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Dorsalis Pedis Artery Aneurysm: A Case Report and Review of the Literature
Case Report Dorsalis Pedis Artery Aneurysm: A Case Report and Review of the Literature Panagitsa Christoforou, Nikolaos Asaloumidis, Konstantina Katseni, and Thomas Kotsis, Athens, Greece
Aneurysms of the foot arteries are rare. A case of a true dorsalis pedis artery aneurysm in a 69year-old man, with no history of local trauma or injury on his foot, is presented. Clinical examination and ultrasonic imaging confirmed the aneurysm. Dorsalis pedis artery aneurysm was resected and an end-to-end anastomosis was performed, without complications. Arterial duplex scan findings, operative procedure, and literature review are presented and discussed.
Dorsalis pedis artery aneurysms (DPAAs), though uncommon, are well recognized and the first clinical presentation is ought to Cuff in 1907, who described a spontaneous aneurysm on the dorsum of the foot of a 53-year-old woman.1 Since then, many authors have described this rare aneurysm and proposed different management modalities.2 From the infrapopliteal true arterial aneurysms, aneurysm of the dorsalis pedis artery (DPA) is extremely rare3 and due to its location may require surgical intervention and removal. The vast majority of DPAAs are pseudoaneurysms and are often secondary to blunt trauma.4 The natural history of DPAAs includes several months or years of development with end points of rupture, thrombosis, and distal microembolization.5 The DPAAs classic manifestations include presentation of a pulsatile mass on the dorsum of the foot, pain or difficulty in wearing shoes, chronic toe ischemia, or blue toe syndrome.5 We present herein
Vascular Unit, 2nd Clinic of Surgery, Aretaieion Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece. Correspondence to: Thomas Kotsis, MD, PhD, National and Kapodistrian University of Athens, Vasilissis Sofias 76, 115 26 Athens, Greece; E-mails: [email protected] or [email protected] Ann Vasc Surg 2016; -: 1–4 http://dx.doi.org/10.1016/j.avsg.2015.12.011 Ó 2016 Elsevier Inc. All rights reserved. Manuscript received: October 19, 2015; manuscript accepted: December 25, 2015; published online: - - -
a case of a patient with a visible true saccular aneurysm of the dorsalis pedis artery with a review of the literature.
CASE REPORT A 69-year-old man presented with a painless pulsatile mass located on the dorsal part of the right foot. The mass was observed by himself over a year ago and the mass, although asymptomatic, had enlarged. No history of blunt, penetrating trauma or surgery in the foot was recorded. The patient receives medications for hypertension and hypercholesterolemia. Family history of aneurysmal disease was negative. On physical examination, the patient was healthy. Examination of the right foot showed a pulsatile, nontender, and compressible mass on the dorsum of the foot. There was no thrill or bruit over the mass. Posterior tibial artery was palpable at the ankle. No signs of toes’ ischemia were observed and no other vascular abnormalities were detected elsewhere (Fig. 1). Arterial color duplex study was performed for bilateral lower limbs which revealed mild atherosclerosis of the arteries without narrowing or blockage, no aneurysms in the popliteal arteries, and confirmed the presence of a right DPA aneurysm with a small mural thrombus (Fig. 2). Right foot toes pressure measurements were normal. Surgical exploration was carried out under local anesthesia. A longitudinal skin incision was made directly over the aneurysm. Sharp dissection through fascia revealed a DPA saccular aneurysm, with a 2 cm diameter. 1
2 Case Report
Fig. 1. Dorsalis pedis aneurysm on the dorsum of the right foot, presented as a pulsatile, nontender, and compressible mass.
Fig. 2. Color Duplex ultrasound, where the dorsalis pedis artery aneurysm can be observed. Mural thrombus appeared within the lumen of the vessel (white arrow). Following intravenous administration of 5,000 IU heparin and proximal and distal control of the DPA (Fig. 3), the aneurysm was resected and an end-to-end anastomosis was performed (Fig. 4). Good pulsation was noted distal to the repair after closure. The patient’s recovery was smooth and uncomplicated and no further problems were identified 8 months following the DPA reconstruction.
DISCUSSION True aneurysms of the DPA are uncommon, with few cases reported in the most recent literature.4 Only 23 cases of true DPAA have been referred
Annals of Vascular Surgery
Fig. 3. Exposure of the dorsalis pedis artery aneurysm. Proximal and distal control of the dorsalis pedis artery.
