The femoral gateway.

Abstract: A patient who abused cocaine intravenously had an abscess in the groin, which healed to form a sinus tract leading directly to the wall of the femoral vein. She used this "gateway" as her primary means of venous access for the next 5 years. It was both "painless and brainless" and led to femoral vein thrombosis and sepsis. This is the second reported case of such a unique means of venous access.

**********

The intravenous (IV) drug abuser is a familiar and frequent visitor to hospitals, often for reasons related to trauma or overdose, but also because these abusers have a propensity for infections. In the subspecialty of infectious diseases, IV drug abusers hold a special place, almost a fond and familiar place. (1) The sharing of needles predisposes them to blood-borne diseases such as human immunodeficiency virus (HIV), hepatitis C, malaria, and syphilis. Injection through skin and into the vein predisposes them to abscesses, cellulitis, thrombosis, septic emboli, endocarditis, and even tetanus. Their addiction results in their being just as committed to the method of drug use as they are to the drug.

A frequent problem encountered by the IV drug abuser is venous access. When the antecubital vein and other superficial and accessible veins become thrombosed, patients may resort to neck veins, leg veins, and even unusual sites such as the dorsal vein of the penis. (2) We describe a patient who, by happenstance and as a result of a past infection, developed a unique means of venous access. She is the second patient with this form of access seen by one of us in the course of 15 years. (3)

Case Report

A 36-year-old white woman came to R.E. Thomason General Hospital in El Paso after sudden onset of right thigh swelling. She had injected cocaine into the right femoral vein the day before admission. The leg was painful, and she could not bear weight or bend the hip. The patient had been using both femoral veins as injection sites on and off for more than 10 years. Five years before admission, an abscess had developed over the right femoral vein, causing severe pain, fever, and chills. She did not see a physician but may have taken street antibiotics. The abscess drained and gradually resolved. When the site was completely healed, she noticed a small "dimple" (Fig. 1) directly over the femoral vein. Probing with a needle, she found this dimple led directly to the wall of the femoral vein. Injections into the femoral vein became effortless, and she could even inject while standing up in a dark toilet stall, operating purely by feel. She could be so sure that she was in the vein that she rarely bothered to pull blood back into the syringe (to "flag it" in her terms). Her "gateway" made her the envy of her fellow users.

At admission, the patient's temperature was 102[degrees]F. She had no stigmata of endocarditis, but the right thigh appeared swollen. No purulence was seen from the femoral dimple, though there was some erythema. A venous Doppler examination suggested the presence of a thrombus in the femoral vein starting at the common femoral vein and terminating just superior to the popliteal vein. Blood cultures were drawn, and she was anticoagulated and treated with 2 g IV nafcillin every 4 hours, along with 300 mg IV gentamicin every 24 hours. The patient's serum was reactive for hepatitis C but not for HIV or hepatitis B. A nutritionally deficient streptococcus along with a coagulase-negative staphylococcus was isolated from one of the two blood cultures. A transthoracic echocardiogram showed no valvular abnormalities. Treatment was changed to 4 million U of penicillin G intravenously every 4 hours. She gradually improved, her leg swelling resolved, and after 11 days in the hospital, she was discharged to oral penicillin VK and warfarin sodium (Coumadin) therapy. Appointments were made for her at a drug rehabilitation center and at the infectious diseases clinic.

Discussion

The femoral vein offers excellent access to a large vein near the surface of the skin, and the site is well concealed by clothing. Use of the femoral vein by IV drug abusers is known to result in venous thrombosis and aneurysm, (4,5) as well as suppurative thrombophlebitis. Our patient had a previous abscess that healed in such a manner as to create a sinus track leading to the vein. It provided her with access that was, as she put it, "painless and brainless." A previous article by one of us, (3) describing a series of patients with suppurative thrombophlebitis of central veins, included a description of a patient who also had a healed abscess over the right femoral vein that left him with a skin dimple leading directly to the vein. Our review of the literature did not reveal additional patients with this kind of a venous gateway. Nevertheless, it is probable that healing of an abscess to provide easy access to a vein occurs from time to time, and people who are addicted may take advantage of it. In both the patients seen with this entity, the gateway had a long period of utility, but eventually infection and thrombosis rendered it useless.

[ILLUSTRATION OMITTED]

Accepted May 28, 2002.

References

1. Verghese A. The Tennis Partner: A Doctor's Story of Friendship and Loss. New York, HarperCollins, 1998, p 74.

2. Sapira JD, Cherubin CE. Drug Abuse: A Guide for the Clinician. Amsterdam, Exerpta Medica, 1975, p 189.

3. Verghese A, Widrich WC, Arbeit RD. Central venous septic thrombophlebitis: The role of medical therapy. Medicine (Baltimore) 1985;64:394-400.

4. Mackenzie AR, Laing RB, Douglas JG, Greaves M, Smith CC. High prevalence of iliofemoral venous thrombosis with severe groin infection among injecting drug users in North East Scotland: Successful use of low molecular weight heparin with antibiotics. Postgrad Med J 2000;76:561-565.

5. Cherubin CE. The medical sequelae of narcotic addiction. Ann Intern Med 1967;67:23-33.

RELATED ARTICLE: Key Points

* Intravenous drug abusers infrequently will use the femoral vein, and such use is fraught with hazard.

* A previous needle-related skin infection left the patient with a deep dimple directly over the femoral vein, which became her favored means of injection because it was convenient and could be performed standing up and even in the dark.

* Thrombosis, infection, or both eventually result in the permanent loss of this means of access to the venous system.

Anthony A. Cauchi, BS, Viral V. Patel, BS, and Abraham Verghese, MD

From the Department of Internal Medicine, Division of Infectious Diseases, Texas Tech University Health Sciences Center at El Paso, El Paso, TX.

Reprint requests to Abraham Verghese, MD, Center for Medical Humanities and Ethics, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, Mail Code 7730, San Antonio, TX 78229-3900. Email: [e-mail]