General and Vascular Surgery, Faculty of Medicine, Cairo University, 20 C 198 Street, Degla, Maadi Cairo 11435 Egypt.
Int J Surg. 2010;8(3):229-32. doi: 10.1016/j.ijsu.2010.01.006. Epub 2010 Jan 28.
Intra-arterial Injection (IAI) of illicit substances by drug abusers may result in acute ischemia, limb loss or permanent functional deficit. No prospective human studies have shown that any specific treatment is superior to another. Thoracoscopic sympathectomy (TS) has proven efficacy in upper limb ischemia due to organic blockade. This is a pilot study to evaluate the effect of thoracoscopic sympathectomy addition to the management protocol of recreational intra-arterial drug injection.
A total of 11 victims of upper limb IAI of recreational drug were recruited (10 males) with age range from 18 to 43 years old (average 30+/-8.3 years). Tissue Ischemia Score (TIS) was used for pretreatment assessment of the degree of ischemic injury and severity of pain was evaluated pre- and post-operatively using visual analog score (VAS) and compared using Student's t test. Pre-operative VAS score was 6.9+/-1.8. All enrolled patients were treated according to the following protocol; anticoagulation, calcium channel blocker, opiates for pain, and TS. Patients received the stated protocol for minimum of 72h (range 3-8 days; mean 5; average 4.7+/-1.5 days). Freedom of amputation and improvement of pain scores were the study endpoints.
No mortality, yet one case had bleeding secondary to anticoagulant and one case of post-operative pneumothorax that required chest tube drainage for 24h. No patients had wet gangrene or spreading infection. Freedom of amputation was achieved in nine patients, 81% (7 patients had normal outcome and other two had permanent neurological deficit). Two patients (18%) had tissue necrosis with dry gangrene and mummification of the affected digits with eventual amputation. Postoperative VAS pain score was 2.09+/-1.37 (p<0.05). Pain medications were suspended in 6 patients (54.5%), reduced in 4 (36%) and unchanged in 1 (9%). All patients with TIS score 2 or less had a normal outcome while those with scores 3 and 4 had a variable outcome. Using regression analysis, initial TIS was significant for outcome prediction (p=0.043) while age, arterial site, drug injected and time delay were not significant.
The addition of TS was an attempt to halt the ischemic process after IAI which permitted, in our belief, optimal symptom control with maximum tissue salvage. Because the procedure is minimally invasive, safe, and associated with a low complication rate; it worth consideration whenever IAI is encountered.
药物滥用者进行动脉内注射（IAI）可能导致急性缺血、肢体丧失或永久性功能缺损。没有前瞻性的人体研究表明任何特定的治疗方法优于另一种。胸腔镜交感神经切除术（TS）已被证明对有机阻塞引起的上肢缺血有效。这是一项前瞻性研究，旨在评估在娱乐性 IA 药物注射管理方案中加入胸腔镜交感神经切除术的效果。
共招募了 11 名上肢 IA 药物注射的娱乐性药物受害者（10 名男性），年龄在 18 至 43 岁之间（平均 30+/-8.3 岁）。组织缺血评分（TIS）用于评估缺血损伤程度，术前和术后使用视觉模拟评分（VAS）评估疼痛程度，并使用学生 t 检验进行比较。术前 VAS 评分为 6.9+/-1.8。所有入组患者均按以下方案治疗：抗凝、钙通道阻滞剂、阿片类药物止痛和 TS。患者接受了最少 72 小时的治疗（范围 3-8 天；平均 5；平均 4.7+/-1.5 天）。截肢的自由和疼痛评分的改善是本研究的终点。
无死亡病例，但 1 例因抗凝剂引起出血，1 例发生术后气胸，需引流 24 小时。无患者发生湿性坏疽或感染扩散。9 例患者（81%）成功避免截肢，7 例患者（63%）预后正常，2 例（18%）因组织坏死导致干性坏疽和受累指节干性坏疽、最终截肢。术后 VAS 疼痛评分 2.09+/-1.37（p<0.05）。6 例（54.5%）患者停用止痛药物，4 例（36%）减少剂量，1 例（9%）未改变剂量。TIS 评分 2 分或以下的患者均预后正常，而 TIS 评分 3 分和 4 分的患者预后不同。回归分析显示，初始 TIS 对预后预测有意义（p=0.043），而年龄、动脉部位、注射药物和时间延迟无意义。
IAI 后行 TS 是为了阻止缺血过程，我们相信这可以最大限度地保存组织，从而获得最佳的症状控制。由于该手术微创、安全，并发症发生率低，因此在遇到 IAI 时值得考虑。