Fig. 4. End-to-end anastomosis. Interrupted suture line (white arrow).
previously in the literature (Table I).3,6e23 However, some authors believe that it occurs more often than it is reported.11 The pathophysiological process of DPA aneurysms is obscure.4 In case of incidental presentation, other locations should also be searched through careful clinical examination and imaging studies.15 Dorsalis pedis aneurysms are rare; absence of DPA in healthy individuals approximates the percentage of 5e10%. Patients may be asymptomatic, as in the case of the patient we present, or complain of pain, itching, paresthesia, and avoid wearing shoes. The symptoms produced are similar with those of other foot lumps, such as ganglion cysts; however, aneurysms are pulsatile. It is not advisable to attempt a needle aspiration of a pulsatile mass.24
Vol.
-,
No.
-, -
2016
Case Report 3
Table I. Reported cases of true dorsalis pedis aneurysm Year/author
Sex/age/risk factors
Symptoms
Type of surgery
1980/Fitzpatrick 1988/De Frutos7 1991/Wu8 1995/Morettini et al.9
F/62/HTN F/63/HTN M/52/no M/38/HTN, smoker
Ligation and resection Resectionepatch angioplasty Ligation and resection Resection with anastomosis
1996/Herrmann10 2000/McKee and Fisher11 2001/Tempest and Wilson12 2002/Taylor et al.13
M/46/unknown F/71/diabetes, HTN
Pulsatile mass Pulsatile mass Pulsatile mass Pulsatile mass, pain wearing shoes Pulsatile mass Pulsatile, itchy mass
Resection with anastomosis Ligation and resection
M/53/HTN, hemodialysis
Forefoot ischemia
Ligation and resection
M/60/diabetes, HTN
Resection, patch angioplasty
2002/Burton et al.14 2003/Bausells et al.15 2004/Kato et al.3 2005/Bellosta et al.16 2007/Maydew17 2008/Legel et al.18 2009/Pasztori et al.5
M/56/unknown M/4/no F/61/HTN F/62/HTN, diabetes F/73/HTN, obesity M/52/HTN M/40/no
2010/Robaldo et al.4
M/53/HTN, diabetes, smoker M/49/no
Pulsatile mass, history of trauma Tender pulsatile, painful mass Pulsatile, painful mass Pulsatile, painful mass Pulsatile mass, minor trauma Tender pulsatile mass Pulsatile, painful mass Blue toes syndrome, history of trauma Pulsatile, painful mass
6
2011/Berard et al.19 2011/Berard et al.19 2012/Bittner et al.20 2012/Ballesteros-Pomar21 2013/Sonntag et al.22 2014/Jin et al.23
M/56/diabetes, hemodialysis, HTN F/61/HTN M/66/hyperuricemia F/54/congenitally high arch of the foot M/41/no
Painful mass Painful mass Pulsatile mass Pulsatile, painful mass Pulsatile, painful mass Pulsatile mass
Resection with anastomosis Resection with anastomosis Ligation and resection Ligation and resection Resection, patch angioplasty Resection with anastomosis Ligation and resection Resection with anastomosis Resection with saphenous graft Resection with saphenous graft Ligation and resection Resection with anastomosis Resection and vein graft Resection with saphenous graft Resection with anastomosis
F, female; HTN, hypertension; M, male.
Paraclinical investigation includes duplex scanning, magnetic resonance imaging, or angiography. A dorsalis pedis aneurysm is categorized as a true aneurysm or a pseudoaneurysm. According to the literature, most DPAAs are pseudoaneurysms and occur after trauma, which may be remote, minor, or repetitive. Risk factors for true aneurysms are hypertension, diabetes, smoking, and hyperlipidemia.24 The treatment includes close observation of small lesions, vascular repair with ligation or repair with resection, and repair of the artery with the maintenance of blood flow from that vessel to the foot. Vascular repair includes use of a saphenous or synthetic conduit or patch, or end-to-end anastomosis; we performed the latter as the aneurysm was saccular and enough proximal and distal arterial tissue could easily be obtained. It has to be noted that, in cases of symptomatic or enlarging DPAAs, assessment and surgical intervention is justified to prevent further damage such as
rupture, or distal foot ischemia due to thrombosis or peripheral embolism.24 The aneurysms of the pedal arteries are infrequent (<1%); true DPAAs are extremely rare.21 We describe a case of a true aneurysm of DPA in a man with no significant atherosclerotic risk factors, trauma, or injuries. The surgical repair with aneurysmectomy and end-to-end anastomosis was successful, with no complications and after 8 months the repaired DPA remains patent.
