Endovascular Therapy with a Covered Stent Graft for Pseudoaneurysm of the Peroneal Artery Complicating High Tibial Osteotomy—A Case Report

Delayed rupture of peroneal artery pseudoaneurysm following endovascular treatment in a patient with chronic limb-threatening ischemia: A case report

Below-the-knee (BTK) pseudoaneurysms that occur after endovascular therapy (EVT) and result in delayed rupture have rarely been reported. In this report, we present a rare case of an 86-year-old man with chronic limb-threatening ischemia who developed delayed rupture of an idiopathic pseudoaneurysm of the peroneal artery (PA) following EVT. The PA chronic total occlusion (CTO) was successfully crossed using a guidewire via an antegrade approach, however, subintimal crossing was confirmed by intravascular ultrasound. Balloon angioplasty was then performed using an appropriately sized balloon, resulting in successful recanalization of the PA CTO with minor dissection and no complications. Postoperatively, the patient's condition was stable until he suddenly complained of right calf pain 10 days after EVT. Computed tomography revealed a rupture of the PA pseudoaneurysm. Urgent angiography revealed two pseudoaneurysms, one saccular and the other spindle-shaped. The ruptured saccular aneurysm was successfully excluded through coil embolization and stent graft placement. To the best of our knowledge, this is the first reported case of delayed rupture of a BTK pseudoaneurysm following EVT. Balloon angioplasty in the subintimal space can lead to the formation of a pseudoaneurysm and its delayed rupture.

Ankle-Angle-Adjusting Fibular Osteotomy in Closed Wedge High Tibial Osteotomy

Closed-wedge high tibial osteotomy (CWHTO) may be carried out to realign the knee in patients with knee osteoarthritis who do not meet the criteria for open-wedge high tibial osteotomy or total knee arthroplasty. The procedure involves both fibular and tibial osteotomy, and care is needed to prevent peroneal nerve and vessel injury during fibular osteotomy. Notably, use of a tourniquet may mask the development of hematomas or aneurysms until after surgery. We developed a 3-step ankle-angle-adjusting (triple-A) technique to relax the muscles, allowing easy retraction of the peroneal vessels. Crucially, the procedure does not require a tourniquet, thus allowing bleeding to be detected and stopped during surgery. The process involves adjusting the ankle angle by plantar-flexion and applying varus stress to highlight the tension difference between the lateral and posterior compartments; plantar-flexion of the great toe to loosen the flexor hallucis longus muscle, thus exposing the fibular posterior aspect; and valgus stress to loosen the peroneus longus muscle. The muscles can then be retracted sufficiently to allow distal and proximal osteotomies to be performed, and any bleeding can be detected and resolved before wound closure. This technique may improve the ease and safety of fibular osteotomy in patients undergoing CWHTO.

Pseudoaneurysm of the Peroneal Artery After Ankle Arthrodesis Treated by Endovascular Coil Embolization: A Case Report

CASE

Pseudoaneurysms of the peroneal artery around the ankle joint have rarely been reported. We present the case of a 64-year-old man with a pseudoaneurysm of the anterior perforating branch of the peroneal artery associated with a screw inserted from the anterolateral distal tibia during ankle arthrodesis. Endovascular treatment with selective catheterization and coil embolization was successfully performed. The ankle joint achieved bone union without delay, and the pseudoaneurysm did not recur at the 18-month follow-up.

CONCLUSION

This is the first report describing a pseudoaneurysm of the peroneal artery after ankle arthrodesis. Successful outcomes can be achieved by endovascular treatment.

Rare Etiology of Ischemic Steal Syndrome in the Left Peroneal Artery

Ischemic steal syndrome (ISS) secondary to an arteriovenous fistula (AVF) in the lower extremity (LE) is a rare occurrence. Herein, we report a case of symptomatic ISS in an adult male due to an iatrogenic AVF in the left LE, which was surgically repaired by placing an arterial stent across the acquired AVF of the peroneal artery to the peroneal vein.

Arteriovenous Fistula of the Peroneal Artery Complicating a Retrograde Access: Successful Endovascular Treatment with Covered Stent Implantation

An 80-year-old woman developed a recurrent chronic limb-threatening ischemia of the right lower limb after a popliteal artery (PA) recanalization with retrograde puncture of the peroneal artery (PR). The angiography showed the PA restenosis and an arteriovenous fistula (AVF) at the previous peroneal retrograde access site. After the PA angioplasty, the AVF was identified through selective contrast injections in multiple projections. A coronary balloon-expandable covered stent was deployed at the AVF site with complete resolution of the AVF. The final angiography demonstrated the patency of PA and PR with complete resolution of the AVF. The patient was discharged without complications, with regression of rest pain. The foot lesion healed within 2 months.

Post-Traumatic Dorsalis Pedis Pseudo-aneurysm Caused by Crush Injury

Introduction

This is the report of an unusual case of a dorsalis pedis artery pseudo-aneurysm resulting from trauma in a 61 year old farmer.

Report

One year previously, the patient's right foot had been crushed under a tractor wheel. The patient complained of pain and pulsatile soaring swelling on his right foot which he noticed two months before presentation. Radiological examinations revealed a pseudo-aneurysm of the dorsalis pedis artery. Resection of the aneurysm was completed without complications. Pathological findings confirmed an aneurysm of traumatic rather than atherosclerotic aetiology.

Discussion

The patient remains under follow up without ischaemia. False aneurysms should be treated by surgical or endovascular intervention when they are detected.

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A case of traumatic infrapopliteal pseudo-aneurysm.

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Symptomatic and growing pseudo-aneurysms require interventional endovascular or open surgery.

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Even if neither symptomatic and/or large, DPA aneurysms have embolic and ischaemic risks.