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A True Aneurysm of Posterior Tibial Artery
A True Aneurysm of Posterior Tibial Artery Hirohisa Murakami, Naoto Izawa, Shunsuke Miyahara, Tasuku Kadowaki, Naoto Morimoto, Yoshihisa Morimoto, Keitaro Nakagiri, Masato Yoshida, and Nobuhiko Mukouhara, Himeji, Japan
True aneurysms of tibial artery are uncommon. We report a case of a 47-year-old woman who suffered from a distal embolism in the left toes. The surgical intervention involved an aneurysmectomy and the interposition of the posterior tibial artery using the saphenous vein graft. She has been doing well 22 months after the operation.
Peripheral true aneurysms distal to the popliteal artery are uncommon, and traumatic false aneurysm is the most common etiology of intrapopliteal aneurysms. We report a rare case of atherosclerotic true aneurysm of the posterior tibial artery (PTA) that was successfully treated surgically.
CASE REPORT A 47-year-old woman presented to our hospital with pain and paleness of the left toes and numbness on the left calf. She had noticed a swelling on the medial calf and denied any preceding trauma on her left leg. Her medical history and the clinical examination did not suggest congenital connective tissue disorders. Three-dimensional computed tomographic scan images revealed a saccular aneurysm 3 cm in diameter in the left PTA (Fig. 1A). Surgical intervention was performed with the medial approach using systemic anesthesia. There was little adhesion and inflammation around the aneurysm and it was easily dissected. The aneurysm was about 20 30 mm2 in size at the bifurcated portion of the tibioperoneal trunk. With an Esmarch tourniquet around the left thigh, without clamping the PTA, the aneurysm was opened and excised. The PTA was reconstructed by interposition using an autograft of the great saphenous vein, in which Department of Cardiovascular Surgery, Hyogo Brain and Heart Center at Himeji, Himeji, Japan. Correspondence to: Hirohisa Murakami, MD, Department of Cardiovascular Surgery, Hyogo Brain and Heart Center at Himeji, 520 Saisho-Ko, Himeji, 670-0981, Japan, E-mail: [email protected] Ann Vasc Surg 2011; 25: 980.e1-980.e2 DOI: 10.1016/j.avsg.2011.02.038 Ó Annals of Vascular Surgery Inc. Published online: May 30, 2011
anastomoses were performed in an end-to-end manner using 7/0 polypropylene running suture. Although histological examination revealed destructed and disrupted elastic lamina in the smooth muscle layer of the dilated aneurysmal wall being replaced by the hyalinized collagen fibrous tissue, the intima, tunica media, and adventitia were also present. Therefore, a true aneurysm of the PTA was diagnosed. Also, there were no signs of connective tissue disorder, arteritis, necrotizing vasculitis, and infection (Fig. 2). The postoperative course was uneventful. Postoperative three-dimensional computed tomographic scan showed the patent interposed graft (Fig. 1B). She has been doing well 22 months after the operation.
DISCUSSION Infrapopliteal aneurysms are uncommon, and most aneurysms of the infrapopliteal arteries appear as false and are associated with trauma, infection, or iatrogenic injury.1-4 True aneurysms are extremely rare. Recent review of previous reports in the English literature described only 33 cases of true aneurysms of infrapopliteal arteries, which revealed only nine cases of atherosclerotic PTA aneurysms.3 Etiology of the 33 aneurysms includes atherosclerosis in 20 cases and unknown in other cases. It is supposed that some traumatic events, collagen matrix alterations, inflammation, or other mechanisms such as fibromuscular dysplasia might be involved in the unknown etiology cases.2,3 The indication of surgical intervention for PTA aneurysm commonly depends on the presence or absence of symptoms. The symptomatic aneurysms accompanying thrombus and distal emboli require surgical intervention. Small and asymptomatic 980.e1
980.e2 Case reports
Annals of Vascular Surgery
an aneurysm should be treated surgically because some cases were reported to present with rupture or leg ischemia.1 Arterial repair by interposition or bypass using the vein graft is favorable. However, when the not-involved infrapopliteal arteries are normal, a simple ligation is permissible as a second option. An alternative to open surgery is provided by an endovascular device for excluding aneurysms by means of stentegraft or coil embolization. There are several reports on the treatment of anterior tibial artery aneurysms for preventing rupture of pseudoaneurysms.5,6 In selected patients, endovascular treatment of tibial artery aneurysms is a useful alternative to a surgical approach, although the role of endovascular and percutaneous procedures has to be assessed.7
Fig. 1. (A) Three-dimensional computed tomographic image reveals a saccular-shaped aneurysm of the posterior tibial artery in the left leg. (B) Postoperative threedimensional computed tomographic image shows patent posterior tibial artery partially interposed with the saphenous vein graft.
