Sural artery pseudoaneurysms after knee arthroscopy: treatment with transcatheter embolization

Coil embolization of an aberrant posterior tibial artery pseudoaneurysm after total knee arthroplasty

Arterial injury is a recognized but rare complication of total knee arthroplasty. These injuries, however, can be exceptionally devastating and potentially result in limb loss. Presentation may be delayed with symptoms associated with mass effect rather than with ischemia. We describe treatment of a patient with presentation delayed 2 weeks. In addition, the patient's arterial branch pattern demonstrated aberrant anatomy with high takeoff of the posterior tibial artery. This patient was successfully treated with transcatheter coil embolization. The current treatment options and published literature are reviewed.

Transcatheter arterial embolization for postoperative arterial complications after pelvic or hip surgery

PURPOSE

We aimed to study the technical and clinical outcome of urgent transcatheter arterial embolization (TAE) for postoperative arterial complications after pelvic or hip surgery, and to accumulate additional experience about the role of embolization for these injuries.

METHODS

Patients who received TAE procedure for arterial complications after pelvic or hip surgery between September 1st, 2002 and December 1st, 2014 were screened on medical records and included in the analysis. Angiographic findings included active contrast agent extravasation, pseudoaneurysm formation, arteriovenous fistula, and other suspicious signs such as sighting of coarse margin or distortion of vessels. Embolic agents consisted of coils, gelatin sponge, and polyvinyl alcohol. Technical success was defined as complete occlusion of targeted artery through angiography, and clinical success as sustained resolution of symptoms.

RESULTS

A total of 22 patients (15 males, 19-76 years old) were enrolled. Prior to TAE, 12 patients developed hemorrhagic shock and the remaining 10 patients had hemorrhage-related pain, hematoma, or anemia. Contrast agent extravasation occurred in 12 cases, pseudoaneurysm formation in 5 cases, and other suspicious signs in 5 cases. Injury occurred in the internal iliac artery stem in 6 cases, inferior gluteal artery in 6 cases and superior gluteal artery in 6 cases. Multiple vascular lesions appeared in 5 cases. After TAE, technical success occurred in 22 patients and clinical success in 21 patients (95.5%). A 36-year-old woman died of irreversible multiple organ failure; no other severe procedure-related complications were recorded.

CONCLUSION

TAE is safe and effective for postoperative arterial complications after pelvic or hip surgery.

Endovascular Therapy of Vascular Trauma—Current Options and Review of the Literature

Objective:

To review the current use of endovascular techniques in trauma.

Summary Background Data:

Multiple studies have demonstrated that, despite current guidelines, endovascular therapies are used in instances of arterial trauma.

Methods:

The existing literature concerning arterial trauma was reviewed. Studies reviewed included case reports, single-center case series, large database studies, official industry publications and instructions for use, and society guidelines.

Results:

Endovascular therapies are used in arterial trauma in all systems. The use of thoracic endografts in blunt thoracic aortic trauma is accepted and endorsed by society guidelines. The use of endovascular therapies in other anatomic locations is largely limited to single-center studies. Advantages potentially include less morbidity due to smaller incisions as well as shorter operating room times. Many report using endovascular therapies even with hard signs of injury. Long-term results are limited by a lack of long-term follow-up but, in general, suggest that these techniques produce acceptable outcomes. The adoption of these techniques may be limited by resource and surgeon availability.

Conclusions:

The use of endovascular therapies in trauma has gained acceptance despite not yet having a place in official guidelines.

Endovascular embolisation is a successful and safe treatment for post-operative arterial complications after total hip arthroplasty and revision surgery

PURPOSE

Arterial complications are rare but clinically critical during or following total hip arthroplasty (THA) surgery. They usually require secondary interventions, either through open or endovascular approaches. In a retrospective study, we analysed indications for, as well as success and safety of, endovascular embolisation for arterial complications after THA.

