Dorsalis pedis artery pseudoaneurysm after Lisfranc surgery

Implications of Dorsalis Pedis Artery Anatomical Variants for Dorsal Midfoot Surgery

BACKGROUND

The dorsalis pedis artery (DPA) usually branches into the arcuate artery (AA) from its lateral side which in turn crosses the bases of the lateral four metatarsals. The DPA then passes into the first interosseous space, where it divides into the first metatarsal artery and the deep plantar artery. In this study, we aimed to determine the extent of variation in the DPA and the distance between the AA and the tarsometatarsal (TMT) joint with the aim of reducing the risk of vascular complications arising from dorsal midfoot surgery.

METHODS

In 29 fresh cadaveric feet, we examined the course of the DPA and the distance between the AA and the TMT joint on computed tomography images with barium sulfate contrast.

RESULTS

The DPA was observed to have a standard course in 11 of the 29 cases (37.9%) but did not give rise to the AA and lateral tarsal artery or branches of the plantar arterial arch supplying to the second to fourth metatarsal spaces in 10 of 29 cases (34.5%). The mean closest distance from the TMT joint to the AA at the second, third, and fourth metatarsal level in the sagittal plane was 11.4, 14.6, and 17.1 mm, respectively.

CONCLUSION

We found substantial variation in the arterial anatomy of the DPA system across the dorsal midfoot.

CLINICAL RELEVANCE

The risk of pseudoaneurysm and frank arterial disruption may be mitigated if the surgeon is aware of the variations of the course of the DPA when performing dorsal midfoot surgery.

Spontaneous pseudoaneurysm of the posterior tibial artery successfully treated by open surgery: Case report and review of the literature

RATIONALE

An extremely rare spontaneous pseudoaneurysm (PSA) of the posterior tibial artery (PTA) in a middle-aged male patient was cured by open surgery effectively.

PATIENT CONCERNS

A 53-year-old man presented with the increasing swollen left shank for 1 day, with intermittent pain, pulselessness and pallor. He denied the history of trauma, infection, and other diseases.

DIAGNOSES

Physical examination, past medical history, ankle brachial index, ultrasonography, computed tomographic angiography (CTA), 3-dimensional reconstruction image of the popliteal artery and its branches and histological examination of intraluminal thrombus and clots helped us diagnose the patient as spontaneous PSA of PTA.

INTERVENTIONS

Our patient underwent excision of PSA and repair operation of PSA.

OUTCOMES

The patient recovered well at 2-year follow-up.

LESSONS

This rare case provides valuable insights for tissue repair and vascular surgery. Therapeutic methods should be in accordance with the best interest of patient. Open surgery is the effective treatment for spontaneous PSA of PTA.

Examination of the Origin and Branching Direction of the Anterior Medial Malleolar Artery From the Anterior Tibial Artery: A Cadaveric Study

BACKGROUND

This study characterized the anterior medial malleolar artery (AMMA) branching from the anterior tibial artery (ATA) to identify problems in anterior ankle arthroscopy possibly contributing to injury to the AMMA.

METHODS

Barium was injected into 12 adult cadaveric feet via the external iliac artery and the origin and branching direction of the AMMA were identified on computed tomography.

RESULTS

The AMMA originated from the level of the ankle joint and below and above the ankle joint line (AJL) in 4 (33.3%), 6 (50.0%), and 1 (8.3%) specimen, respectively. Mean distance from the AJL to the branching point of the AMMA on the sagittal plane was 2.5 mm distal to the AJL. Mean angle between the distal longitudinal axis of the ATA and AMMA was 83.2°.

CONCLUSIONS

This study established the origin and branching of the AMMA from the ATA. The AMMA should be examined carefully during ankle arthroscopy.

LEVELS OF EVIDENCE

Level IV: Cadaveric study.