CONCLUSIONS We described a case of true aneurysm of the PTA. It is a rare vascular lesion sometimes accompanying distal embolism and thrombotic occlusion as the sequelae. Open repair is favorable by interposition or bypass with a saphenous vein graft.
REFERENCES
Fig. 2. Optical microscopy image of the aneurysmal wall shows destruction of the elastic lamina and disrupted smooth muscle layer of the dilated aneurysmal wall being replaced by the hyalinized collagen fibrous tissue. A: adventitia, B: median, C: intima (Original magnification: 40; MassoneGoldner stain plus Elastica van Gieson stain).
aneurysms may be observed safely.4 Asymptomatic large aneurysms are controversial; however, such
1. M€ onig SP, Walter M, Sabine Sorgatz S, Erasmi H. True infrapopliteal artery aneurysms: report of two cases and literature review. J Vasc Surg 1996;24:276-278. 2. Mahmood A, Salaman R, Sintler M, Smith SRG, Simms MH, Vohra RK. Surgery of popliteal artery aneurysms: a 12-year experience. J Vasc Surg 2003;37:586-893. 3. Tshomba Y, Papa M, Marone EM, Kahlberg A, Rizzo N, Chiesa R. A true posterior tibial artery aneurysm: a case report. Vasc Endovasc Surg 2006;40:243. 4. Kanaoka T, Matsuura H. A true aneurysm of the posterior tibial artery: a case report. Ann Thorac Cardiovasc Surg 2004;10:317-318. 5. Golledge J, Velu R, Quigley F. Use of a covered stent to treat two large false aneurysms of the anterior tibial artery. J Vasc Surg 2008;47:1090. 6. Larena-Avellaneda A, Debus ES, Daum H, Kindel M, GrossFengels W, Imig H. Mycotic aneurysms affecting both lower legs of a patient with Candida endocarditis. Endovascular therapy and open vascular surgery. Ann Vasc Surg 2004;18: 130-133. 7. Barbano B, Gigante A, Zaccaria A, et al. True posterior tibial artery aneurysm in a young patient: surgical or endovascular treatment? BMJ Case Rep 2009 (in press). doi:10.1136/bcr. 04.2009.1812.
True aneurysms of tibial artery are uncommon. We report a case of a 47-year-old woman who suffered from a distal embolism in the left toes. The surgical intervention involved an aneurysmectomy and the interposition of the posterior tibial artery using the saphenous vein graft. She has been doing well 22 months after the operation.
Peripheral true aneurysms distal to the popliteal artery are uncommon, and traumatic false aneurysm is the most common etiology of intrapopliteal aneurysms. We report a rare case of atherosclerotic true aneurysm of the posterior tibial artery (PTA) that was successfully treated surgically.
CASE REPORT A 47-year-old woman presented to our hospital with pain and paleness of the left toes and numbness on the left calf. She had noticed a swelling on the medial calf and denied any preceding trauma on her left leg. Her medical history and the clinical examination did not suggest congenital connective tissue disorders. Three-dimensional computed tomographic scan images revealed a saccular aneurysm 3 cm in diameter in the left PTA (Fig. 1A). Surgical intervention was performed with the medial approach using systemic anesthesia. There was little adhesion and inflammation around the aneurysm and it was easily dissected. The aneurysm was about 20 30 mm2 in size at the bifurcated portion of the tibioperoneal trunk. With an Esmarch tourniquet around the left thigh, without clamping the PTA, the aneurysm was opened and excised. The PTA was reconstructed by interposition using an autograft of the great saphenous vein, in which Department of Cardiovascular Surgery, Hyogo Brain and Heart Center at Himeji, Himeji, Japan. Correspondence to: Hirohisa Murakami, MD, Department of Cardiovascular Surgery, Hyogo Brain and Heart Center at Himeji, 520 Saisho-Ko, Himeji, 670-0981, Japan, E-mail: [email protected] Ann Vasc Surg 2011; 25: 980.e1-980.e2 DOI: 10.1016/j.avsg.2011.02.038 Ó Annals of Vascular Surgery Inc. Published online: May 30, 2011
anastomoses were performed in an end-to-end manner using 7/0 polypropylene running suture. Although histological examination revealed destructed and disrupted elastic lamina in the smooth muscle layer of the dilated aneurysmal wall being replaced by the hyalinized collagen fibrous tissue, the intima, tunica media, and adventitia were also present. Therefore, a true aneurysm of the PTA was diagnosed. Also, there were no signs of connective tissue disorder, arteritis, necrotizing vasculitis, and infection (Fig. 2). The postoperative course was uneventful. Postoperative three-dimensional computed tomographic scan showed the patent interposed graft (Fig. 1B). She has been doing well 22 months after the operation.
