Metachronous Bilateral Posterior Tibial Artery Aneurysms in Ehlers-Danlos Syndrome Type IV

Spontaneous bilateral superficial femoral artery pseudoaneurysms and a unilateral posterior tibial artery aneurysm in an immunocompromised patient

Key Clinical Message

The presence of multiple pseudoaneurysms in a patient should prompt investigations for the underlying etiologies including autoimmune and immunosuppressive disease processes. Treatment options include open repair and endovascular stenting.

Abstract

Pseudoaneurysms (also known as false aneurysms) are atypical dilatations or outpouchings from a vessel which are not always contained by the three layers of a normal vessel wall, namely the intima, media, and adventitia. These are distinct from a true aneurysm which has a wall comprising all three layers. The underlying etiology for both true aneurysms and pseudoaneurysm can vary. We present the rare case of bilateral superficial femoral artery pseudoaneurysms, of unknown etiology and a concurrent posterior tibial artery saccular aneurysm in a patient with Human Immunodeficiency Virus (HIV) infection and multiple comorbidities. This was managed using a combination of endovascular covered stent grafts and open surgical repair technique. The patient is doing well on follow-up a year later with no post-operative infections. A literature review of the existing reports of superficial femoral artery pseudoaneurysms and posterior tibial artery aneurysms and their management is also reported.

Case Report: Hybrid approach as a Rescue Treatment in a patient with vascular Ehlers-Danlos Syndrome

Vascular Ehlers-Danlos Syndrome (vEDS) is a rare connective tissue disorder associated with COL3A1 gene mutation encoding type III collagen. Given the possible fatal prognosis if not treated timely, it is important to suspect and diagnose as soon as possible. Despite advances in endovascular technique, access point complications remain a serious challenge in patients with vEDS. Here, we describe a 30-year-old male patient who was diagnosed with vEDS after consecutive events of bilateral iliac vessels at an interval of 3 months: (1) spontaneous dissecting aneurysm of right iliac artery and (2) arteriovenous fistula between left internal iliac artery (IIA) and left common iliac vein. This patient was treated with iliac stent-grafts and overlapping femoral interposition graft (Dacron) in the 1st operation and access artery repair with surgical dissection after coil embolization of IIA and stent-graft insertion into left common to external iliac arteries in the 2nd operation. The patient has been treated with beta-blockers and anticoagulants for the management of vEDS and postoperative deep vein thrombosis, respectively. The stent-grafts in both iliac arteries and the access sites have been well-tolerated without any adverse effects for 14 months following the 2nd operation. In conclusion, given the vascular fragility and the potential for future events, additional vascular manipulation should be avoided unless it is in a life-threatening condition. In particular, meticulous hybrid interventions can be effective treatments.

Endovascular Management of Vascular Complications in Ehlers-Danlos Syndrome Type IV

(1) Background: The vascular type of Ehlers-Danlos syndrome (vEDS) is a rare genetic connective tissue disorder caused by pathogenic variants in the COL3A1 gene that result in arterial and organ fragility and premature death. We present five cases of vEDS that highlight the diagnosis and treatment challenges encountered by clinicians with these patients. (2) Case presentations: we present the cases of five patients with vascular complications of vEDS who were successfully managed using endovascular interventions or hybrid techniques at our institution from 2005 to 2022. (3) Conclusions: These data emphasize that a multidisciplinary approach is needed for vEDS patients and that when endovascular or hybrid treatment is performed in a timely manner by a skilled team of interventional radiologists, good results can be achieved. Our report also demonstrates that the prognosis of vEDS patients has improved over the past 20 years with a new prevention program including celiprolol therapy, physical activity adaptation and limitation, and scheduled monitoring by expert clinicians.

Aneurysmectomy and Revascularization of Anterior Tibial Artery Aneurysm: Case Report

An 86-year-old man presented with a pulsatile mass in the anterior compartment of the right lower leg. He had become aware of it two months earlier. Computed tomography angiography revealed a fusiform 3.2×5 cm aneurysm of the anterior tibial artery. Mural thrombosis in the aneurysm was absent. Peripheral pulse was normal. We performed aneurysmectomy and revascularization using a saphenous vein graft. Histological findings revealed that the mass was a true aneurysm. The clinical course was good, and the graft has remained patent for six months.

