Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 4  |  Issue : 3  |  Page : 112-114

Anterior Tibial Artery Pseudoaneurysm-Case Series


Institute of Vascular Surgery, Madras Medical College, Chennai, Tamil Nadu, India

Date of Web Publication31-Jul-2017

Correspondence Address:
Velladuraichi Boologapandian
Institute of Vascular Surgery, Madras Medical College, Chennai, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_24_17

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  Abstract 


Anterior tibial artery (ATA) pseudoaneurysm is a rare condition that occurs following lower extremity orthopedic intervention or after trauma. We report a series of cases of pseudoaneurysm which were treated surgically. The diagnosis was confirmed with computed tomography angiogram. Aneurysmal sac excision with ligation of ATA was performed.

Keywords: Aneurysmal sac excision, anterior tibial artery, pseudoaneurysm, surgical ligation


How to cite this article:
Boologapandian V, Joseph A, Selvapackiam J, Narayanan S, Paramasivam I. Anterior Tibial Artery Pseudoaneurysm-Case Series. Indian J Vasc Endovasc Surg 2017;4:112-4

How to cite this URL:
Boologapandian V, Joseph A, Selvapackiam J, Narayanan S, Paramasivam I. Anterior Tibial Artery Pseudoaneurysm-Case Series. Indian J Vasc Endovasc Surg [serial online] 2017 [cited 2020 Dec 3];4:112-4. Available from: https://www.indjvascsurg.org/text.asp?2017/4/3/112/211902




  Introduction Top


Pseudoaneurysms of anterior tibial artery (ATA) are associated with penetrating trauma, high-injury blunt trauma,[1],[2],[3] bone fractures, sports activities,[4],[5] and less frequently after orthopedic interventions.[6] Here, we report a series of cases of ATA pseudoaneurysm that developed posttrauma and spontaneously. History, clinical presentation, treatment, and review of the literature are presented.


  Case Reports Top


The details of the presentation, diagnosis, and treatment of ATA pseudoaneurysms in five male patients are presented in [Table 1]. All the patients presented to our outpatient clinics except one patient who presented to our emergency department with bleeding 7 days after insertion of Steinmann pin. Two elderly patients denied the history of trauma presented to us with swelling associated with ulcer and cellulitis of leg [Figure 2]. All the patients were examined clinically. There was no history of fever. There were no findings suggestive of connective tissue disorders. Their blood investigations were within normal limits. On physical examination, there was a pulsatile swelling with an area of skin ulceration at the lateral aspect of upper one-third of the leg. Both posterior tibial artery and dorsalis pedis artery pulses were palpable with good triphasic signals, and the plantar arch was patent in all the patients. Ultrasound Doppler studies [Figure 3] were performed, which demonstrated the presence of an ATA pseudoaneurysm, confirmed by Angiogram [Figure 4].
Table 1: Six patients with anterior tibial artery pseudo aneurysms

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Figure 1: Pseudoaneurysm with ulcer and cellulitis

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Figure 2: Duplex scan showing pseudoaneurysm

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Figure 3: CT Angiogram showing anterior tibial artery pseudoaneurysm

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Figure 4: Pseudoaneurysm opening at anterior tibial artery

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Under regional anesthesia, with tourniquet at the thigh, through an incision over the swelling, the pseudoaneurysm was opened, and the clots were removed. All the patients had opening at the proximal ATA ranging from 5 mm to 1 cm [Figure 5]. Since the posterior tibial artery and the peroneal artery was normal with patent plantar arch, the ATA was ligated [Figure 6] in all the cases.
Figure 5: Ligation of anterior tibial artery

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Figure 6: Post traumatic anterior tibial artery pseudoaneurysm

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The postoperative period was uneventful. All the patients had normal posterior tibial artery pulse with the good triphasic flow in the dorsalis pedis artery. The culture of the pseudoaneurysm sac wall was negative in all the patients except in one elderly patient with cellulitis, positive for acinetobacter and he was treated with appropriate antibiotics.


  Discussion Top


False peripheral artery aneurysms have an incidence of <1%, most are located in the popliteal artery. These aneurysms are caused by trauma or after surgical procedures, either orthopedic or vascular leading to the formation of a pseudoaneurysm. The time from injury to the detection of the pseudoaneurysms has been reported to vary from hours to years, depending on the site, size, and clinical signs and symptoms.[7] The latter may include pain, swelling, a pulsatile mass, distal emboli, neurological deficit, and bleeding. The differential diagnosis includes abscesses, hematoma, and neoplasms.[8],[9] Therefore, high index of suspicion is justified in dealing with such swellings in the vicinity of a major vessel.

To treat pseudoaneurysms of the ATA, the surgical approach has been preferred even recently, to prevent complications of rupture or rapid expansion with resultant pressure on the adjacent nerves. Several methods of repair have been described in the literature for the treatment of a pseudoaneurysm. These include excision of the aneurysmal sac and repair of the lateral wall, end to end anastomosis, graft placement, and ligation of the artery.[5],[6],[10],[11],[12],[13]

Before planning the procedure additional research (duplex ultrasonography, computed tomography, and magnetic resonance imaging) should have been undertaken to plan the procedure, whereby collateral flow through the posterior tibial and dorsalis pedis needs to be sufficient.[14]

Other less invasive options for the treatment of anterior tibial pseudoaneurysm included transfemoral embolization with coils,[15] Ultrasound-guided compression, closure with transluminal temporary occlusion of the pseudoaneurysm neck or balloon embolization,[16] covered stent, and direct thrombin injection.[17],[18]

In our case series, hence the openings of the pseudoaneurysms were wide, and the artery was friable, we ligated the ATA.