METHODS

We reviewed all arterial complications that had occurred through THA surgery and been treated by endovascular embolisation. We analysed angiographic findings, endovascular treatment, location in relation to the surgical approach and success of the interventions.

RESULTS

Between 1997 and 2013 we performed 3,891 THAs at our hospital. We identified 14 patients with acute arterial complications treated by minimally invasive endovascular embolisation. Clinical findings included swelling of the ipsilateral leg, pain, prolonged wound bleeding, decreased haemoglobin and/or haemodynamic instability. Angiography revealed pseudoaneurysm in 11 patients, arteriovenous fistulas in two and extravasation of contrast media in one. Two patients showed no signs of acute bleeding. Twelve patients were treated, each with a single session of endovascular embolisation; in two additional patients, the haematoma was evacuated. No complications from the endovascular treatment were observed in this series.

CONCLUSION

Endovascular embolisation is a safe and successful minimally-invasive method to treat arterial injuries occurring through THA. Therefore, it should be considered as a first-line option of treatment for those injuries.

Pseudoaneurysm after arthroscopic procedure in the knee

The aim of this study was to review all cases of pseudoaneurysm in the literature, in predominantly arthroscopic procedures on the knee, and to report on a case of pseudoaneurysm that we treated. A bibliographic search was conducted for scientific articles published in Brazilian and foreign periodicals over the last 23 years. Forty-seven cases were found, in 40 articles. In addition to these 47 cases, there was the case that we treated, which was also included in the data. Among the operations that progressed with formation of a pseudoaneurysm, 60% were cases of meniscal injuries and 23%, anterior cruciate ligament injuries. In 46% of the cases, the artery affected with the popliteal, and in 21%, the inferomedial genicular artery. The commonest clinical symptom was pain (37%), followed by pulsating tumor (31%), edema of the calf (12%) and hemarthrosis (11%). The median time taken to make the diagnosis was 11 days, but it ranged from one day to 10 weeks after the procedure. Although rare, pseudoaneurysms are a risk that is inherent to arthroscopic surgery. All patients should be made aware of the vascular risks, even in small-scale procedures.

Sural artery injury with arteriovenous fistula: case report about a rare complication following arthroscopic medial meniscectomy

This case report presents a patient with hematoma and pain after a knee arthroscopy with partial medial meniscectomy. A lesion of the sural artery was treated by endovascular coiling. The level of evidence is IV.

Pseudoaneurysm of the sural artery: a rare complication of lower limb angioplasty

INTRODUCTION

Percutaneous transluminal angioplasty (PTA) is a common therapeutic option for the treatment of peripheral vascular disease. Pseudoaneurysm at the puncture site is a well-documented complication in patients.

CASE PRESENTATION

This case report describes a patient who presented to hospital several days following a left superficial femoral and popliteal artery PTA with lower limb pain and swelling. The working diagnosis included a deep vein thrombosis based on the Wells criteria. However, a combination of a duplex scan and computed tomography angiography confirmed a clinically rare occurrence of pseudoaneurysm of the sural artery, a branch of the popliteal artery. This was managed successfully with a thrombin injection, leading to complete resolution of the patient's symptoms.

CONCLUSION

This case highlights the importance of the technical aspects of performing a PTA. We believe that the guide-wire position was not confirmed to be completely in the popliteal artery upon inflation of the balloon.

Endovascular Repair of Popliteal Artery Pseudoaneurysm With Arteriovenous Fistula After Knee Arthroscopy

We report a case of postarthroscopic popliteal artery pseudoaneurysm (PSA) with arteriovenous fistula (AVF; PSA-AVF) in a 53-year-old woman who presented with limb edema, pain, and bruit 1 year after arthroscopic meniscectomy. She was treated percutaneously by covered stent deployment. After 6 months of follow-up, the patient was asymptomatic, with patency of the stent and occlusion of the AVF. A review of the literature was also performed to investigate the prevalence of postarthroscopic PSAs and highlight the endovascular approach of treatment. Endovascular approach with covered stent appears to be less invasive and might be an effective and feasible way of treatment of postarthroscopic popliteal PSA-AVF.

