Pseudoaneurysm of the posterior tibial artery as an early complication after Fogarty catheter thrombectomy

Catheter-based therapy for traumatic pseudoaneurysm of the anterior tibial artery

Tibial artery pseudoaneurysms often result from penetrating or blunt trauma to the lower extremities, or after orthopedic and endovascular interventions. Clinically, these lesions manifest as an expanding pulsatile mass of the affected area accompanied with pain and erythema. Despite the rare occurrence, traumatic tibial pseudoaneurysms can be associated with significant morbidity including local discomfort, rupture, and lower limb ischemia. Duplex ultrasound is considered the gold standard for diagnosis. Treatment options include surgical repair, ultrasound-guided compression or thrombin injection, and endovascular repair. In this report, we describe a 42-year-old male who presented to our center with pulsatile swelling over the mid-lateral aspect of the left leg. The diagnosis of a large anterior tibial artery pseudoaneurysm was made on clinical basis and was confirmed with computed tomography angiography. The lesion was treated endovascularly with a covered stent graft. In conclusion, this case highlights the role of endovascular therapy as a surgery-sparing and minimally invasive approach in managing traumatic peripheral arterial pseudoaneurysms with excellent clinical outcomes.

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.

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.

Transverse rupture of ring-supported Dacron graft 10 years after axillobifemoral artery bypass: induced by graft deterioration and Fogarty thrombectomy

A 70-year-old woman underwent an axillobifemoral artery bypass using a bifurcated ring-supported Dacron graft in 2004 and then noticed a pulsatile mass in the left flank 10 years later. A Fogarty thrombectomy was performed for acute graft occlusion. Eight months later, computed tomography revealed pseudoaneurysm formation in the graft body and surgical graft interposition was performed. The operative findings showed a transverse rupture of the graft just above the bifurcation. Histological findings revealed graft deterioration with filaments broken off from the graft. Although the cause of pseudoaneurysm formation was not apparent, the combination of graft deterioration and additional damage from the Fogarty thrombectomy was highly suspicious.

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.

Iatrogenic peroneal artery pseudoaneurysm treated by transluminal coil embolization

An 82-year-old male presented to our institution with sudden onset pain in the bilateral lower extremities. Emergent angiography showed thrombus in the right common femoral and left popliteal arteries. Thromboembolectomy was performed using a Fogarty-balloon catheter through the bilateral femoral arteriotomy. A few hours later, he complained of pain in the left calf. Emergent angiography showed a 3.6 × 2.4 cm pseudoaneurysm at the peroneal artery (PA). Coil embolization to the pseudoaneurysm of PA was performed with 8 coils. It is considered that use of the Fogarty-balloon catheter without angiographic guidance caused the pseudoaneurysm for this case. Endovascular coil embolization for a PA pseudoaneurysm is safer, less invasive and more effective.

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.

Mid-term follow-up after percutaneous hydrodynamic thrombectomy in lower limb ischemia: initial experience with two-dimensional MR imaging and three-dimensional MR angiography

PURPOSE

To assess noninvasively mid-term patency, reocclusion, and mid-term changes of the arterial wall after percutaneous hydrodynamic thrombectomy in patients with acute lower limb ischemia using magnetic resonance (MR) imaging/MR angiography (MRA).

MATERIALS AND METHODS

Arterial wall and luminal changes were evaluated in 16 patients (10 men, six women; mean age, 70 years), with a minimum follow-up of 12 months after percutaneous thrombectomy with a hydrodynamic catheter for acute lower limb ischemia (embolic, n = 5; thrombotic, n = 11). Adjunctive PTA was performed in 44%. The mean follow-up was 23 months +/- 7.6 (range, 12-33 months). MR imaging and MRA were performed on a 1.0 T system using an extremity coil and two-dimensional (2D) time-of-flight, turbo spin echo, 2D gradient echo, and contrast enhanced three-dimensional (3D) gradient echo sequences.

RESULTS

In one patient, a complete reocclusion was noted and, in two patients, a hemodynamically insignificant restenosis (< or = 50%) was identified with MR imaging. This was in accordance with color flow duplex sonography, physical examination, ankle/brachial index measurements, and the treadmill test. The MR morphometry documented an increase of the entire vessel area from 48.9 mm2 +/- 3.3 (control segments) to 55.5 mm2 +/- 2.8 at the treated segments (+13.3%; P < .05). The vessel wall area increased from 31.7 mm2 +/- 1.8 to 39.4 mm2 +/- 2.3 (+24.4%; P < .05). The mean area stenosis grade was 12%.

CONCLUSION

MR imaging with use of morphometric analysis is a possible tool to noninvasively determine the mid-term patency and restenosis/reocclusion and remodeling process after percutaneous thrombectomy and other interventional procedures.

True infrapopliteal artery aneurysms: report of two cases and literature review

Aneurysms of the infrapopliteal arteries are rare and commonly associated with trauma. Most appear as false aneurysms. Because they are quite rare events, we describe for the first time in the English-language literature two cases of a combination of true aneurysms of the popliteal and tibial arteries. Symptoms at initial examination are calf mass and distal ischemia. Clinical features, radiographic findings, surgical management, and a review of the literature on true infrapopliteal aneurysms are discussed.