REFERENCES 1. Cuff A. Spontaneous aneurysm of the dorsalis pedis artery. Br Med J 1907;2:16. 2. Al-Omran M. Repair of a true dorsalis pedis artery saccular aneurysm. J Surg Case Rep 2012;2012:15. 3. Kato T, Takagi H, Sekino S, et al. Dorsalis pedis artery true aneurysm due to atherosclerosis: case report and literature review. J Vasc Surg 2004;40:1044e8.
4 Case Report
4. Robaldo A, Colotto P, Palombo D. True atherosclerotic pedis artery aneurysm. Interact Cardiovasc Thorac Surg 2010;11: 216e7. 5. Pasztori M, Avram J, Manciu S, et al. Case report of a dorsalis pedis artery aneurysm. J Exp Med Surg Res 2009;16: 118e23. 6. Fitzpatrick WH. Idiopathic aneurysm of the dorsalis pedis artery. J Foot Surg 1980;19:185e6. 7. De Frutos JL, Gomez Palones FJ, Caldero Pardo J, et al. Arteriosclerotic aneurysm of the pedal artery. Angiologia 1988;40:109e12. 8. Wu KK. True aneurysm of the dorsalis pedis artery mimicking a soft tissue tumor. J Foot Surg 1991;30: 304e7. 9. Morettini G, Ventura M, Marino GA, et al. Isolated aneurysm of the dorsalis pedis artery. Eur J Vasc Endovasc Surg 1995;9:485e6. 10. Herrmann M. Pedal aneurysms. Eur J Vasc Endovasc Surg 1996;11:250. 11. McKee T, Fisher J. Dorsalis pedis artery aneurysm: case report and literature review. J Vasc Surg 2000;31:589e91. 12. Tempest HV, Wilson YG. Acute forefoot ischaemia: an unreported complication of dorsalis pedis artery aneurysm. Eur J Vasc Endovasc Surg 2001;22:472e3. 13. Taylor DT, Mansour MA, Bergin JT, et al. Aneurysm of the dorsalis pedis artery: a case report. Vasc Endovascular Surg 2002;36:241e5. 14. Burton S, Himpson R, Kumar K, et al. Repair of a dorsalis pedis artery aneurysm. Eur J Vasc Endovasc Surg 2002;3: 21e2.
Annals of Vascular Surgery
15. Bausells MI, Raymundo SR, Menezes da Silva AA, et al. Aneurysm of the dorsalis pedis artery: case report and literature review. J Vasc Bras 2003;21:26e8. 16. Bellosta R, Talarico M, Luzzani L, et al. Non-atherosclerotic dorsalis pedis artery true aneurysm; case report and literature review. Eur J Vasc Endovasc Surg 2005;10:146e8. 17. Maydew MS. Dorsalis pedis aneurysm: ultrasound diagnosis. Emerg Radiol 2007;13:277e80. 18. Legel K, Savard M, Blanco CJ, et al. Dorsalis pedis aneurysm: a case report and review of the literature. Foot Ankle J 2008;1:1e6. 19. Berard X, Bodin R, Saucy F, et al. Current management of true aneurysm of the dorsalis pedis artery. Ann Vasc Surg 2011;25:265.e13e6. 20. Bittner JG, Hardy D, Biddinger PW, et al. Giant, metachronous bilateral dorsalis pedis artery true aneurysms. Ann Vasc Surg 2012;26:279.e13e6. 21. Ballesteros-Pomar M, Sanz-Pastor N, Vaquero-Morillo F. Repair of bilateral true aneurysms of the dorsalis pedis artery. J Vasc Surg 2013;57:1387e90. 22. Sonntag M, Hopper N, Graham A. ‘‘Sandal strap’’ trauma and atherosclerosis are dual pathologies leading to bilateral true aneurysms of the dorsalis pedis arteries. J Vasc Surg 2013;57:1391e4. 23. Jin PH, van der Elst A, Nio D. A man with a pulsating mass on the dorsal side of his foot. Ned Tijdschr Geneeskd 2014;158:A7829. 24. Agzarian An, Agzarian Al. An unusual cause of a lump on the foot: aneurysm of the dorsalis pedis artery. Proceedings of UCLA Healthcare 2013;17.