Pseudoaneurysm of the Perforating Peroneal Artery following Ankle Arthroscopy

The use of standard anterolateral and anteromedial portals in ankle arthroscopy results in reduced risk of vascular complications. Anatomical variations of the arterial network of the foot and ankle might render the vessels more susceptible to injury during procedures involving the anterior ankle joint. The literature, to our knowledge, reports only one case of a pseudoaneurysm involving the peroneal artery after ankle arthroscopy. Here, we report the unusual case of a 48-year-old man in general good health with the absence of the anterior tibial artery and posterior tibial artery. The patient presented with a pseudoaneurysm of the perforating peroneal artery following ankle arthroscopy for traumatic osteoarthritis associated with nonunion of the medial malleolus. The perforating peroneal artery injury was repaired by performing end-to-end anastomosis. The perforating peroneal artery is at higher risk for iatrogenic injury during ankle arthroscopy in the presence of abnormal arterial variations of the foot and ankle, particularly the absence of the anterior tibial artery and posterior tibial artery. Before ankle arthroscopy, surgeons should therefore carefully observe the course of the perforating peroneal artery on enhanced 3-dimensional computed tomography, especially in patients with a history of trauma to the ankle joint.

Pseudoaneurysm following ankle arthroscopy: a systematic review of case series

BACKGROUND/OBJECTIVE

Pseudoaneurysms (PA) are rare complications following ankle arthroscopy (AA). Delay in diagnosis is reported to be frequent and could lead to serious complications. Evidence synthesis on the clinical context of such complication lacks in the literature.

METHODS

A systematic review is conducted to locate all relevant papers. In total, 23 case reports were included in the review. Data of 23 patients with a mean of 40.9 ± 10.3 years were extracted and analyzed. Outcomes included comorbidities, portals and procedure types performed during AA, PA location and size, time to diagnosis and treatment, and therapeutic modalities.

RESULTS

The results showed that d-ATA and the dorsal pedis artery (DPA) were involved in 18 and 4 cases, respectively. A single case of PA of the fibular artery was described. The mean PA size was found to be 4.2 × 3.9 × 2.1 cm. Five of the 14 patients (35.7%) with a reported detailed medical history were treated for a cardiovascular or hemostasis condition. Delay in PA diagnosis was found to be at a mean time of 50.45 ± 74.6 days. The most commonly reported surgical indications were anterior synovectomy and removal of anterior osteophytes. Ligation was the most common procedure in treating PA.

CONCLUSION

While portal placement might be a minor factor, the variability of the d-ATA and/or DPA anatomical position and its affection with foot position and distraction during AA could play a role in the arterial injury. Synovectomy and removal of anterior, particularly big-sized, osteophytes could be considered as risk factors as well. A state of hypocoagulability might affect injury healing and consequently PA formation. PA diagnosis should be raised whenever a non-resolving or pulsatile swelling over a portal incision is observed.

Ruptured Pseudoaneurysm of the Dorsalis Pedis Artery Following Ankle Arthroscopy: A Case Report

CASE

We describe the case of a pseudoaneurysm of the dorsalis pedis artery that developed following a repeat ankle arthroscopy for persistent osseous impingement. The patient underwent attempted fluid aspiration for a presumed effusion, and ultimately experienced rupture of the pseudoaneurysm with substantial blood loss, which required emergency vascular repair.

CONCLUSION

Anterior tibial artery and dorsalis pedis artery pseudoaneurysms are relatively rare, but they are well-documented complications of ankle arthroscopy; however, their clinical importance is poorly understood. To our knowledge, this is the first reported case of a ruptured pseudoaneurysm of the dorsalis pedis artery following ankle surgery, and it highlights the need for timely diagnosis.

Pseudoaneurysm of the Anterior Tibial Artery following Ankle Arthroscopy in a Soccer Player

Ankle arthroscopy carries a lower risk of vascular complications when standard anterolateral and anteromedial portals are used. However, the thickness of the fat pad at the anterior ankle affords little protection for the thin-walled anterior tibial artery, rendering it susceptible to indirect damage during procedures performed on the anterior ankle joint. To our knowledge, only 11 cases of pseudoaneurysm involving the anterior tibial artery after ankle arthroscopy have been described in the literature. Here we reported a rare case of a 19-year-old soccer player who presented with pseudoaneurysm of the anterior tibial artery following ankle arthroscopy using an ankle distraction method and underwent anastomosis for the anterior tibial artery injury. Excessive distraction of the ankle puts the neurovascular structures at greater risk for iatrogenic injury of the anterior tibial artery during ankle arthroscopy. Surgeons should look carefully for postoperative ankle swelling and pain after ankle arthroscopy.

