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Unrecognized pseudoaneurysm following foot surgery
TheFoot(1998) 8, 102-103 0 1998 Harcourt Brace &Co
Ltd
CASE REPORT
Unrecognized pseudoaneurysm following foot surgery J.M.D. Wheeler,A. Shandall Royal Gwent Hospital, Newport, Gwent, UK
INTRODUCTION Pseudoaneurysms may develop following either blunt or penetrating trauma, caused by unrecognized arterial damage’s2. In contrast, however, iatrogenic pseudoaneurysms of pedal vessels following surgery are rare3. We report a case of pseudoaneurysm of the lateral plantar artery following surgery for club foot.
CASE REPORT A 3-year-old boy underwent a ‘Dilwyn Evans’ procedure to the left foot for talipes. This was performed under tourniquet control. Five months later he presented with a fluctuant swelling on the medial aspect of the foot. An MRI scan suggested a false aneurysm of the posterior tibia1 artery. A colour duplex scan showed that the anterior tibia1 artery was occluded at the ankle, and arteriography under anaesthetic prior to surgery confirmed the absence of the dorsalis pedis artery (Fig. 1). The medial aspect of the foot was explored and on-table arteriography demonstrated the pseudoaneurysm to be fed from the lateral plantar artery (Fig. 2). This was ligated together with the multiple venous communications as illustrated by Figure 2. His recovery was uneventful with no clinical abnormality at the 12-month follow-up.
Fig. l-Preoperative arteriogram showing the pseudoaneurysm (arrowed) m the distribution of the posterior tibia1 artery.
DISCUSSION Pseudoaneurysms, although rare, are recognized to follow paediatric foot surgery3. They present as pulsatile masses that gradually enlarge, with a delay to first presentation ranging from days to years*. Mardjetko et al reviewed 2,756 foot operations and found an overall incidence of 0.14%3. All these four /
Correspondence to: J.M.D.Wheeler FRCS, Research Fellow, ICRF, IMM. John Radcliffe Hospital. Oxford OX3 9DIJ. A.Shandall FRCS MCh, Consultant Surgeon, Royal Gwent Hospital, Newport, Gwent, UK.
,, ‘ ..II&.. e
Fig. con-table arteriogram showing the pseudoaneurysm (thin white arrow) being supplied by the lateral plantar artery (dark arrow). Note also the early venous return (broad white arrow) resulting from the venous communications. 102
Unrecognized pseudoaneurysm following foot surgery patients had pseudoaneurysms of posterior tibia1 branches and presented within 3 months of surgery, as did our case. Pseudoaneurysms of anterior tibia1 branches have been reported secondary to trauma“. In our patient the diagnosis was made on MRI with duplex scanning showing an absent dorsalis pedis artery. On-table arteriography was essential as preoperative arteriography had not been successful in identifying the pseudoaneurysm’s arterial supply, although it had confirmed the absence of the dorsalis pedis artery. With this in mind, it is of interest to note that the anterior tibia1 pulse has been shown to be absent in 39% of children over the age of 3 with severe club foe?. This was of immediate significance as the posterior tibia1 supply could obviously not be compromised. In conclusion, preoperative duplex scanning and on-table arteriography are necessary to achieve accurate identification of the arterial anatomy and in particular the pseudoaneurysm’s precise arterial supply. Furthermore, as pseudoaneurysms are frequently not
0 1998
Harcourt
Brace
& Co. Ltd
103
recognized at the time due to surgery under tourniquet control’s’, its release before closure at the original operation may identiFy an unrecognized arterial aneurysm. ACKNOWLEDGEMENT
We thank Mr. K. Tayton for referring this interesting patient
REFERENCES
1. Bole P, Munda R. Purdy et al. Traumatic pseudoaneurysms: a review of 32 cases.Trauma 1976; 16: 63-70. 2. Economou P, Paton R, Galasko C. Traumatic pseudoaneurysm of the lateral plantar artery in a child. Journal of Paediatnc Surgery 1993; 28: 626. 3. Mardjetko S, Lubicky J, Kuo K, Smrcina C. Pseudoaneurysm after foot surgery. Journal of Paediatric Orthopaedics 1991; 11: 657-662. 4. Bogokomsky H, Slutzi S, Negri M, Halpern 2. Pseudoaneurysm of the dorsalis pedis artery. Injury 1985; 16: 424425. 5. Edelson J, Husseini N. The pulseless club foot. J Bone Joint Surg 1984: 66: 700-702.