Aneurysms of the foot arteries are rare. A case of a true dorsalis pedis artery aneurysm in a 69year-old man, with no history of local trauma or injury on his foot, is presented. Clinical examination and ultrasonic imaging confirmed the aneurysm. Dorsalis pedis artery aneurysm was resected and an end-to-end anastomosis was performed, without complications. Arterial duplex scan findings, operative procedure, and literature review are presented and discussed.
Dorsalis pedis artery aneurysms (DPAAs), though uncommon, are well recognized and the first clinical presentation is ought to Cuff in 1907, who described a spontaneous aneurysm on the dorsum of the foot of a 53-year-old woman.1 Since then, many authors have described this rare aneurysm and proposed different management modalities.2 From the infrapopliteal true arterial aneurysms, aneurysm of the dorsalis pedis artery (DPA) is extremely rare3 and due to its location may require surgical intervention and removal. The vast majority of DPAAs are pseudoaneurysms and are often secondary to blunt trauma.4 The natural history of DPAAs includes several months or years of development with end points of rupture, thrombosis, and distal microembolization.5 The DPAAs classic manifestations include presentation of a pulsatile mass on the dorsum of the foot, pain or difficulty in wearing shoes, chronic toe ischemia, or blue toe syndrome.5 We present herein
Vascular Unit, 2nd Clinic of Surgery, Aretaieion Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece. Correspondence to: Thomas Kotsis, MD, PhD, National and Kapodistrian University of Athens, Vasilissis Sofias 76, 115 26 Athens, Greece; E-mails: [email protected] or [email protected] Ann Vasc Surg 2016; -: 1–4 http://dx.doi.org/10.1016/j.avsg.2015.12.011 Ó 2016 Elsevier Inc. All rights reserved. Manuscript received: October 19, 2015; manuscript accepted: December 25, 2015; published online: - - -
a case of a patient with a visible true saccular aneurysm of the dorsalis pedis artery with a review of the literature.
CASE REPORT A 69-year-old man presented with a painless pulsatile mass located on the dorsal part of the right foot. The mass was observed by himself over a year ago and the mass, although asymptomatic, had enlarged. No history of blunt, penetrating trauma or surgery in the foot was recorded. The patient receives medications for hypertension and hypercholesterolemia. Family history of aneurysmal disease was negative. On physical examination, the patient was healthy. Examination of the right foot showed a pulsatile, nontender, and compressible mass on the dorsum of the foot. There was no thrill or bruit over the mass. Posterior tibial artery was palpable at the ankle. No signs of toes’ ischemia were observed and no other vascular abnormalities were detected elsewhere (Fig. 1). Arterial color duplex study was performed for bilateral lower limbs which revealed mild atherosclerosis of the arteries without narrowing or blockage, no aneurysms in the popliteal arteries, and confirmed the presence of a right DPA aneurysm with a small mural thrombus (Fig. 2). Right foot toes pressure measurements were normal. Surgical exploration was carried out under local anesthesia. A longitudinal skin incision was made directly over the aneurysm. Sharp dissection through fascia revealed a DPA saccular aneurysm, with a 2 cm diameter. 1
2 Case Report
Fig. 1. Dorsalis pedis aneurysm on the dorsum of the right foot, presented as a pulsatile, nontender, and compressible mass.
Fig. 2. Color Duplex ultrasound, where the dorsalis pedis artery aneurysm can be observed. Mural thrombus appeared within the lumen of the vessel (white arrow). Following intravenous administration of 5,000 IU heparin and proximal and distal control of the DPA (Fig. 3), the aneurysm was resected and an end-to-end anastomosis was performed (Fig. 4). Good pulsation was noted distal to the repair after closure. The patient’s recovery was smooth and uncomplicated and no further problems were identified 8 months following the DPA reconstruction.
DISCUSSION True aneurysms of the DPA are uncommon, with few cases reported in the most recent literature.4 Only 23 cases of true DPAA have been referred
Annals of Vascular Surgery
Fig. 3. Exposure of the dorsalis pedis artery aneurysm. Proximal and distal control of the dorsalis pedis artery.
