An anterior tibial artery aneurysm in a patient with neurofibromatosis

Stent graft placement in anterior tibial artery pseudoaneurysm in a patient with type I neurofibromatosis: A case report

RATIONALE

Vascular involvement manifests as aneurysms, stenosis, and arteriovenous malformations in patients with type I neurofibromatosis (NF-I). Aneurysms are rare; however, the renal artery is the most common site. Herein, we report a rare case of stent graft placement in an anterior tibial artery (ATA) pseudoaneurysm in a patient with NF-I.

PATIENT CONCERNS

A 52-year-old woman with NF-1 was admitted to the emergency room with painful swelling in the left lower leg. At presentation, the patient's blood pressure was 100/60 mmHg and the hemoglobin level was 9 g/dL.

DIAGNOSES

Computed tomography scan revealed a small aneurysm arising from the left ATA and an adjacent large hematoma.

INTERVENTION

Stent graft placement was performed to treat ATA pseudoaneurysm.

OUTCOMES

After stent graft placement, the aneurysm disappeared and the distal flow was patent through the ATA.

LESSONS

Stent graft placement should be considered as another option for endovascular treatment in patients in whom coil embolization or surgery cannot be performed.

Potential Fatal Complication of Neurofibromatosis Type 1: Acute Upper Airway Obstruction Due to Ruptured Transverse Cervical Artery Aneurysm

Neurofibromatosis type 1 (NF1) can cause vascular complications even in undiagnosed NF1 patients. A ruptured aneurysm of the branches of the subclavian artery is a rare but life-threatening event, and the hemorrhage can cause upper airway obstruction. We present a case of NF1 patient with a ruptured transverse cervical artery aneurysm, which led to a nearly obstructed airway. A 52-year-old man who was not previously diagnosed with NF1 presented with sudden pain from the left shoulder to the neck. Since childhood, he has had multiple cutaneous neurofibromas and café-au-lait macules, and freckling in the bilateral axillae. His swollen left side of the neck and left shoulder suggested a hematoma, which compressed the upper airway. Contrast-enhanced computed tomography revealed a cervical hematoma caused by a ruptured aneurysm of the transverse cervical artery. We performed awake fiberoptic intubation because a difficult airway was predicted and surgical airway management may have been impossible due to the anterior cervical hematoma. His airway was secured, and his aneurysm was successfully treated by coil embolization. Based on his cutaneous findings, he was finally diagnosed with NF1. Those who have café-au-lait macules and cutaneous neurofibromas may present with acute cervical hematoma, and it is important to consider the possibility of ruptured aneurysms in the neck region. When patients develop an acute cervical hematoma that causes an acute upper airway obstruction, emergency physicians should consider awake fiberoptic intubation to secure the airway.

Ruptured tibial artery in neurofibromatosis type 1: A case report

Introduction

Neurofibromatosis type 1 (NF-1) or von Recklinghausen's disease, an autosomal dominant genetic disorder, is characterized by a café au lait spot and cutaneous neurofibromas. It typically involves the skin, nerves, bones, muscles, and eyes, and occasionally involves vascular complications and can lead to life-threatening hemorrhage.

Case presentation

We present the case of a 77-year-old female with a posterior tibial artery rupture with NF-1. She presented with sudden right lower leg swelling, pain, paresthesia, and paralysis; computed tomography images revealed popliteal artery aneurysm with surrounding hematoma, expanding from the posterior aspect of the knee to the calf. Diagnosed with compartment syndrome, due to a ruptured right popliteal artery aneurysm, she underwent prosthetic replacement of the popliteal aneurysm. Intraoperatively, the fragility of the popliteal artery was noted, although no perforation site was recognized despite the aneurysm; active bleeding originated from the hematoma between the calf muscles. Intraoperative digital subtraction angiography revealed an extravasation at the branch of the posterior tibial artery that was managed by coil embolization of the posterior tibial artery.

Clinical discussion

Although the frequency of NF-1 vasculopathy is unknown, vasculopathy is the second most common cause of mortality in patients with NF-1, after malignancy. The less invasive endovascular approach might be preferable for treating NF-1-related aneurysm. The NF-related vasculopathy lesion sites are diverse, and intraoperative angiography would help confirm the diagnosis.

Conclusion

NF-1-related vasculopathy may be associated with vascular fragility, and the endovascular approach might be preferable. Endovascular-first approach could have helped in correct diagnosis in the present case.

