Large iatrogenic pseudoaneurysm of the posterior tibial artery treated with sonographically guided thrombin injection

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.

Posterior Tibial Artery Aneurysm

Aneurysms of tibial vessels are extremely rare. The majority are pseudoaneurysms caused by trauma. Those that are true aneurysms have been associated with an inflammatory process or were mycotic in origin. We are reporting on a patient with a true posterior tibial artery aneurysm without any causative history. The aneurysm was repaired by resection and interposition of a reversed saphenous vein segment.

Posterior tibial artery aneurysm: a case report with review of literature

Background

Aneurysms infra-patellar region are uncommon. Of them, true aneurysms are very rare and that of posterior tibial artery are extremely rare. The more common, pseudoaneurysms are commonly associated with trauma whereas the true ones are linked with either inflammatory or mycotic origins.

Case Presentation

We reported another case of true aneurysm of posterior tibial artery without any evident aetiology. This was repaired with resection of aneurysm followed by interposition vein graft.

Conclusion

Through this report, we discussed the rarity, review of literature and management of this unusual condition.

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.

Endovascular treatment in emergency setting of acute arterial injuries after orthopedic surgery

PURPOSE

To assess the feasibility and effectiveness of emergency endovascular treatment of acute arterial injuries after orthopedic surgery.

MATERIALS AND METHODS

Fifteen patients (mean age 68.3 years) with acute arterial injuries after orthopedic surgery were observed, in particular, 5 patients with pseudoaneurysm, 9 patients with active bleeding, and 1 patient with arterial dissection. Transarterial embolization (TAE) and positioning of covered and noncovered stents were the treatments performed. Follow-up after stent implantation (mean 36 months) was performed with color Doppler US (CDU) at 1, 3, 6, and 12 months and yearly thereafter. Plain X-ray was performed to evidence dislodgment or fracture of the graft. A minimum of 12 months' follow-up is available after TAE.

RESULTS

Immediate technical success was obtained in all cases. No major complications occurred. Overall clinical success rate was 100%. During mean follow-up, stent-graft occlusions did not occurred. No recurrence and/or consequence of TAE was registered during a minimum follow-up of 12 months.

CONCLUSIONS

Percutaneous treatment is a feasible and safe tool for treating arterial injuries because it can provide fast and definitive resolution of the damage. This low-invasiveness approach can be proposed as first-line treatment in patients with acute injuries after orthopedic surgery.

The role of stent grafts in the management of traumatic tibial artery pseudoaneurysms: case report and review of the literature

Tibial artery pseudoaneurysms can occur in the setting of trauma. Operative exposure and repair of these injuries can be challenging, and surgical management options include direct arterial repair, interposition grafting, or arterial ligation. Other techniques including duplex-guided compression, thrombin injection, and endovascular intervention have been described. We present the case of a 39-year-old man who sustained blunt trauma to his right lower extremity and developed a delayed symptomatic pseudoaneurysm of the posterior tibial artery. He was successfully managed with endovascular stent graft exclusion of the pseudoaneurysm. Endovascular stent-grafting techniques can be successfully applied to the management of traumatic tibial pseudoaneurysms.

Posterior tibial artery pseudoaneurysm identified subsequent to surgical wound dehiscence

The development of a pseudoaneurysm of the posterior tibial artery is a rare event. In this article, we describe the case of a 63-year-old female with rheumatoid arthritis, who initially presented with a symptomatic subcutaneous nodule localized to the medial aspect of the right ankle. After excision of the subcutaneous nodule, she failed to heal the surgical wound and, eventually, the pseudoaneurysm of the posterior tibial artery was identified. It was not until after the posterior tibial artery was ligated and the pseudoaneurysm excised, that the wound finally healed.

LEVEL OF CLINICAL EVIDENCE

4.

Mycotic aneurysm of the posterior tibial artery -- a rare complication of bacterial endocarditis: a case report

Introduction

Distal arterial embolisation and subsequent aneurysm formation are rare occurrences and most are secondary to trauma. We have found no case reports that describe posterior tibial aneurysm formation secondary to bacterial endocarditis.

Case presentation

We report the case of a 47-year-old Caucasian man who, 2 years after an episode of subacute bacterial endocarditis, presented with signs and symptoms consistent with posterior tibial aneurysm formation.

Conclusion

Posterior tibial aneurysm formation is a rare occurrence, most commonly occurring after trauma and, although other causes have been described, to our knowledge, endocarditis has not been implicated before, and as such should therefore be borne in mind when dealing with cases where no obvious aetiology is evident.

Distal posterior tibial artery pseudoaneurysm after fracture calcaneous

Here we report a case of pseudoaneurysm of distal posterior tibial artery following closed fracture of calcaneous. Association of pseudoaneurysm of posterior tibial artery with fracture of calcaneous is extremely uncommon. It is always suggested that pseudoaneurysm be treated by reconstruction, but here we present the case treated by ligation, obliteration and excision as it was situated distally and the plantar arch circulation was maintained. The purpose of this case report is to bring attention to this complication of vascular trauma, which may cause delayed symptoms long time after the injury as well as the rare incidence of posterior tibial artery involvement with fracture calcaneous.

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.

RA, Diniz CAM, Perozin IS, Gonçalves JP, Diniz JAM. Pseudo-aneurisma de artéria tibial posterior pós-tratamento de fratura de perna com fixador externo: relato de caso e revisão da literatura

Este trabalho descreve um caso de pseudo-aneurisma da artéria tibial posterior devido ao uso de fixador externo para tratamento de fratura dos ossos da perna (técnica de Ilizarov), bem como as técnicas utilizadas para seu tratamento. A compressão guiada por ultra-som e a injeção de trombina guiada por ultra-som foram realizadas, sem sucesso. O tratamento definitivo do pseudo-aneurisma e reconstrução arterial foi conseguido através do tratamento cirúrgico clássico, usando enxerto interposto de veia safena magna homóloga invertida. As indicações, vantagens e desvantagens das técnicas de tratamento não invasivo (compressão guiada por ultra-som e injeção de trombina guiada por ultra-som) e as possíveis causas de sua incapacidade na obliteração do pseudo-aneurisma são discutidas. Também foi realizada a revisão de casos de pseudo-aneurisma da artéria tibial posterior na literatura médica, encontrando-se apenas um caso semelhante, entre 24 publicados.

Popliteal artery pseudoaneurysm after a revision of total knee arthroplasty: endovascular treatment with a stent graft

Injury to the popliteal artery during total knee arthroplasty is a very rare but dangerous complication. Several mechanisms are capable of generating a direct trauma to the vessel, like posterior retractor and oscillating saw. We report a case of popliteal artery pseudoaneurysm in a 52-year-old woman that occurred during revision of total knee arthroplasty, requiring emergency repair by means of percutaneous endovascular covered stenting.

Hand and Wrist Arterial Aneurysms

Hand and wrist aneurysms are a rare pathology, but recently the number of cases is increasing because of iatrogenic injuries such as catheter placement for endovascular procedures, invasive blood pressure monitoring, and arterial blood collection. In the period between January 1992 and January 2005, seven patients were treated at our institution for hand and wrist aneurysms. Five were true aneurysms and two were false aneurysms. All patients underwent surgery: four had aneurysmectomy and ligation of the arterial stumps and three had lesion removal, with arterial break suture in two cases and reconstruction with interposition of reversed autologous vein in the other case. In all cases, we did not have any postoperative ischemic or neurological complications. Symptoms like pain, paresthesia, and disesthesia combined with the minimal morbidity associated with repair suggest that operative repair of these aneurysms should be routinely performed.