A cadaveric study showing the anatomical variations in the branches of the dorsalis pedis artery at the level of the ankle joint and its clinical implication in ankle arthroscopy

Introduction Pseudoaneurysm formation following ankle arthroscopy is a rare but potentially catastrophic complication. The placement of anterior ankle portals carries inherent risk to the superficial and deep peroneal nerves, as well as to the dorsalis pedis artery. Anatomical variations in the dorsalis pedis and the presence of branches at the joint line may increase the risk of vascular injury and pseudoaneurysm formation during arthroscopy. There is limited anatomical evidence available regarding the branches of the dorsalis pedis artery, which occur at the point at which they cross the ankle joint. Objectives The objective of the study was to describe the frequency and direction of branches of the dorsalis pedis crossing the ankle joint. Materials and Methods Nineteen cadaveric feet were carefully dissected to explore the course of the dorsalis pedis artery, noting in particular the branching pattern at the joint line. Results Eleven of the nineteen feet had a branch of the dorsalis pedis artery that crossed the level of the ankle joint. Out of these, six were lateral, four medial and one bilateral. Eight of the eleven specimens had one branch at, or just before, the level of the joint. Two specimens had two branches and one had three branches crossing the ankle, which were all in the same direction, crossing laterally to the main trunk of the dorsalis pedis. Conclusions Our study demonstrated high rates of branching of the dorsalis pedis artery at the level of the ankle joint. The role of these branches in pseudoaneurysm formation during anterior hindfoot surgery remains unclear.

Pseudoaneurysm of the Dorsalis Pedis Artery: Case Report and Literature Review

Aneurysms and pseudoaneurysms of the dorsalis pedis artery are rare vascular entities usually caused by traumatic injury or iatrogenic intervention, producing a focal soft pulsatile tissue mass in the dorsal foot. Gradual expansion of the fibrous capsule can produce secondary physical signs through the pressure exerted on surrounding structures. We report the case of a 57-year-old male with an idiopathic pseudoaneurysm of the dorsalis pedis artery. A focused history found a low-grade blunt trauma to the dorsal foot that had occurred 2 years previously. The diagnosis of a pseudoaneurysm was confirmed by ultrasound examinations and computed tomography angiograms. The pseudoaneurysm was treated with resection, and a short reversed great saphenous vein interposition graft was placed. He recovered well after surgery and remained free of symptoms 18 months postoperatively. The literature review of this uncommon vascular pathologic entity and the diagnosis and management are discussed.

Dorsalis pedis psuedoaneurysm: A complication followed extensor tendoscopy of the ankle in a non-tuberculosis patient with tenosynovitis with rice body formation

Tenosynovitis with rice body formation is very rare in the ankle region. A case of this condition in a non-tuberculosis patient was presented. He was treated by extensor tendoscopy of the ankle. The tenosynovitis subsided after the procedure. However, it was complicated by formation of a dorsalis pedis pseudoaneurysm.

Endovascular Treatment of a Dorsalis Pedis Artery Pseudoaneurysm

Pseudoaneurysm of the dorsalis pedis artery (DPA) is an extremely rare entity that most commonly occurs secondary to trauma or surgery. All reported cases describe surgical treatment. We illustrate a case of enlarging DPA pseudoaneurysm causing pain and disability in a 49-year-old woman who was treated with transcatheter embolization and pseudoaneurysm aspiration resulting in near-immediate resolution of symptoms.

Pseudoaneurysm of the Perforating Peroneal Artery After Ankle Fracture Fixation: Case Report and Review of the Literature

Pseudoaneurysm formation around the ankle area is a very rare complication of an anatomic region that is highly exposed to trauma. A review of the published medical data revealed the rarity of the condition. Pseudoaneurysms of the perforating branch of the peroneal artery account for only 8 in the published data, with 6 (75%) cases related to sprain injury and only 2 (25%) to fracture fixation. We present a pseudoaneurysm of the perforating peroneal artery after a bimalleolar ankle fracture in a patient taking warfarin and a review of the published data. Our patient was treated successfully with thrombin embolization, and at 6 weeks after embolization, she remained completely free of symptoms.

Pseudoaneurysms around the foot and ankle: case report and literature review

Pseudoaneurysms developing around the foot and ankle are known to be an uncommon complication following surgery. We present a case of a pseudoaneurysm following ankle surgery for a tibial plafond fracture and comprehensively review the literature with emphasis on their anatomic location, aetiology and treatment options.