Fig. 4. End-to-end anastomosis. Interrupted suture line (white arrow).
previously in the literature (Table I).3,6e23 However, some authors believe that it occurs more often than it is reported.11 The pathophysiological process of DPA aneurysms is obscure.4 In case of incidental presentation, other locations should also be searched through careful clinical examination and imaging studies.15 Dorsalis pedis aneurysms are rare; absence of DPA in healthy individuals approximates the percentage of 5e10%. Patients may be asymptomatic, as in the case of the patient we present, or complain of pain, itching, paresthesia, and avoid wearing shoes. The symptoms produced are similar with those of other foot lumps, such as ganglion cysts; however, aneurysms are pulsatile. It is not advisable to attempt a needle aspiration of a pulsatile mass.24
Vol.
-,
No.
-, -
2016
Case Report 3
Table I. Reported cases of true dorsalis pedis aneurysm Year/author
Sex/age/risk factors
Symptoms
Type of surgery
1980/Fitzpatrick 1988/De Frutos7 1991/Wu8 1995/Morettini et al.9
F/62/HTN F/63/HTN M/52/no M/38/HTN, smoker
Ligation and resection Resectionepatch angioplasty Ligation and resection Resection with anastomosis
1996/Herrmann10 2000/McKee and Fisher11 2001/Tempest and Wilson12 2002/Taylor et al.13
M/46/unknown F/71/diabetes, HTN
Pulsatile mass Pulsatile mass Pulsatile mass Pulsatile mass, pain wearing shoes Pulsatile mass Pulsatile, itchy mass
Resection with anastomosis Ligation and resection
M/53/HTN, hemodialysis
Forefoot ischemia
Ligation and resection
M/60/diabetes, HTN
Resection, patch angioplasty
2002/Burton et al.14 2003/Bausells et al.15 2004/Kato et al.3 2005/Bellosta et al.16 2007/Maydew17 2008/Legel et al.18 2009/Pasztori et al.5
M/56/unknown M/4/no F/61/HTN F/62/HTN, diabetes F/73/HTN, obesity M/52/HTN M/40/no
2010/Robaldo et al.4
M/53/HTN, diabetes, smoker M/49/no
Pulsatile mass, history of trauma Tender pulsatile, painful mass Pulsatile, painful mass Pulsatile, painful mass Pulsatile mass, minor trauma Tender pulsatile mass Pulsatile, painful mass Blue toes syndrome, history of trauma Pulsatile, painful mass
6
2011/Berard et al.19 2011/Berard et al.19 2012/Bittner et al.20 2012/Ballesteros-Pomar21 2013/Sonntag et al.22 2014/Jin et al.23
M/56/diabetes, hemodialysis, HTN F/61/HTN M/66/hyperuricemia F/54/congenitally high arch of the foot M/41/no
Painful mass Painful mass Pulsatile mass Pulsatile, painful mass Pulsatile, painful mass Pulsatile mass
Resection with anastomosis Resection with anastomosis Ligation and resection Ligation and resection Resection, patch angioplasty Resection with anastomosis Ligation and resection Resection with anastomosis Resection with saphenous graft Resection with saphenous graft Ligation and resection Resection with anastomosis Resection and vein graft Resection with saphenous graft Resection with anastomosis
F, female; HTN, hypertension; M, male.
Paraclinical investigation includes duplex scanning, magnetic resonance imaging, or angiography. A dorsalis pedis aneurysm is categorized as a true aneurysm or a pseudoaneurysm. According to the literature, most DPAAs are pseudoaneurysms and occur after trauma, which may be remote, minor, or repetitive. Risk factors for true aneurysms are hypertension, diabetes, smoking, and hyperlipidemia.24 The treatment includes close observation of small lesions, vascular repair with ligation or repair with resection, and repair of the artery with the maintenance of blood flow from that vessel to the foot. Vascular repair includes use of a saphenous or synthetic conduit or patch, or end-to-end anastomosis; we performed the latter as the aneurysm was saccular and enough proximal and distal arterial tissue could easily be obtained. It has to be noted that, in cases of symptomatic or enlarging DPAAs, assessment and surgical intervention is justified to prevent further damage such as
rupture, or distal foot ischemia due to thrombosis or peripheral embolism.24 The aneurysms of the pedal arteries are infrequent (<1%); true DPAAs are extremely rare.21 We describe a case of a true aneurysm of DPA in a man with no significant atherosclerotic risk factors, trauma, or injuries. The surgical repair with aneurysmectomy and end-to-end anastomosis was successful, with no complications and after 8 months the repaired DPA remains patent.