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Vasculopathy in neurofibromatosis type1 (NF-1) occurs in any blood vessels and preoperative diagnosis is sometimes difficult

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Open surgery for NF-1 vasculopathy is sometimes difficult due to vascular fragility

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Endovascular approach is not only less invasive, but also useful for diagnosis

Urgent Endovascular Repair of an Anterior Tibial Artery Aneurysm: Case Report and Literature Review

True aneurysms of the anterior tibial artery are rare with less than 20 published reports in the literature. We report an urgent endovascular repair of a true anterior tibial artery aneurysm in a patient with Ehlers-Danlos type IV, vascular type. This approach resulted in an uneventful recovery without the elevated risks associated with open vascular repair in the setting of connective tissue disorder. Continuous follow-up in the subsequent 4 years has demonstrated durability and efficacy of the original intervention.

Ruptured Popliteal Aneurysm Resulting from Neurofibromatosis

Rupture of an aneurysm in a patient suffering from neurofibromatosis is a rare though documented complication. Presented here is the case of a 33-year-old woman with known neurofibromatosis who underwent repair of a symptomatic popliteal aneurysm. The presentation, diagnostic evaluation, and treatment are discussed, and the literature is reviewed on this rare entity.

A True Posterior Tibial Artery Aneurysm

Aneurysms of infrapopliteal arteries are rare. The etiology is usually traumatic, and most aneurysms are false. The English-language literature reports only 33 cases of infrapopliteal arterial true aneurysms, of which 8 involve the posterior tibial artery. The etiology of these lesions is unclear; a fibromuscular fibrodysplasia similar to ulnar aneurysm may be hypothesized, but traumatic, atherosclerotic, inflammatory, and other pathological processes are also probably involved. The natural history seems to be related to thrombosis and distal embolism more than to rupture. Surgical indications are debated. Aneurysm repair with a complete restoration of the blood flow through the affected artery is particularly challenging owing to the small size of the vessels, and ligation may be required. We report, to the best of our knowledge, the first case of an atherosclerotic posterior tibial artery true aneurysm successfully treated with aneurysmectomy and end-to-end direct reconstruction with a documented good long-term patency. Clinical features, imaging findings, and surgical management are described; indications and treatments (open or endovascular) are discussed.

Ruptured left external carotid artery aneurysm presenting as upper airway obstruction in von Recklinghausen's disease

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Vascular abnormalities are recognized but rare manifestations of Neurofibromatosis type 1.

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Stenoses, aneurysms and pseudoaneurysm are the most common vascular abnormalities.

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External carotid aneurysm has not been reported before in the litterature.

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The most common clinical presentation of aneurysms is their spontaneous rupture.

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Carotid aneurysm rupture can cause a life-threatening upper airway obstruction.

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Carotid aneurysm in NF-1 can be treated by surgical or endovascular approach or combination of the both.

Introduction

Neurofibromatosis type 1 (NF-1) is an autosomal dominant disorder characterized by café-au-lait macules, neurofibromas, and iris hamartomas. Carotid artery aneurysms rarely affect patients with NF-1 but may be associated with rupture. We report the first episode of a ruptured external carotid aneurysm with severe life-threatening airway obstruction in a NF-1 patient.

Presentation of case

We report a case of NF-1 32-year-old woman admitted to our department for life-threatening upper airway obstruction caused by spontaneous expanding swelling in the left sided neck. The diagnosis of ruptured aneurysm was suspected clinically and confirmed by computed tomography of the neck. The patient required tracheotomy for breathing difficulties and hemostasis was assured surgically by ligation of the external carotid artery.

Discussion

Vascular abnormalities are rare but recognized manifestation of type NF-1. They often affect medium and large sized vessels. Carotid aneurysms are asymptomatic in most patients; they are subject to sudden rupture with potentially devastating consequences. CT angiography is the gold standard for diagnosis of an aneurysmal rupture in NF-1 patients. Treatment consists on surgical ligation, resection and reconstruction or on percutaneous embolization.

Conclusion

Patients with NF-I have a wide spectrum of vascular abnormalities. Particularly, aneurysms can be life-threatening for these patients; their surgical management must be urgent in these situations.

Nontraumatic Aneurysms Affecting Crural Arteries: Case Report and Review of the Literature

Aneurysms involving the infrapopliteal arteries are rare, with most cases being attributed to a previous traumatic event. Mycotic aneurysms in this location are even more uncommon. Owing to their infrequency, these aneurysms represent a difficult diagnostic challenge. We present a case of a symptomatic anterior tibial artery aneurysm in a 59-year-old male with a medical history significant only for an episode of bacterial endocarditis, subsequently requiring an aortic valve replacement. Surgical repair was performed with a popliteal to anterior tibial bypass with a reversed saphenous vein graft. The patient's recovery was uneventful. We also reviewed the literature on this type of aneurysm to assess the incidence, etiology, options for treatment, and outcomes.