The Foot (1998)
8, 102-l
03
Ltd
CASE REPORT
Unrecognized pseudoaneurysm following foot surgery J.M.D. Wheeler,A. Shandall Royal Gwent Hospital, Newport, Gwent, UK
INTRODUCTION Pseudoaneurysms may develop following either blunt or penetrating trauma, caused by unrecognized arterial damage’s2. In contrast, however, iatrogenic pseudoaneurysms of pedal vessels following surgery are rare3. We report a case of pseudoaneurysm of the lateral plantar artery following surgery for club foot.
CASE REPORT A 3-year-old boy underwent a ‘Dilwyn Evans’ procedure to the left foot for talipes. This was performed under tourniquet control. Five months later he presented with a fluctuant swelling on the medial aspect of the foot. An MRI scan suggested a false aneurysm of the posterior tibia1 artery. A colour duplex scan showed that the anterior tibia1 artery was occluded at the ankle, and arteriography under anaesthetic prior to surgery confirmed the absence of the dorsalis pedis artery (Fig. 1). The medial aspect of the foot was explored and on-table arteriography demonstrated the pseudoaneurysm to be fed from the lateral plantar artery (Fig. 2). This was ligated together with the multiple venous communications as illustrated by Figure 2. His recovery was uneventful with no clinical abnormality at the 12-month follow-up.
Fig. l-Preoperative arteriogram showing the pseudoaneurysm (arrowed) m the distribution of the posterior tibia1 artery.
DISCUSSION Pseudoaneurysms, although rare, are recognized to follow paediatric foot surgery3. They present as pulsatile masses that gradually enlarge, with a delay to first presentation ranging from days to years*. Mardjetko et al reviewed 2,756 foot operations and found an overall incidence of 0.14%3. All these four /
Correspondence to: J.M.D.Wheeler FRCS, Research Fellow, ICRF, IMM. John Radcliffe Hospital. Oxford OX3 9DIJ. A.Shandall FRCS MCh, Consultant Surgeon, Royal Gwent Hospital, Newport, Gwent, UK.
,, ‘ ..II&.. e
Fig. con-table arteriogram showing the pseudoaneurysm (thin white arrow) being supplied by the lateral plantar artery (dark arrow). Note also the early venous return (broad white arrow) resulting from the venous communications. 102
Unrecognized pseudoaneurysm following foot surgery patients had pseudoaneurysms of posterior tibia1 branches and presented within 3 months of surgery, as did our case. Pseudoaneurysms of anterior tibia1 branches have been reported secondary to trauma“. In our patient the diagnosis was made on MRI with duplex scanning showing an absent dorsalis pedis artery. On-table arteriography was essential as preoperative arteriography had not been successful in identifying the pseudoaneurysm’s arterial supply, although it had confirmed the absence of the dorsalis pedis artery. With this in mind, it is of interest to note that the anterior tibia1 pulse has been shown to be absent in 39% of children over the age of 3 with severe club foe?. This was of immediate significance as the posterior tibia1 supply could obviously not be compromised. In conclusion, preoperative duplex scanning and on-table arteriography are necessary to achieve accurate identification of the arterial anatomy and in particular the pseudoaneurysm’s precise arterial supply. Furthermore, as pseudoaneurysms are frequently not
0 1998
Harcourt
Brace
& Co. Ltd
103
recognized at the time due to surgery under tourniquet control’s’, its release before closure at the original operation may identiFy an unrecognized arterial aneurysm. ACKNOWLEDGEMENT
We thank Mr. K. Tayton for referring this interesting patient
REFERENCES
1. Bole P, Munda R. Purdy et al. Traumatic pseudoaneurysms: a review of 32 cases.Trauma 1976; 16: 63-70. 2. Economou P, Paton R, Galasko C. Traumatic pseudoaneurysm of the lateral plantar artery in a child. Journal of Paediatnc Surgery 1993; 28: 626. 3. Mardjetko S, Lubicky J, Kuo K, Smrcina C. Pseudoaneurysm after foot surgery. Journal of Paediatric Orthopaedics 1991; 11: 657-662. 4. Bogokomsky H, Slutzi S, Negri M, Halpern 2. Pseudoaneurysm of the dorsalis pedis artery. Injury 1985; 16: 424425. 5. Edelson J, Husseini N. The pulseless club foot. J Bone Joint Surg 1984: 66: 700-702.
The Foot (1998)
8, 102-l
03