DISCUSSION Infrapopliteal aneurysms are uncommon, and most aneurysms of the infrapopliteal arteries appear as false and are associated with trauma, infection, or iatrogenic injury.1-4 True aneurysms are extremely rare. Recent review of previous reports in the English literature described only 33 cases of true aneurysms of infrapopliteal arteries, which revealed only nine cases of atherosclerotic PTA aneurysms.3 Etiology of the 33 aneurysms includes atherosclerosis in 20 cases and unknown in other cases. It is supposed that some traumatic events, collagen matrix alterations, inflammation, or other mechanisms such as fibromuscular dysplasia might be involved in the unknown etiology cases.2,3 The indication of surgical intervention for PTA aneurysm commonly depends on the presence or absence of symptoms. The symptomatic aneurysms accompanying thrombus and distal emboli require surgical intervention. Small and asymptomatic 980.e1
980.e2 Case reports
Annals of Vascular Surgery
an aneurysm should be treated surgically because some cases were reported to present with rupture or leg ischemia.1 Arterial repair by interposition or bypass using the vein graft is favorable. However, when the not-involved infrapopliteal arteries are normal, a simple ligation is permissible as a second option. An alternative to open surgery is provided by an endovascular device for excluding aneurysms by means of stentegraft or coil embolization. There are several reports on the treatment of anterior tibial artery aneurysms for preventing rupture of pseudoaneurysms.5,6 In selected patients, endovascular treatment of tibial artery aneurysms is a useful alternative to a surgical approach, although the role of endovascular and percutaneous procedures has to be assessed.7
Fig. 1. (A) Three-dimensional computed tomographic image reveals a saccular-shaped aneurysm of the posterior tibial artery in the left leg. (B) Postoperative threedimensional computed tomographic image shows patent posterior tibial artery partially interposed with the saphenous vein graft.
CONCLUSIONS We described a case of true aneurysm of the PTA. It is a rare vascular lesion sometimes accompanying distal embolism and thrombotic occlusion as the sequelae. Open repair is favorable by interposition or bypass with a saphenous vein graft.
REFERENCES
Fig. 2. Optical microscopy image of the aneurysmal wall shows destruction of the elastic lamina and disrupted smooth muscle layer of the dilated aneurysmal wall being replaced by the hyalinized collagen fibrous tissue. A: adventitia, B: median, C: intima (Original magnification: 40; MassoneGoldner stain plus Elastica van Gieson stain).
aneurysms may be observed safely.4 Asymptomatic large aneurysms are controversial; however, such
1. M€ onig SP, Walter M, Sabine Sorgatz S, Erasmi H. True infrapopliteal artery aneurysms: report of two cases and literature review. J Vasc Surg 1996;24:276-278. 2. Mahmood A, Salaman R, Sintler M, Smith SRG, Simms MH, Vohra RK. Surgery of popliteal artery aneurysms: a 12-year experience. J Vasc Surg 2003;37:586-893. 3. Tshomba Y, Papa M, Marone EM, Kahlberg A, Rizzo N, Chiesa R. A true posterior tibial artery aneurysm: a case report. Vasc Endovasc Surg 2006;40:243. 4. Kanaoka T, Matsuura H. A true aneurysm of the posterior tibial artery: a case report. Ann Thorac Cardiovasc Surg 2004;10:317-318. 5. Golledge J, Velu R, Quigley F. Use of a covered stent to treat two large false aneurysms of the anterior tibial artery. J Vasc Surg 2008;47:1090. 6. Larena-Avellaneda A, Debus ES, Daum H, Kindel M, GrossFengels W, Imig H. Mycotic aneurysms affecting both lower legs of a patient with Candida endocarditis. Endovascular therapy and open vascular surgery. Ann Vasc Surg 2004;18: 130-133. 7. Barbano B, Gigante A, Zaccaria A, et al. True posterior tibial artery aneurysm in a young patient: surgical or endovascular treatment? BMJ Case Rep 2009 (in press). doi:10.1136/bcr. 04.2009.1812.