REFERENCES 1. Cuff A. Spontaneous aneurysm of the dorsalis pedis artery. Br Med J 1907;2:16. 2. Al-Omran M. Repair of a true dorsalis pedis artery saccular aneurysm. J Surg Case Rep 2012;2012:15. 3. Kato T, Takagi H, Sekino S, et al. Dorsalis pedis artery true aneurysm due to atherosclerosis: case report and literature review. J Vasc Surg 2004;40:1044e8.
4 Case Report
4. Robaldo A, Colotto P, Palombo D. True atherosclerotic pedis artery aneurysm. Interact Cardiovasc Thorac Surg 2010;11: 216e7. 5. Pasztori M, Avram J, Manciu S, et al. Case report of a dorsalis pedis artery aneurysm. J Exp Med Surg Res 2009;16: 118e23. 6. Fitzpatrick WH. Idiopathic aneurysm of the dorsalis pedis artery. J Foot Surg 1980;19:185e6. 7. De Frutos JL, Gomez Palones FJ, Caldero Pardo J, et al. Arteriosclerotic aneurysm of the pedal artery. Angiologia 1988;40:109e12. 8. Wu KK. True aneurysm of the dorsalis pedis artery mimicking a soft tissue tumor. J Foot Surg 1991;30: 304e7. 9. Morettini G, Ventura M, Marino GA, et al. Isolated aneurysm of the dorsalis pedis artery. Eur J Vasc Endovasc Surg 1995;9:485e6. 10. Herrmann M. Pedal aneurysms. Eur J Vasc Endovasc Surg 1996;11:250. 11. McKee T, Fisher J. Dorsalis pedis artery aneurysm: case report and literature review. J Vasc Surg 2000;31:589e91. 12. Tempest HV, Wilson YG. Acute forefoot ischaemia: an unreported complication of dorsalis pedis artery aneurysm. Eur J Vasc Endovasc Surg 2001;22:472e3. 13. Taylor DT, Mansour MA, Bergin JT, et al. Aneurysm of the dorsalis pedis artery: a case report. Vasc Endovascular Surg 2002;36:241e5. 14. Burton S, Himpson R, Kumar K, et al. Repair of a dorsalis pedis artery aneurysm. Eur J Vasc Endovasc Surg 2002;3: 21e2.
Annals of Vascular Surgery
15. Bausells MI, Raymundo SR, Menezes da Silva AA, et al. Aneurysm of the dorsalis pedis artery: case report and literature review. J Vasc Bras 2003;21:26e8. 16. Bellosta R, Talarico M, Luzzani L, et al. Non-atherosclerotic dorsalis pedis artery true aneurysm; case report and literature review. Eur J Vasc Endovasc Surg 2005;10:146e8. 17. Maydew MS. Dorsalis pedis aneurysm: ultrasound diagnosis. Emerg Radiol 2007;13:277e80. 18. Legel K, Savard M, Blanco CJ, et al. Dorsalis pedis aneurysm: a case report and review of the literature. Foot Ankle J 2008;1:1e6. 19. Berard X, Bodin R, Saucy F, et al. Current management of true aneurysm of the dorsalis pedis artery. Ann Vasc Surg 2011;25:265.e13e6. 20. Bittner JG, Hardy D, Biddinger PW, et al. Giant, metachronous bilateral dorsalis pedis artery true aneurysms. Ann Vasc Surg 2012;26:279.e13e6. 21. Ballesteros-Pomar M, Sanz-Pastor N, Vaquero-Morillo F. Repair of bilateral true aneurysms of the dorsalis pedis artery. J Vasc Surg 2013;57:1387e90. 22. Sonntag M, Hopper N, Graham A. ‘‘Sandal strap’’ trauma and atherosclerosis are dual pathologies leading to bilateral true aneurysms of the dorsalis pedis arteries. J Vasc Surg 2013;57:1391e4. 23. Jin PH, van der Elst A, Nio D. A man with a pulsating mass on the dorsal side of his foot. Ned Tijdschr Geneeskd 2014;158:A7829. 24. Agzarian An, Agzarian Al. An unusual cause of a lump on the foot: aneurysm of the dorsalis pedis artery. Proceedings of UCLA Healthcare 2013;17.