Anterior tibial artery rupture treated using covered stent in a patient with vascular Ehlers-Danlos syndrome

Vascular Ehlers-Danlos syndrome (vEDS) is a rare degenerative connective tissue disease caused by a mutation of the COL3A1 gene that results in systemic vascular fragility. Arterial rupture is a potentially fatal serious complication that is the most commonly reported cause of death among patients with this disease, as ruptured vessels remain fragile even after surgical or endovascular reconstruction. Therefore, treatment for vascular complications in patients with vEDS remains controversial. Rupture or pseudoaneurysm of the infrapopliteal artery is extremely rare. We describe a 38-year-old woman with vEDS who presented with sudden widespread rupture of the anterior tibial artery. She was treated by endovascular reconstruction using covered stents. She has remained free of vascular events for two years after surgery, and the course has been uneventful. Endovascular reconstruction using covered stents might offer an alternative for relatively small ruptured arteries and avoid disturbing blood flow in the lower extremities of patients with vEDS. <Learning objective: Vascular Ehlers-Danlos syndrome (vEDS) causes systemic vascular fragility that results in arterial rupture. However, rupture of the arteries in the lower extremities is rare, and definitive treatment has not been established. Endovascular reconstruction with covered stents might offer an alternative treatment for ruptured arteries in the lower extremities of patients with vEDS.>.

A true giant aneurysm of the anterior tibial artery

Aneurysms of the anterior tibial artery are rare. We will describe a case of a woman with an asymptomatic true aneurysm of the anterior tibial artery. The patient presented with a pulsatile mass in the lateral face of the distal portion of the left leg, and both ultrasound examination and computed tomography angiography scan showed a giant aneurysm of the anterior tibial artery. We chose open treatment.

CT angiography of the upper extremity arterial system: Part 2- Clinical applications beyond trauma patients

OBJECTIVE

CT angiography using modern MDCT scanners has evolved into a highly accurate noninvasive diagnostic tool for the evaluation of patients with pathologic abnormalities of the upper extremity arterial system.

CONCLUSION

Here we focus on the use of this modality in patients with nontraumatic vascular pathologic abnormalities.

Treatment of vascular Ehlers-Danlos syndrome: a systematic review

OBJECTIVE

To provide the collected evidence from all literature reports.

BACKGROUND

Vascular Ehlers-Danlos syndrome (EDS) is a rare connective tissue disorder with serious hemorrhagic consequences. Most experience on treatment is based on case reports and small case series.

METHOD

A systematic literature review was performed. PubMed and reference lists were scrutinized.

RESULTS

A total of 231 patients were identified with no gender preponderance. Aneurysms were present in 40%, often multiple. In 33%, there was an arterial rupture without an underlying aneurysm. Carotidocavernous fistula was seen in 18%. After open surgery the mortality was 30%; after endovascular procedures, it was 24%; in a group of miscellaneous cases, it was 60%; and the overall mortality was 39%. The median age of patients at death was 31 years. The median follow-up time was 12 months (5 days-7 years), but in 20% cases, it was not reported. In only 29 of the 119 recent patients (24%) the mutation was verified with molecular genetic testing.

CONCLUSIONS

Vascular EDS is a serious disorder with high mortality, which does not seem to have been influenced by new treatment methods. Invasive methods should be used only when necessary, primarily to save the patients' life. Whenever possible, the genetic molecular defect should be identified. The results of this review may be affected by publications bias. Ideally, a prospective registry should be created.

Traumatic pseudoaneurysm of the posterior tibial artery treated by endovascular coil embolization

Pseudoaneurysms of the posterior tibial artery are rare, but a high index of suspicion should be maintained in evaluating patients who present with a painful swelling after arterial trauma. We report a case of a posterior tibial artery pseudoaneurysm in a young patient sustained from a laceration and associated profuse arterial bleeding. Because of the risk of rupture and the presence of an infection and high venous flow, an embolization of the aneurysm proximally and distally was carried out after verifying that distal collateral circulation ensured foot vascularization. Endovascular treatment of a pseudoaneurysm seems to be a safe therapeutic and noninvasive choice, particularly in young patients in whom the presence of collaterals guarantees distal vascularization and in whom the procedure can be safely performed in the presence of a superficial wound infection.