G Chir Vol. 32 - n. 8/9 - pp. 379-383
Tibioperoneal true aneurysm: case report and literature review
F. Faccenna, A. Alunno, M.M.G. Felli, A. Castiglione, P. Izzo, B. Gossetti,
F. Stagnitti, A. Laurito, L. Izzo, R. Gattuso
“Sapienza” University of Rome, Italy
Vascular Surgery Department
Summary: Tibioperoneal true aneurysm: case report and literature review.
F. Faccenna, A. Alunno, M.M.G. Felli, A. Castiglione,
P. Izzo, B. Gossetti, F. Stagnitti, A. Laurito, L. Izzo, R. Gattuso
Background. The true aneurysms of the infrapopliteal arteries are an unusual pathology with low incidence in the general population. They appear in the literature only as isolated case reports. True aneurysms of the infrapopliteal arteries represent a surgical problem, especially when a bifurcation is involved and when the distal vessels are affected by occlusive disease.
Case report. A 67 year old man with an aneurysm which involved the tibioperoneal trunk and the origin of peroneal and posterior tibial arteries was surgical treated. At three months follow up, a duplex ultrasonography (DUS) control showed the bypass patency and the total exclusion of the aneurismal sac.
Discussion. Although the aneurysms of the infrapopliteal arteries are very uncommon and often asymptomatic, their associated vascular lesions and/or ischemic complications can lead to high risk of limb loss. When the aneurysm is large and/or symptomatic, the surgical treatment becomes mandatory. A conservative treatment and DUS follow up could be reserved to elderly patients and when the aneurysm is small and asymptomatic.
Riassunto: Aneurisma vero dell’arteria tibio-peroniera: caso clinico e revisione della letteratura.
F. Faccenna, A. Alunno, M.M.G. Felli, A. Castiglione,
P. Izzo, B. Gossetti, F. Stagnitti, A. Laurito, L. Izzo, R. Gattuso
L’arteria tibiale è raramente colpita da aneurisma vero; la maggior parte dei casi riportati in letteratura sono aneurismi falsi, dal momento che un evento traumatico si trova spesso nell’anamnesi del paziente. L’aneurisma vero infra-popliteo rappresenta un problema chirurgico soprattutto quando è coinvolta la biforcazione e quando i vasi distali sono affetti da malattia occlusiva periferica. Più frequentemente la causa è una degenerazione aterosclerotica della parete arteriosa, ma a volte l’eziologia è micotica.
Gli Autori riportano un caso di aneurisma tibio-popliteo vero, in una donna di 67 anni, trattato chirurgicamente. Il follow-up a 3 mesi ha dimostrato la validità dell’intervento chirurgico.
Key Words: Aneurysm - Tibial artery - Surgery.
Aneurisma - Arteria tibiale - Chirurgia.
Tibial arteries are rarely involved by true aneurysms; most of cases reported in the literature are false aneurysms, since a traumatic event is often found in the patient’s history. The true infrapopliteal aneurysms represent a surgical problem, especially when a bifurcation is involved and when the distal vessels are affected by occlusive disease. More frequently the cause is an atherosclerotic degeneration of arterial wall, but sometimes mycotic etiology is reported in literature (1-3).
In our case, a true aneurysm involving the origin of the posterior tibial and peroneal arteries was found and a surgical repair was carried out successfully.
A 67 year old man was admitted to our Department for a pulsatile painful mass in the antero-lateral compartment of the right leg and for an omolateral blue toe syndrome. The onset of symptoms was only few days before admission, during his working activity. There was not history of trauma, claudication and/or foot ischemia. No risk factors for atherosclerotic disease were detected: he had never been a smoker and his serum cholesterol level and blood pressure values were in normal range. His past medical history was also not contributory.
On physical examination, a painful pulsatile mass was found on the antero-lateral compartment of the leg just below the knee. All peripheral pulses were present at the ankle. After a duplex ultrasonography (DUS) of the popliteal and tibial vessels, an angiography was carried out and a 5 cm diameter saccular aneurysm was confirmed. It involved the tibioperoneal trunk and the origin of peroneal and posterior tibial arteries (Fig.1).
