Cas cliniques

DOI of or1Vascular

Hospital, Turi2Vascular

pital, Asti, Ita

CorrespondSurgery Unit,Turin, Italy, E

Ann Vasc SurDOI: 10.1016/� Annals of V�Edit�e par ELS

Rupture d’un an�evrysme vrai g�eant de l’art�eretibiale post�erieure de 6 cm de diam�etre

Emanuele Ferrero,1 Michelangelo Ferri,1 Andrea Viazzo,1 Andrea Gaggiano,2

Giuseppe Berardi,1 Salvatore Piazza,1 Pia Cumbo,1 Claudio Castagno,1 Alberto Pecchio,1

Franco Nessi,1 Asti et Turin, Italie

Les an�evrysmes vrais de l’art�ere tibiale sont rares et leur rupture est tr�es rare. Nous rapportonsle cas d’un homme de 59 ans qui, apr�es un �episode d’endocardite bact�erienne, a pr�esent�e unan�evrysme tibial post�erieur rompu. �A notre connaissance, c’est le premier cas d’une v�eritablerupture d’un an�evrysme g�eant de l’art�ere tibiale post�erieure (diam�etre, 6 cm). Le traitement s’estcompos�e de l’an�evrysmectomie avec ligature art�erielle. Un ult�erieur de 24 mois a �et�e fait avecde bons r�esultats.

True aneurysms of tibial artery are uncommon and

it is really rare rupture. The etiology is unclear:

fibromuscular fibrodysplasia, trauma, atherosclero-

sis, inflammation, infection, and other pathological

processes are also probably involved. As all aneu-

rysm, they can evolve to thrombosis and distal

embolism more than to rupture. The literature

reports only 14 cases of posterior tibial artery and

only one case of tibial artery aneurysm rupture.

CASE REPORT

On March 6, 2007, a 59-year-old man presented to our

hospital for treatment of bacterial endocarditis (mitral

valve vegetations demonstrated on echocardiography).

Patient medical history: McArdle’s disease, hyperten-

sion, dyslipidemia, on October 2006 onset of evening

fever regressed without specific treatment (no ematic or

iginal article: 10.1016/j.avsg.2010.01.016.

and Endovascular Surgery Unit, Mauriziano Umberto In, Italie.

and Endovascular Surgery Unit, Cardinal Massaia Hos-lie.

ence : Emanuele Ferrero, Vascular and EndovascularMauriziano Umberto I Hospital, Largo Turati 62, 10128-mail: emaferrero@libero.it

g 2010; 24: 1134.e9-1134.e13j.acvfr.2011.04.007ascular Surgery Inc.EVIER MASSON SAS

lymphatic pathologies neither infectious diseases found

with the exception of doubtful positive for Parvovirus), on

February diagnosis of spondylodiscitis (diagnosticated by

magnetic resonance and confirmed by bone scan and

positron emission tomography imaging) and under anti-

biotic treatment (ceftriaxone and amikacin), on February

diagnosis deep vein thrombosis (DVT) of the left lower leg

under therapy with low molecular weight heparin

(LMWH). During hospitalization hewas given appropriate

antibiotic therapy, and the patient underwent color flow

color duplex ultrasound study (DUS) to check the DVT.

The DUS confirmed the presence of DVT of the left lower

leg and showed a 28-mm diameter aneurysm of the pos-

terior tibial artery to a length of 25 mm never diagnosed

before (Fig. 1). The arterial lumen was patent with little

eccentric mural thrombus, the diameter of undiseased

proximal and distal posterior tibial artery was regular, and

velocity spectral analysis identified distal stenosis and poor

flows at level of posterior tibial artery and peroneal artery;

the analysis of anterior tibial artery identified no stenosis

with regular distal flow. A computed tomography (CT)

scan, performed for evaluation of thoracic, abdomen, and

legs, confirmed the presence of both spondylodiscitis that

left posterior tibial artery aneurysm (diameter, 30 mm;

Fig. 2). The patient, few days after the CT scan, developed

an intracerebral hemorrhage (presumably due to rupture

of cerebral mycotic aneurysm) with consequent coma

state associated to right hemiplegia and aphasia, it was

necessary to perform a cranial decompression with

hematoma evacuation. Therefore, given the clinical con-

dition of the patient (comatose state, hemiplegia, enteral

nutrition through a nasogastric tube, breathing through a

1226.e5

Fig. 2. Computed tomography scan showing the pos-

terior tibial artery true aneurysm (3 cm diameter).