  Conclusion Top


ATA pseudoaneurysms are rare. It can be managed by ligation, provided the posterior tibial artery is patent and maintains vascularity to the anterior compartment and distal limb.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Suri T, Dabas V, Sural S, Dhal A. Pseudoaneurysm of the anterior tibial artery: A rare complication of proximal tibial steinman pin insertion. Indian J Orthop 2011;45:178-80.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Gillespie DL, Woodson J, Kaufman J, Parker J, Greenfield A, Menzoian JO. Role of arteriography for blunt or penetrating injuries in proximity to major vascular structures: An evolution in management. Ann Vasc Surg 1993;7:145-9.  Back to cited text no. 2
    
3.
Rosa P, O'Donnell SD, Goff JM, Gillespie DL, Starnes B. Endovascular management of a peroneal artery injury due to a military fragment wound. Ann Vasc Surg 2003;17:678-81.  Back to cited text no. 3
    
4.
Bandy WD, Strong L, Roberts T, Dyer R. False aneurysm – A complication following an inversion ankle sprain: A case report. J Orthop Sports Phys Ther 1996;23:272-9.  Back to cited text no. 4
    
5.
Skudder PA, Gelfand ML, Blumenberg RM, Fulco J. Tibial artery false aneurysm: Uncommon result of blunt injury occurring during athletics. Ann Vasc Surg 1999;13:589-91.  Back to cited text no. 5
    
6.
Maxwell-Armstrong CA, Taylor AM, Majkowski RS, Colton CL. False aneurysm of the anterior tibial artery following removal of tibial plate. Eur J Vasc Endovasc Surg 1995;10:505-6.  Back to cited text no. 6
    
7.
Lädermann A, Stern R, Bettschart V, Riand N. Delayed posttraumatic pseudoaneurysm of the anterior tibial artery mimicking a malignant tumor. Orthopedics 2008;31:500.  Back to cited text no. 7
    
8.
Dominguez R, de Santos LA. Traumatic pseudoaneurysm of the anterior tibial artery simulating soft tissue malignancy. Skeletal Radiol 1986;15:622-4.  Back to cited text no. 8
    
9.
Gantz ED, Sweet MB, Jakim I. False aneurysm mimicking an aggressive soft-tissue tumor. A case report. J Bone Joint Surg Am 1988;70:1090-2.  Back to cited text no. 9
    
10.
Edwards H, Martin E, Nowygrod R. Nonoperative management of a traumatic peroneal artery false aneurysm. J Trauma 1982;22:323-6.  Back to cited text no. 10
    
11.
Kang SS, Labropoulos N, Mansour MA, Michelini M, Filliung D, Baubly MP, et al. Expanded indications for ultrasound-guided thrombin injection of pseudoaneurysms. J Vasc Surg 2000;31:289-98.  Back to cited text no. 11
    
12.
De Roo RA, Steenvoorde P, Schuttevaer HM, Den Outer AJ, Oskam J, Joosten PP. Exclusion of a crural pseudo aneurysm with a PTFE-covered stent-graft. J Endovasc Ther 2004;11:344-7.  Back to cited text no. 12
    
13.
Kurihashi A, Tamai K, Saotome K. Peroneal arteriovenous fistula and pseudo aneurysm formation after blunt trauma. A case report. Clin Orthop Relat Res 1994;(304):218-21.  Back to cited text no. 13
    
14.
Sigterman TA, Dolmans DE, Welten RJ, Krasznai A, Bouwman LH. Anterior tibial artery aneurysm: Case report and literature review. Int J Surg Case Rep 2013;4:243-5.  Back to cited text no. 14
    
15.
McIvor J, Treweeke PS. Case report: Direct percutaneous embolisation of a false aneurysm with steel coils. Clin Radiol 1988;39:205-7.  Back to cited text no. 15
    
16.
Hebrang A, Grga A, Brkljacic B, Drinkovic I. Successful closure of large PSA of peroneal artery using transluminal temporary occlusion of the neck with the catheter. Eur Radiol 2001;11:1206-9.  Back to cited text no. 16
    
17.
Albrecht RJ, Parra JR. Traumatic peroneal artery pseudoaneurysm: Use of preoperative coil embolization. J Vasc Surg 2004;39:912.  Back to cited text no. 17
    
18.
Spirito R, Trabattoni P, Pompilio G, Zoli S, Agrifoglio M, Biglioli P. Endovascular treatment of a post-traumatic tibial pseudoaneurysm and arteriovenous fistula: Case report and review of the literature. J Vasc Surg 2007;45:1076-9.  Back to cited text no. 18
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
 
 
    Tables

  [Table 1]


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