The patient was operated upon through a medial approach: the popliteal artery, the anterior tibial artery and the tibio-peroneal trunk were exposed to allow a good control of vessels inflow. A very careful dissection was carried out beyond the aneurysm to expose the outflow vessels. A short segment of autologous saphenous vein graft was used. The aneurysm was not removed but sewn with polypropylene 5/0 thread. The venous graft was connected above to the tibio-peroneal trunk by an end-to-end anastomosis, and below to the posterior tibial artery by an end-to-side anastomosis; 6/0 and 7/0 polypropylene sutures were used, respectively (Fig.2). Peroneal artery was ligated at the origin. At the end of procedure the posterior tibial artery showed a good pulsatility and an intraoperative angiography showed the patency of the graft (Fig.3).
The patient was discharged after 8 days with relief of symptoms and posterior tibial pulse presence. Three months postoperatively, a DUS control showed the bypass patency and the total exclusion of the aneurismal sac.
The true aneurysms of the infrapopliteal arteries are an unusual pathology with low incidence in general population. They appear in the literature as isolated case reports (Tab.1). When those aneurysms become symptomatic, the patients can be observed on emergency for acute or critical leg or foot ischemia due to distal embolization or thrombosis of the aneurysm itself (4,5). In 2 cases microembolization with subsequent blue toe syndrome was reported (6,7). Sometimes the patients complain for chronic symptoms like claudicatio, rest pain or painful pulsatile mass. In only one case compression of the peroneal nerve was reported (8). Two patients had the rupture of tibial aneurysm: one of them complained for an acute painful calf swelling (9) and the other one had an acute compartment syndrome of both lower legs due to ruptured mycotic aneurysms of tibial arteries (10). Furthermore, it must be emphasized that those aneurysms may be identified accidentally by angiography or computed tomography (CT) scan carried out for occlusive disease (11,12). The diagnosis is not easy since digital or leg ischemia, claudicatio and pain are not typical or suggestive. Only the finding of a pulsatile mass can led to suspect an aneurysm (13-15). Nevertheless, the diagnosis can be reached by means of ultrasound, CT scan, magnetic resonance imaging (MRI) or digital subtraction angiography (DSA).
The treatment depends on the clinical presentation. When the aneurysms are small and asymptomatic, they can be followed for a long period by DUS, since the incidence of complications and the progression in size seems to be low. However, complications can occur indeed. When large and/or symptomatic aneurysm is found, the choice treatment is surgery.
There is no evidence in literature about endovascular exclusion by covered stent of infrapopliteal true aneurysms, probably due to the small vessels diameter, although a case of coil embolization is described (16). The procedure should be planned on the basis of angiographic findings (DSA, CT scan or MRI) and, if possible, the tibial arteries should be repaired to allow a better perfusion of the leg, especially when other vessels are occluded by microembolization or atherosclerotic lesions. In such conditions, the use of autogenous saphenous vein graft as a bypass (2,6,13,17-20) or as a patch (7,21) is the first choice, since it allows the best long-term patency rate. When the autologous vein is not available, a thin wall polytetrafluoroethylene (PTFE) graft could be used, but its employment is described principally in popliteal aneurysm repair; in three cases a PTFE popliteal-tibial artery bypass was carried out (22,23) In one patient an end-to-end anastomosis was performed after aneurysm excision (24). If the tibial arteries are in good conditions, the simple ligation of the aneurysm can be sufficient and safe and it can be left in place (8,10,14) or resected (4,15,25-30).
Although the aneurysms of the infrapopliteal arteries are very uncommon and often asymptomatic, their associated vascular lesions and/or ischemic complications can lead to high risk of limb loss; therefore we believe that, when the aneurysm is large and/or symptomatic, the surgical treatment becomes mandatory.
The reconstruction of the arteries should be preferred especially when those ones are involved by occlusive disease.
A conservative treatment and a follow up by of DUS could be reserved to elderly patients and when the aneurysm is small and asymptomatic.
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