Fig. 1. Color duplex sonography showing the aneurysm

in the posterior tibial artery (2.8 cm diameter).

1226.e6 Cas cliniques Annales de chirurgie vasculaire

tracheostomy tube), the left tibial artery aneurysm has

become a secondary issue, and it was decided tomonitor it

over time. Two months after cerebral bleeding, the pa-

tient presented clinical and neurological improvement,

although his general condition remained critical (per-

cutaneous endoscopic gastrostomy tube placement was

thought necessary for nutrition) but the echocardio-

graphy control scan revealed no more valvular vegeta-

tions. At 8 months after the diagnosis of tibial aneurysm,

the patient was referred to our attention for the detection

of a sudden swelling of the left calf with pulsating mass

associated; the urgent DUS showed a 60-mm diameter

aneurysm of the posterior tibial artery ruptured. The

patient underwent surgery, through medial approach the

giant left tibial posterior aneurysm was detected (Fig. 3)

and was found the rupture of the posterior wall of the

aneurysm. The patient was successfully treated with

aneurysmectomy and surgical arterial ligation under spi-

nal anesthesia. Before, during, and after surgery there was

a regular pulse at the dorsal artery of the left foot. Thus,

both for regular blood supply of the foot (guaranteed by

the anterior tibial artery) and for the suspicion of a

mycotic aneurysm, we felt that the treatment by pro-

sthetic graft or by vein graft was inappropriate because of a

high risk of superinfection and subsequent prosthetic

detachment; hence, we considered the surgical ligation of

the posterior tibial artery as an acceptable treatment. The

postoperative course was uneventful, the patient under-

went intravenous antibiotic therapy for at least 6 weeks.

The patient had no ischemic signs in the lower left leg.

Histologic examination showed wall aneurysmal dilata-

tion with disappearance of the inner limiting tunic,

fibrosis of the medial tunic with atrophy of muscle fibers,

elastic fibers fragmentation of external tunic and fibrosis

limiting periadventitial tunic and hyaline sclerosis of

subintimal plaque; it also showed the absence of inflam-

matory elements in the material examined. At 24 months

follow-up neither foot nor digital ischemia has been

observed; the patient has no paresthesias, pain, dis-

comfort, or leg limitation. A 24 months duplex

scan follow-up examination revealed good patency

of the anterior tibial artery without stenosis, no pseudo-

aneurysm or recurrent aneurysm of the posterior tibial

artery.

DISCUSSION

The aneurysms of the infrapopliteal arteries are rare,

lots of them appear as false and are associated with

trauma or iatrogenic injury.1 True aneurysms of the

posterior tibial artery are really rare, only 14 isolated

case reports in the literature, and themajority of these

were described as either idiopathic or degenerative in

origin. The etiology is unclear: traumatic events,

collagen matrix alterations, infection, inflammation,

fibromuscular dysplasia are more commonly invol-

ved thanatherosclerosis.2 Themycotic etiology iswell

documented and reported in literature,3-6 usually

mycotic aneurysms occur most frequently in the

intracranial arteries (65%), followed by visceral

arteries and vessels of the upper and lower limbs. In

our case thepatientdidnot suffer fromatherosclerotic

disease, vasculitic disorders, or trauma of the leg.

Initially, we thought that this unusual aneurysm

originated from an embolic vegetation that had

settled on the vessel wall and caused erosion and

subsequent mural weakness with consequent rup-

ture; moreover, the intracerebral hemorrhage was

presumably caused due to the rupture of another

mycotic aneurysm, and the histologic examination

was negative (no microbiological examination was

performed). For diagnosis of tibial aneurysm the color

flow duplex ultrasound is usually sufficient (as in our

case); with an accurate evaluation of the run-in and

the run-off it is possible to proceed with repair,

Fig. 3. Intraoperative images of tibial artery true aneurysm (6 cm diameter, rupture image).

