Successful Stenting of Iatrogenic Anterior Tibial Artery Pseudoaneurysm.

INTRODUCTION: The use of covered tibial stents extends beyond the treatment of atherosclerotic disease. Tibial artery pseudoaneurysms have traditionally been managed with open surgery; however, the endovascular option is an emerging treatment. REPORT: This report describes endovascular management of an iatrogenic anterior tibial artery pseudoaneurysm using a covered stent.
CONCLUSION: This case highlights the use of a covered stent for pseudoaneurysm exclusion, vascular control, and to minimize dissection in a patient with multiple previous surgeries.

Introduction

Tibial artery pseudoaneurysms have traditionally been managed with open surgery. Case reports utilizing the endovascular strategy are reported in the literature; however, this approach in the setting of multiple interventions is ill defined (Table 1). As stent technology progresses, this minimally invasive strategy may become a durable option for pseudoaneurysm exclusion.

Table 1

Summary of published case reports using covered stents for tibial pseudoaneurysm.

Author	Etiology	Stent	Location	Size, mm
De Roo (2004)10	Fibulectomy	PTFE Symbiot (Boston Scientific)	ATA	4 × 31
Spirito (2007)5	Blunt trauma	ePTFE Graftmaster Jostent (Abbott Vascular)	ATA	4 × 26
Van Hensbroek (2007)7	Tibial plate Insertion	PTFE Symbiot (Boston Scientific)	ATA	3 × 20
Joglar (2010)8	Blunt trauma/fracture	ePTFE Graftmaster Jostent (Abbott Vascular)	PTA	3 × 19
Marks (2011)9	Penetrating trauma	iCAST (Abbott Vascular)	TPT	5 × 16
De Troia (2014)6	Penetrating trauma	ePTFE (InSitu Direct Stent Technologies)	PTA	3 × 19

ATA = anterior tibial artery; PTA = posterior tibial artery; TPT = tibioperoneal trunk.

Report

A 52-year-old female, a smoker, presented with an acutely painful, pulsatile mass in the anterior compartment of the left lower leg. One week earlier, internal fixation hardware for a tibial plateau fracture had been electively removed without immediate complication. Examination revealed a tense, tender, pulsatile mass in the anterior compartment with threatened skin along the recent surgical incision (Fig. 1). There was no evidence of compartment syndrome or bleeding and the peripheral pulses were normal.

Figure 1

Left leg swelling (red arrow) below the knee (black arrow) viewed from the medial side.

Blood chemistry including white cell count and C-reactive protein were normal. An arterial phase computed tomography angiography scan showed an 18 × 2.5 × 3.8 cm pseudoaneurysm arising from the proximal anterior tibial artery (ATA). There were no radiological features of infection in the surrounding tissues (Fig. 2).

Figure 2

Sagittal computed tomography angiogram of the left leg demonstrating a pseudoaneurysm from the proximal anterior tibial artery (red arrow).

Because of the recent revision surgery and proximal location of the pseudoaneurysm arising from the ATA, an endovascular approach was favored. Retrograde arterial access via the contralateral common femoral artery was obtained with a 5F sheath and a stiff 0.035 glide wire (Terumo, Tokyo). This sheath was exchanged to a 55 cm, 6F, Check-flow ANL1 sheath (Cook, Bloomington, IL, USA) that was positioned over the aortic bifurcation into the superficial femoral artery. An angiogram demonstrated the ATA pseudoaneurysm and confirmed distal runoff via three vessels (Fig. 3A). The ATA was secured using a V14, 0.014 Control wire (Boston Scientific, Marlborough, MA, USA) and 65 cm Vanschie 1 catheter (Cook, Bloomington, IL, USA). An ePTFE 3.5 × 26 mm Graftmaster RX covered stent (Abbott Vascular Devices, Abbott Park, IL, USA) was deployed across the pseudoaneurysm neck. Angiogram confirmed both the absence of flow in the pseudoaneurysm and preserved flow distally (Fig. 3B). Following pseudoaneurysm exclusion, the resultant hematoma was then surgically evacuated with minimal dissection. The tissue microscopy and culture was negative for infection. Dual antiplatelet therapy was commenced post operatively. Because of geographical factors, normal perfusion has been reported by the local primary care physician at 12 months.

Figure 3

(A) Preintervention angiogram demonstrating the pseudoaneurysm of the anterior tibial artery (ATA- Red Arrow) below a high take-off posterior tibial artery (PTA). (B) Post intervention angiogram confirming adequate stent placement (red arrow) with exclusion of the ATA pseudoaneurysm using a covered stent.

Discussion

Tibial artery pseudoaneurysms are uncommon and have been reported following blunt and penetrating soft tissue trauma, following long bone fractures and also as a complication of fracture fixation.1, 2 Open surgery with simple ligation or interposition vein grafting has been the standard of practice. Conservative management, coil embolization, and ultrasound-guided thrombin injection also have been reported.3, 4 Case reports using covered stents have been described in the literature following trauma with immediate technical success; however, no reports have been published in the setting of multiple previous surgeries.5, 6 In this situation with the open approach more challenging because of obliterated tissue planes, an alternative to open surgery has clear benefits. The use of a covered stent to gain intravascular control avoids multiple operative incisions to gain proximal and distal control while achieving the aim of preservation of distal flow. The avoidance of extensive dissection within an area of scar tissue and distorted tissue planes also facilitates a minimalist approach to hematoma evacuation following pseudoaneurysm exclusion. This technique allows rapid vascular control and can be performed using local anesthetic in the endovascular suite.

This case highlights the advantages of an endovascular strategy when managing tibial artery pseudoaneurysms in patients with multiple previous surgeries.

Conflict of Interest

None.

Funding

None.