CASE REPORT Year : 2022  |  Volume : 9  |  Issue : 5  |  Page : 415-417

Spontaneous pseudoaneurysm of posterior tibial artery with deep vein thrombosis and compartment syndrome

Neelamjingbha Sun, Sriram Manchikanti, Aditya Gupta, Shivanesan Pitchai
Department of CVTS, Division of Vascular Surgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India

Date of Submission17-Jul-2022Date of Acceptance21-Jul-2022Date of Web Publication13-Jan-2023

Correspondence Address:
Dr. Shivanesan Pitchai
Department of CVTS, Division of Vascular Surgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/ijves.ijves_44_22

Posterior tibial artery (PTA) aneurysms are rare and associated with trauma and orthopedic interventions. We present a rare case of spontaneous pseudoaneurysm of the PTA, complicated with deep vein thrombosis and compartment syndrome. The patient was managed with popliteal to PTA bypass using contralateral limb reversed saphenous vein graft, and yielded good results.

Keywords: Posterior tibial artery pseudoaneurysm, pseudoaneurysm with deep vein thrombosis, spontaneous pseudoaneurysm

How to cite this article:
Sun N, Manchikanti S, Gupta A, Pitchai S. Spontaneous pseudoaneurysm of posterior tibial artery with deep vein thrombosis and compartment syndrome. Indian J Vasc Endovasc Surg 2022;9:415-7
How to cite this URL:
Sun N, Manchikanti S, Gupta A, Pitchai S. Spontaneous pseudoaneurysm of posterior tibial artery with deep vein thrombosis and compartment syndrome. Indian J Vasc Endovasc Surg [serial online] 2022 [cited 2023 Jan 14];9:415-7. Available from: https://www.indjvascsurg.org/text.asp?2022/9/5/415/367718   Introduction 

Aneurysms of posterior tibial artery (PTA) are rare and have been reported with trauma and orthopedic interventions.[1],[2],[3] We present a case of spontaneous pseudoaneurysm of the PTA complicated with deep vein thrombosis (DVT) and compartment syndrome.

  Case Report 

An 85-year-old man, known hypertensive, presented with acute-onset right lower-limb pain for 5 days, elsewhere diagnosed with right unprovoked femoropopliteal DVT and started on anticoagulation. After 4 days on anticoagulation, he developed a swelling in the right calf, which was associated with severe pain and numbness. On examination, his vitals were stable and a tense, tender swelling was palpable in the right calf. His leg was cold to touch, sensations were absent, and distal pulses were absent, with decreased movements of the toes and ankle. On a handheld Doppler, his right PTA signals and anterior tibial artery (ATA) signals were absent. Computed tomography angiogram revealed the presence of a pseudoaneurysm arising from the PTA, of size approximately 6.2 cm × 4.5 cm × 4 cm, causing compression of the compartment muscles [Figure 1] and [Figure 2]. Imaging also confirmed the presence of thrombosed popliteal vein. His blood investigations were normal, and echocardiography showed no features of infective endocarditis, with good biventricular function. No other aneurysms were detected elsewhere in the body.

Figure 1: CT angiogram showing right PTA aneurysm. (a) Volume rendered image. (b and c) Axial sections showing the aneurysm with peripheral thrombus. CT: Computed tomography, PTA: Posterior tibial artery

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Figure 2: CT, axial images. (a) Venous phase, axial image showing thrombosed right popliteal vein (yellow arrow). (b) Plain CT, axial image showing the peripheral thrombus, with stretched posterior compartment muscles. CT: Computed tomography

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After written and informed consent, the patient was taken up for surgical intervention in order to repair the pseudoaneurysm and decompress the compartment, via medial approach under spinal anesthesia. Supragenicular popliteal artery (P1) was exposed and control was taken. Infragenicular popliteal artery (P3) was inflamed and densely adherent to the popliteal vein. Gastrocnemius and soleus muscles were edematous but contractile. On tracing the P3 vessel distally, pseudoaneurysm of the PTA of size approximately 6 cm × 4 cm was visualized [Figure 3]. Heparin 1 mg/kg was given.

Figure 3: Intraoperative image showing the infragenicular exposure of popliteal artery and pseudoaneurysm

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The pseudoaneurysm was opened, and fresh clots were present in the sac, with a 5-mm rent in the proximal PTA. The rent was occluded with a 5Fr Fogarty catheter. PTA distal to the pseudoaneurysm was traced till midleg and control was taken. Contralateral limb great saphenous vein was harvested and used for P1 to PTA bypass.

Post procedure, he had good pulses palpable in the PTA. Culture sensitivity report of the clots evacuated from the pseudoaneurysm was negative. Histopathology examination was negative for vasculitis and inflammatory disorders.