Pseudoaneurysm of the superior medial genicular artery following knee arthroscopy

We describe a case of a pseudoaneurysm of the superior medial genicular artery following arthroscopic knee surgery, which was diagnosed by means of computed tomography and arterial duplex ultrasound. The treatment consisted of surgical exploration with excision of the pseudoaneurysm, followed by ligation of the feeding artery.

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.

Embolisation for vascular injuries complicating elective orthopaedic surgery

OBJECTIVES

The study aims to present the indications and emphasise the role of embolisation for vascular injuries in orthopaedic surgery.

METHODS

Thirty-one patients with vascular injuries complicating elective orthopaedic surgery had embolisation from 2003 to 2010. N-2-butyl cyano-acrylate (NBCA) was used as embolic agent in 28 patients, gelatin sponge in three and coil embolisation in addition to NBCA or gelatin sponge in two patients. The mean follow-up period was 37 months (range, 4-96 months).

RESULTS

The most common orthopaedic operations associated with vascular injuries amenable to embolisation were hip-joint procedures; and the most common injuries were arterial tears of branch vessels or non-critical axial vessels, most commonly of the superior glutaeal artery. In all cases, angiography showed the bleeding point, and a single embolisation session effectively stopped bleeding. Embolisation-related complications were not observed.

CONCLUSIONS

Embolisation should be considered the treatment of choice for vascular injuries of branch vessels or non-critical axial vessels following elective orthopaedic surgery because of the advantages of minimally invasive therapy and the lack of complications.

Endovascular treatment of arterial injury as an uncommon complication after orthopedic surgery

PURPOSE

To evaluate selective and superselective catheter therapy of serious arterial damage associated with orthopedic surgery of the pelvis, hip joint, femur, and knee.

MATERIALS AND METHODS

Between 1989 and 2005, 16 consecutive patients with arterial damage after orthopedic surgery (seven women, nine men; mean age, 62 years; age range, 21-82 y) underwent angiographic exploration. Seven patients were in hemodynamically unstable condition. Initial orthopedic procedures were iliac crest internal fixation (n = 1); total hip prosthesis (n = 3); revision of total hip prosthesis (n = 4); revision of acetabular cup prosthesis (n = 1); gamma-nailing, nail-plate fixation, or intramedullary nailing (n = 3); and total knee prosthesis (n = 4).

RESULTS

Angiography showed pseudoaneurysms (n = 11), vascular lacerations with active extravasation (n = 3), and arteriovenous fistulas with extravasation (n = 2). After angiographic documentation of serious arterial injury, 14 patients were treated with a single or coaxial catheter technique in combination with coils alone, coils and polyvinyl alcohol particles, coils and Gelfoam pledgets, or Gelfoam pledgets; or balloon occlusion with isobutyl cyanoacrylate and coils. Two patients were treated with covered stents. In all, bleeding was effectively controlled in a single session in 16 patients, with immediate circulatory stabilization. Major complications included death, pulmonary embolism, and postprocedural hematoma.

CONCLUSION

Selective and superselective catheter therapy may be used for effective, minimally invasive management of rare but potentially life-threatening vascular complications after orthopedic surgery.

Embolization of traumatic pseudoaneurysms after total knee arthroplasty

We report on 2 cases of traumatic pseudoaneurysm after total knee arthroplasty. In one patient, a hemarthrosis and a pulsatile antecubital mass developed 1 month after arthroplasty, prompting angiography. In the second patient, evacuation of a large hemarthrosis was performed before angiography and embolization. In both patients, the pseudoaneurysm was successfully treated without the need for surgical repair, using percutaneous thrombin injection or transcatheter embolization. No recurrence of hemarthrosis was seen in either patient at up to 24 months of follow-up evaluation. These cases show the use of angiography in reconstructed joints when acute or delayed hemarthrosis occurs, and the role of embolization techniques in this setting.