleeding (37, 43.5%) was relatively high in our observation, most of them were minor bleeding, which can be immediately discovered and easily resolved by reinforcing the compression or exerting an extra local skin suture. Especially for patients after local skin sutures, no recurrent hemorrhage has been observed.
Second, after more comprehensive preoperative preparation, the overall physical condition can be significantly improved, with the hemodynamic indicators stabilized and disturbance of the inner environment corrected, and without the results compromised. Patients remained stable in the perioperative period, and no severe complications were observed after the following operation or anesthesia. There is no direct comparison conducted between the prognosis of nonurgent operations and urgent operations due to actual clinical practice and experimental design. Nevertheless, comparable results can still be speculated on several main factors, including mortality and the incidence of severe complications, such as ischemia aggravation, postoperative bleeding, reintervention, and amputation, when compared to previous reports[3,8,13,14].
Third, preoperative local compression and skin sutures do not significantly lead to local infection aggravation or systematic infection deterioration, as they might be easily questioned. After 24-48 hours, most of the patients in this cohort still had received extra-anatomy bypass. Some patients did not have enough bypass space because of the large aneurysm sac or extensive local infection, and a sole ligation was the only choice. No case presented any presentation of deterioration of systematic inflammation, such as septic shock, or increased inflammation indicators. We assume this may be due to the low immune state of this population. The incidence of craft infection was near 40%, which is in accordance with other reports. Local compression acerbated the overall swelling of the affected limb, as observed, by extra impedance of venous drainage, which might add some inconvenience to surgical manipulation. However, this adverse effect is neither as severe to affect dissection or identification nor affects wound healing.
According to our experiences, the appropriate interval between arrival and operation should be 24-48 hours. Some patients underwent surgery more than 72 hours in this cohort for various reasons, and comparable results were obtained. However, on the one hand, 24-48 hours is generally enough to achieve satisfactory preparation in most places, and on the other hand, it might be inappropriate to further postpone due to potentially increased risks of repeated bleeding or aggravation of infection.
One of the key points is preoperative hemostatic techniques. For most cases, bandage compression is a sufficient measure to achieve temporary hemostasis. It should be addressed the bandage must cover the whole hips with abduction of both legs. Several pads of carbasus under the bandage would provide extra compression of the wound site. The patients should be asked to immobilize on bed because hip joint movement would rapidly lead to malfunction of the bandage. (shown in Fig 1.). For those who are admitted with massive hemorrhage, bedside local suturing of the skin tear is both simple and effective. It provides extra tension of the coverage tissue and helps prevent bleeding. In most circumstances, when a direct suture cannot be achieved due to tension, a suture with compression material tamping in the skin tear would reduce the tension. (shown in Fig 2.)
There are some shortages of this study. First, it is a retrospective and descriptive analysis of a single center, with limited cases and less satisfactory follow-up. Another important shortage is the lack of control. A direct results comparison between urgent operation and delayed operation cannot be acquired. However, when compared with other reports, which mostly adopted urgent operation strategies, there was no significant inferiority observed in some important indicators, including patient mortality, complication rate, and surgical treatment outcome. Reinfection of grafts remains an important problem; however, it is the same for urgent operations, and it did not bring together any severe complications, as we observed.