Vol. 24, No. 8, 2010 Cas cliniques 1226.e7

although a study of second level (CT/magnetic

resonance or angiography) is better required for

aneurysm assessment and its relationship with sur-

rounding structures. Natural evolution of the tibial

aneurysms seems to be related to distal embolism and

thrombosis, whereas rupture is extremely rare. The

indications for treating these lesions are debated in

literature,7 someauthors assert thataneurysmsof any

origin must be treated promptly even if they are

asymptomatic supported by works that show infra-

popliteal aneurysm abruptly rupture with no

precursive symptoms8,9 or show leg ischemia which

requires limb amputation.10,11 In literature we found

only one case of ruptured aneurysm of the anterior

tibial artery causing acute compartment syndrome,9

but it is also reported that small and asymptomatic

Table I. Single case reports of posterior tibial arteries aneurysms in the English literature

Author Age (yr)/Gender Treatment Etiology Follow-up

Pappas et al.23 UK/UK UK UK UK

Katz et al.24 37/M Saphenous vein bypass Lupus-like syndrome Polyarthritis onset

3 mo after operation

Hasaniya and Katzen9 32/F Ligation Polyarteritis nodosa Death in 19th

postoperative day

Yao and McCarthy12 46/M UK UK Good perioperative

result

Kanaoka and

Matsuura269/F Saphenous vein bypass Degenerative Good perioperative

result

Jenyo17 60/F Ligation UK Good perioperative

result

Danes et al.25 UK/UK Saphenous vein bypass UK UK

Tshomba et al.22 54/M End-to-end

recontruction

Degenerative Alive and well

at 38 mo

UK, unknow.

1226.e8 Cas cliniques Annales de chirurgie vasculaire

aneurysms may be observed safely12 without deve-

lopment of symptoms or enlargement. Generally the

treatment indicated are for symptomatic aneurysms,

asymptomatic large aneurysms, or those with lami-

nated thrombus.13,14 The choice of the treatment is

debated: surgical (arterial repair, ligation) or endo-

vascular (embolization, percutaneous occlusion with

thrombin).15 In literature some authors assert that if

the residual infrapopliteal arteries are normal, a sim-

ple ligation is permissible,16-18 others that one func-

tional artery distal to the knee is sufficient for distal

blood flow.9,19 Bypass procedures are complicated by

the inherent presence of a septic focus and/or peri-

vascular inflammation: prosthetic grafts should the-

refore be avoided and autologous vein graft can be

used or extra-anatomical bypass through uninfected

tissue planes may avoid this. For more extensive

infective lesions or for presence of small size vessels or

poor run-off vessels the surgical option of ligature,

particularly in an emergency setting, may be per-

formed.20 In the caseof ligationanalternative toopen

surgery is given by endovascular embolization or

fibrin adhesive injection, generally these techniques

areused in the treatmentof pseudo-aneurysms rather

than true ones and are related to an increased risk of

limb ischemia.1,15,21 Open repair is themost common

management reported in the literature,2,22 with

ligation as a second option. In literature only eight

cases of repair of posterior tibial artery aneurysms are

reported (Table I): threewith saphenousveinbypass,2

twowith ligation, two casewithunknown treatment,

and one with end-to-end direct reconstruction.22 In

our case the etiology of aneurysm remained unk-

nown, probably it was mycotic, the cause of rupture

was related to rapid improvementof aneurismal sac in

few time (grow in 3 cm in 8 month). The authors

think that when an aneurysm of tibial artery is

detected it must be treated; the surgical repair, if the

anatomy is favorable, may be performed (by a direct

end-to-end anastomosis or by bypass), when surgical

reconstruction is not available, arterial ligation is a

good alternative, provided that residual infrapopliteal

arteries are normal (as in our case), not causing

complications; the role of endovascular and per-

cutaneous procedures has to be assessed.

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