Ruptured aneurysm of the ulnar artery in a woman with neurofibromatosis

A 61-year-old woman with neurofibromatosis type 1 (Recklinghausen's disease) was referred for massive swelling of the right forearm, pain, increasing numbness, and impaired movement of the fingers. Angiography demonstrated a 13- x 11-mm aneurysm and a capped rupture of the ulnar artery. Because of the complicated soft-tissue condition, interventional treatment was indicated. Two 360 degrees coils were placed for embolization of the ruptured aneurysm. Arterial involvement in neurofibromatosis is a well known but infrequent occurrence. Stenotic lesions predominate. Aneurysmal defects are less common, and rupture of peripheral arteries is exceptional.

Lower leg compartment syndrome in neurofibromatosis 1 patient with plexiform neurofibrom: a case report of aneurysm rupture

A 37-year-old woman with neurofibromatosis type 1 was referred for a rapidly growing plexiform neurofibroma of the left lower leg, acute serious pain, and leg palsy because of concern for malignant transformation of the tumor. Contrast-enhanced computed tomography confirmed a rupture of anterior tibial artery aneurysm, resulting in both anterior and posterior compartment syndrome in her left leg. Arterial involvement in neurofibromatosis is a well known; however, rupture of peripheral arteries is exceptional. Moreover, coexistence with plexiform neurofibroma occasionally delays the diagnosis with suspicion of malignant transformation without awareness of a vascular rupture.

Anterior tibial artery aneurysm: Case report and literature review

INTRODUCTION

We present a patient with a true anterior tibial artery aneurysm without any causative history.

PRESENTATION OF CASE

A 59 year old male was referred with a swelling on his left lateral ankle which he noticed 2 months ago, with symptoms of soaring pain. Additional radiological research showed a true arterial tibialis anterior aneurysm. True anterior tibial artery aneurysm is a rare condition. The aneurysm was repaired by resection and interposition of a venous bypass.

DISCUSSION

Patients may complain about symptoms like calf pain, distal ischemia, paresthesias due to nerve compression and the presence of a pulsating or increasing mass. Symptomatic aneurysms require surgical intervention, where bypass with a venous saphenous graft have shown good patency and endovascular treatment have shown good short term results. Asymptomatic and small aneurysm can be followed for several years with DUS.

CONCLUSION

Clinical features, radiographic findings, surgical management, and a review of the literature on true anterior tibial aneurysms are discussed.

Brachial artery aneurysm rupture in a patient with neurofibromatosis: a case report

Peripheral vascular manifestations of neurofibromatosis are rare but may result in fatal haemorrhaging when they rupture. Surgeons should be aware of this life-threatening condition. We report a case of 35-year-old woman with neurofibromatosis who presented with a swollen and tender mass around her right arm. Angiography revealed 2 aneurysms in the brachial artery. Surgical occlusion revealed a large amount of clotted blood within the subfascial space, and the bleeding point was identified as a pinpoint opening in the aneurysm. The brachial artery abutting the aneurysm and the surrounding soft tissues was extremely brittle and fragile, with massive oozing during dissection. The brachial artery was irreparable and was resected after ligation of the artery and surrounding soft tissues and the aneurysm. Despite an uneventful recovery, the patient died on day 4.

Crural artery traumatic injuries: treatment with embolization

The purpose of this paper is to report our experience with the endovascular treatment of crural arterial injuries using transcatheter and direct embolization techniques. A total of eight consecutive patients have been treated during a 7-year period. Six males and two females, mean age 32 years (range, 15-56 years), presented with penetrating trauma to the lower extremities. Mechanisms of injuries were stab wounds in six patients, gun shot wound in one patient, and iatrogenic injury in one patient. Five patients presented with acute trauma, while three patients presented with delayed injuries. Crural arterial injuries encountered included pseudoaneurysms with arteriovenous fistulas (n = 6), pseudoaneurysms with vessel transections (n = 2), and pseudoaneurysm (n = 1). Proximal and distal embolization with coils was used in three cases, proximal embolization with coils in three cases, percutaneous thrombin injection in one case, and liquid n-butyl cyanoacrylate in one case. Complete exclusion of the lesions was accomplished by sacrifice of one crural vessel in seven cases and of two crural vessels in one case. Two cases of delayed injuries required combined coil and liquid embolization techniques for lesion exclusion. A minor complication (groin hematoma) occurred in one patient, no distal ischemia was seen, and no amputations were required. Mean follow-up was 61 days (range, 1-180 days). One pseudoaneurysm treated with thrombin injection recurred and required surgical excision. We conclude that transcatheter embolization alone or in combination with different endovascular techniques is useful in the treatment of traumatic crural vessel injuries.

