|Year : 2018 | Volume
| Issue : 4 | Page : 289-291
A rare case of symptomatic true aneurysm of posterior tibial artery
Department of Vascular and Endovascular Surgery, Yashoda Hospital, Hyderabad, Telangana, India
|Date of Web Publication||11-Dec-2018|
Dr. Devender Singh
Department of Vascular and Endovascular Surgery, Yashoda Hospital, Hyderabad, Telangana
Source of Support: None, Conflict of Interest: None
Aneurysms of the infrapopliteal region are uncommon. Of them, true aneurysms are very rare and that of the posterior tibial artery (PTA) are extremely rare. We present a case of a 25-year-old female presented with a pulsatile mass behind the right medial malleolus for 1-year duration. Arterial duplex and angiogram revealed a true saccular aneurysm of the PTA. The aneurysm was resected, and the PTA was reconstructed with a reverse saphenous vein graft.
Keywords: Posterior tibial artery, surgery, true aneurysm, vasculitis
|How to cite this article:|
Singh D. A rare case of symptomatic true aneurysm of posterior tibial artery. Indian J Vasc Endovasc Surg 2018;5:289-91
| Introduction|| |
An aneurysm is a permanent, localized dilatation of a blood vessel, with at least 50% increase of its expected normal diameter. Aneurysms are considered either true or false based on the involvement of blood vessel wall layers. Pseudoaneurysms are more common and usually secondary to trauma. The infrarenal aorta is the most common site of the arterial aneurysms. The incidence of infrapopliteal aneurysms is very rare., The most serious complication of the aneurysms is rupture, which could lead to high morbidity, including amputation. Other complications include thrombosis, embolism, and compression of the adjacent structures. We present an extremely rare case of a true posterior tibial artery (PTA) aneurysm, which, to the best of our knowledge, is the 13th case report in the English literature.
| Case Report|| |
A 25-year-old female presented with a history of a painful pulsatile mass in the medial aspect of the right leg for 1 year. In the past 4 months, it increased in size and had become painful. There was no history of trauma, and the patient's history is not significant. On examination, there was a 3 cm × 2 cm size pulsatile mass behind the right medial malleolus [Figure 1]. There was no thrill or bruit. Pedal pulses were palpable. There was no evidence of any other aneurysm on clinical examination. Color Doppler of the right lower limb revealed a PTA aneurysm. An computed tomography angiogram was performed which confirmed a saccular PTA aneurysm with patent pedal arteries [Figure 2]. A screening color Doppler excluded the presence of an aneurysm in any other part of the body. Laboratory investigations including erythrocyte sedimentation rate, C-reactive protein, and antinuclear antibodies were normal. The patient was symptomatic, and the aneurysm size was increasing as per the history, and, because of that, the patient was scheduled for surgical intervention. The aneurysm was resected, and PTA was reconstructed with a interposition reverse great saphenous vein graft [Figure 3] and [Figure 4]. Histopathological examination revealed intimal fibrosis with increased inflammation composed of lymphocytes, few neutrophils, and foamy macrophages with fragmentation of internal elastic lamina, features consistent with vasculitic changes [Figure 5]. She is planned to be investigated thoroughly for systemic vasculitis point of view and referred to the Department of Rheumatology.
|Figure 2: Computed tomography angiogram confirming a saccular aneurysm of the right posterior tibial artery|
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|Figure 3: Preoperative picture of the right posterior tibial artery aneurysm|
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|Figure 4: Repair of right posterior tibial artery aneurysm with a reverse saphenous vein graft after excision|
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|Figure 5: Histopathological examination confirming vasculitis changes in the posterior tibial artery aneurysm|
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| Discussion|| |
False aneurysms are more common in comparison to the true aneurysms of infrapopliteal blood vessels. There have been only very few case reports of true aneurysms of PTA published., The precise etiological factors are not identified, but trauma, collagen vascular pathology, fibromuscular dysplasia, inflammation, infection, and atherosclerosis were suggested.
The most common clinical presentations include asymptomatic lump swelling, distal embolism, and aneurysm thrombosis. Paraesthesia secondary to such aneurysm is rare but reported in the literature. Tshomba et al. reported that 9% of cases presented with distal critical ischemia, of which two-thirds ended up having midfoot amputation, while only 3% of cases presented with rupture that resulted in acute compartment syndrome. Differential diagnoses of this aneurysm include tendon cyst, neurinoma, soft-tissue tumor, or pulsatile masses.
In our case, though preoperative assessment could not find any etiological factor for the aneurysm development, histopathological examination revealed the possibility of vasculitis. Of the 12 published case reports of true PTA aneurysms, in five of them, etiology was unknown.,, Two cases were reported secondary to degenerative changes,,, and another three cases were secondary to mycotic infection., In one case, polyarteritis nodosa was responsible for such aneurysm, while in another case, histology was suggestive of syphilitic infection, but immunostaining and culture isolation did not confirm the diagnosis.
The management options vary from conservative approach to surgical excision followed by reconstitution of PTA. Due to very limited number of published cases, a standard treatment has not been defined. Therefore, the indications for treating these lesions are still a matter of debate, but symptomatic aneurysms, asymptomatic large aneurysms, and those with laminated thrombus should be offered treatment. Yao and McCarthy observed asymptomatic aneurysm for 7 years without any enlargement of aneurysm or any development of symptoms. Borozan also reported and suggested conservative approach in asymptomatic aneurysms. Although ligation of PTA may be performed, especially in emergency settings, surgical excision with PTA reconstitution either by primary repair or by interposition vein graft is the preferred treatment. Endovascular embolization and percutaneous occlusion of aneurysm with various modalities are more commonly used in pseudoaneurysms and are associated with risk of limb ischemia.
This patient underwent surgical excision followed by interposition vein graft. Of the 12 published case reports, seven patients had undergone surgical excision of PTA aneurysm with interposition vein graft,, while four patients had ligation of PTA.,, One patient had surgical excision with primary end-to-end anastomosis of PTA. In our patient, the anterior tibial artery was intact, and one might question the need for reconstruction; however, we believe that infrapopliteal aneurysms should be treated irrespective of symptomatology due to the risk of embolization, thrombosis, and rupture, leading to potential ischemia and amputation.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]