The postoperative period was uneventful, and he was started on heparin infusion. Oral anticoagulation was started from the 3rd postoperative day and continued till the next 6 months. On follow-up, he had improved movements of the toes, ankle joint. On 1-year follow-up, he has palpable PTA pulse, with good ATA signals and ambulates with support.

  Discussion 

The first case of PTA aneurysm was reported in 1987 by Rowe et al., and since then, majority of publications have been case reports.[4] Most cases have been reported as posttraumatic or iatrogenic following endovascular procedures, embolectomy, or orthopedic interventions.[1],[2],[3],[5] Genetic and inflammatory disorders have also been described.[6],[7] The cause of the pseudoaneurysm in our patient is unknown, but it could have been related to atherosclerosis. It is also possible that our patient already had a pseudoaneurysm of the PTA, which caused DVT, and increased in size when the patient was started on anticoagulation.

Presenting complaints include swelling in the leg, pain, and paresthesias, which may be related to compression by the pseudoaneurysm.[8] Distal thrombosis and rupture have also been reported but rare.[8] Our patient presented with DVT, which has not been reported yet in prior case reports.

Imaging helps to define the size and extent of the aneurysm, along with assessment for the presence of other aneurysms that may not be clinically appreciated. Such cases should be investigated for the presence of vasculitis, infective endocarditis, and genetic disorders.[6],[7],[9] In this patient, imaging confirmed the presence of the pseudoaneurysm and DVT, along with stretched posterior compartment muscles indicating the need for a release of the compartment and assessment of the muscles for viability.

Management modalities include stenting, thrombin injection, ligation of PTA, and aneurysm repair with or without bypass.[2],[10] Our patient had features of compartment syndrome, hence an open repair was more feasible as it allowed surgical decompression and an option for bypass. The role of observation in PTA aneurysm is questionable as there is always the risk of thrombus formation and distal embolization. Hence, it is routinely advised to correct the aneurysm. Guidelines on the management of infrapopliteal aneurysms are yet to be defined.

We would like to conclude that a case of spontaneous PTA pseudoaneurysm presenting with DVT and compartment syndrome is a rare clinical entity, and should be addressed in view of the complication risks.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 

  References 
1.de Troia A, Biasi L, Iazzolino L, Azzarone M, Tecchio T, Rossi C, et al. Endovascular stent grafting of a posterior tibial artery pseudoaneurysm secondary to penetrating trauma: Case report and review of the literature. Ann Vasc Surg 2014;28:1789.e13-7.  
    2.Singh D, Ferero A. Traumatic pseudoaneurysm of the posterior tibial artery treated by endovascular coil embolization. Foot Ankle Spec 2013;6:54-8.  
    3.Brigido SA, Bleazey ST, Oskin TC, Protzman NM. Pseudoaneurysm of the posterior tibial artery after manipulation under anesthesia of a total ankle replacement. J Foot Ankle Surg 2013;52:655-8.  
    4.Rowe P, Taylor P, Franklin A, McColl I, Missen A, Spencer J. Unusual causes of calf swelling-1. Unusual presentation of a tibial artery false aneurysm. Postgrad Med J 1987;63:649-52.  
    5.Gangadharan A, Sekhar R, Bhanushali J, Thusay P. Pseudoaneurysm of posterior tibial artery management: Case report and review of literature. J Curr Surg 2015;5:209-12.  
    6.Arici V, Corbetta R, Fossati LG, Odero A. Acute first onset of Ehlers-Danlos syndrome type 4 with spontaneous rupture of posterior tibial artery pseudoaneurysm. Vascular 2013;21:43-5.  
    7.Maga P, Batko B, Kaczmarczyk P, Krawiec P, Krzanowski M. Unusual presentation of polyarteritis nodosa with unilateral pseudoaneurysm of the posterior tibial artery. Pol Arch Med Wewn 2015;125:301-2.  
    8.Tshomba Y, Papa M, Marone EM, Kahlberg A, Rizzo N, Chiesa R. A true posterior tibial artery aneurysm – A case report. Vasc Endovascular Surg 2006;40:243-9.  
    9.Jiang C, Lu H, Guo Y, Zhu L, Luo T, Ziai W, et al. Blood culture-negative but clinically diagnosed infective endocarditis complicated by intracranial mycotic aneurysm, brain abscess, and posterior tibial artery pseudoaneurysm. Case Rep Neurol Med 2018;2018:1236502.  
    10.Nemeth K. A tricky nontraumatic pseudoaneurysm of the posterior tibial artery. J Vasc Surg 2016;64:1483.  
    
  [Figure 1], [Figure 2], [Figure 3]