Ruptured femoropopliteal artery aneurysms in von Recklinghausen neurofibromatosis

A 38-year-old woman with neurofibromatosis type 1 was referred for massive swelling of the left thigh, pain, and anemia. Angiography demonstrated three saccular aneurysms of the femoropopliteal artery. The largest measured 3 cm in diameter. Resection of the aneurysms and femoropopliteal interposition grafting using reversed saphenous vein was performed through a medial surgical approach. Arterial involvement in neurofibromatosis is a well known but infrequent occurrence. Stenotic lesions predominate. Aneurysmal defects are less common, and rupture of peripheral arteries is exceptional. Neurofibromatous invasion and dysplasia of the tunica media of the femoropopliteal vessel were confirmed by means of pathologic study. We think this is the second reported case of a femoropopliteal artery aneurysm and rupture associated with neurofibromatosis.

Spontaneous rupture of the hepatic artery in a patient with type 1 neurofibromatosis treated by embolization: a case report

We report the case of a 48-year-old man with neurofibromatosis presenting with sudden-onset abdominal pain, profound hypotension, and a drop in hemoglobin. CT scan demonstrated a massive hematoma within the right lobe of the liver with rupture into the peritoneal cavity. Angiography demonstrated diffuse abnormalities of the hepatic circulation with fusifom, ectatic, and stenotic segments. Acute extravasation from a peripheral branch of the right hepatic artery was identified and successfully embolized with subsequent hemodynamic stabilization of the patient. To the best of our knowledge this is the first case report of this kind in a patient with type I neurofibromatosis.

Superficial femoral vein invasion by a benign neurofibroma in a non-neurofibromatosis patient: case report

OBJECTIVE AND IMPORTANCE

Neurofibromas are benign neural sheath tumors arising from intraneural supporting cells. Such tumors are characteristic of neurofibromatosis Type I (von Recklinghausen disease) but also occur sporadically. Vascular involvement by neurofibromata is rare, but has been described in the past in the context of neurofibromatosis. There is, to our knowledge, no description of vascular involvement by a neurofibroma in a non-neurofibromatosis patient.

CLINICAL PRESENTATION

A 40-year-old woman presented with a 4 year history of a right thigh mass associated with diffuse lower extremity pain. She had no other clinical manifestations of neurofibromatosis and no known family member with neurofibromatosis Type I. Magnetic resonance imaging scans revealed a well-defined solid mass in the anteromedial aspect of the right thigh closely associated with the superficial femoral vein.

INTERVENTION

The vessel segment and encapsulated mass were resected "en bloc" after proximal and distal ligation of the vein. The pathological appearance of the mass was consistent with a benign neurofibroma that had infiltrated all layers of the vessel.

CONCLUSION

Vessel invasion by a benign sporadic neurofibroma is a rare occurrence with potentially severe implications for the patient. It suggests that surgical removal of asymptomatic benign-appearing lesions of that type should be considered if they are adjacent to important anatomical structures.

Aneurysm of the popliteal artery in neurofibromatosis

The neurofibromatoses are a heterogeneous set of genetic disorders having clinical manifestations that involve the skin, the nervous system, or both. In addition, the disease can be confounded by a broad spectrum of complications, such as various kinds of osseous lesion, vascular lesions, aqueduct stenosis, optic glioma, and learning disabilities. Neurofibromatosis results in vascular involvement in approximately 10% of cases. Stenotic lesions predominate, but aneurysms have been documented as well. Rarely noted, however, have been peripheral aneurysms. In this report, we discuss the case of a 66-year-old woman with type 1 neurofibromatosis and a popliteal artery aneurysm who was operated upon because of threatened limb ischemia. Histological findings confirmed neurofibromatous invasion of the vessel wall.

Dorsalis pedis artery true aneurysm due to atherosclerosis: Case report and literature review

We describe a dorsalis pedis artery true aneurysm due to atherosclerosis. A 61-year-old woman had a pulsatile and painful tumor on the right dorsal part of the foot, and magnetic resonance imaging revealed an aneurysm of the dorsalis pedis artery. Resection of the aneurysm was completed without complications. Pathologic analysis showed true aneurysm due to atherosclerosis. We review the literature on true aneurysm of the infrapopliteal arteries, including the dorsalis pedis artery, and discuss the clinical presentation and surgical management.