versão impressa ISSN 1677-5449
J. vasc. bras. v.6 n.2 Porto Alegre jun. 2007
Domingos de Morais FilhoI; Ramzi Abdallah El Hosni Jr.II; Carlos Alberto Morselli DinizIII; Igor Schincariol PerozinIV; Juliana Palmeira GonçalvesIV; José Antônio Morselli DinizV
professor, Universidade Estadual de Londrina (UEL), Londrina, PR, Brazil. Member,
IIVascular surgeon. Member, SBACV
IIISpecialist in Vascular Surgery, SBACV
IVMedical student, UEL, Londrina, PR, Brazil
VSpecialist in Vascular Surgery, SBACV. Member, Colégio Brasileiro de Cirurgiões
We describe a case of pseudoaneurysm in the posterior tibial artery following treatment for tibial and fibula fractures using external fixation (Ilizarov technique), as well as the techniques used for its treatment. Ultrasound-guided compression and ultrasound-guided thrombin injection were unsuccessfully performed. Definite treatment of pseudoaneurysm and arterial reconstruction was achieved through the traditional surgical treatment, using interposed graft of inverted homologous great saphenous vein. Indications, advantages and disadvantages of noninvasive treatment techniques (ultrasound-guided compression and ultrasound-guided thrombin injection) and the possible causes of their inability in obliterating the pseudoaneurysm are discussed. A literature review of pseudoaneurysms of the posterior tibial artery was also carried out, resulting in only one similar case out of 24 published cases.
Keywords: Pseudoaneurysm, posterior tibial artery, ultrasound-guided compression, ultrasound-guided thrombin injection, vascular ultrasound, duplex ultrasound.
Despite being relatively frequent, leg bone fractures and its surgical treatment rarely cause arterial pseudoaneurysms.1 External fixation for leg fractures are also an unusual cause of vascular lesions.2 The incidence of pseudoaneurysm (PA) located in the posterior tibial artery (PTA) is documented only in case reports,3-25 and there is no consensus for its treatment.
As a rule, the PA should be removed and the arterial lesion that caused it should be repaired. The classical treatment is surgical, consisting of the excision of the aneurysmal sac and arterial reconstruction or through a bypass, generally using homologous vein due to the possibility of infection. The treatment of PA has recently included endovascular techniques (obliteration with coils or covered stents)26 or noninvasive techniques, such as ultrasound-guided compression (USGC)19 and ultrasound-guided injection of thrombin (USGIT).18,21,22,27
We report a case in which a PA of the PTA occurred after treatment of tibial and fibular fracture using Ilizarov external fixator. Noninvasive techniques to obliterate PA (USGC, USGIT) were unsuccessfully used. Classical surgical treatment was necessary. The PA was resected and an interposed graft was developed using the inverted homologous great saphenous vein for the PTA. A review of the literature was performed, comparing the results to our case (Table1).
A 22-year-old male patient with multiple trauma was submitted to fixation of left tibia and fibula using Ilizarov's technique due to fracture in its middle third. Removal of fixation wires occurred after 4 months. Fifteen days after this procedure, the patient presented pulsatile mass in the distal third of the medial aspect of the left leg. On physical examination, all pulses in the lower limbs were present, with ankle-brachial index equal to 1 bilaterally. Clinical suspicion of PA of the PTA was confirmed by vascular ultrasound (VUS) of the left lower limb. This examination, besides confirming arterial lesion, showed that PA diameters were 3.58 x 3.9 cm (AP and lateral) with possible longitudinal laceration of 10.1 mm in the posterior tibial artery wall (Figure 1).
The patient was submitted to two sessions of treatment using USGC, with immediate obliteration of the PA, but aneurysmal sac refilling occurred in 24 hours (Figure 2). We then chose the USGTI technique, which also achieved initial PA obliteration for 24 hours. To control the PA during thrombin injection, and as an attempt to prevent thrombin to migrate distally, we proximally compressed the leg arteries using a pressure cuff inflated at suprasystolic pressure (Figure 3). At control after 24 hours, there was PA refilling, and a new attempt of USGTI was performed, with the same initial and late outcome (Figure 4). We then chose to perform a surgical treatment by resecting the PA and placing an interposed graft in the PTA. During the surgery, longitudinal laceration of the PTA was confirmed.
In general, PA of the PTA, as other PA, result from arterial traumas. PA are more frequently located in the common femoral artery, due to frequent use of this artery as an approach to cardiac catheterization and endovascular techniques. PA of leg arteries are much less frequent, even as a consequence of using external fixators.2
Even much rarer are PA of the PTA, with only 24 cases3-25 in the literature (Table1). Their cause, which is always traumatic, cab be provoked by fractures (nine reported cases, 36%),3,4,6,7,11,15,20,24 after using embolectomy catheters (six cases, 24%),5,10,13,21-23 by lacerations (two cases, 8%),8,19 undefined (two cases, 8%)9,17 and by application of Ilizarov's external fixator12 (two cases, including ours, 8%). Cases of blunt trauma,18 orthopedic surgery to lengthen the Achilles tendon,14 plantar fasciotomy16 and perforating wound25 were responsible for one case each. In the only case report similar to ours,12 the authors performed a review of vascular complications in treatments using Ilizarov's technique. In that review, case 2 presented a PA of the PTA diagnosed by angiography on the 46th postoperative day with the patient still using a traction wire. Ligation of the posterior tibial artery was the treatment used.
The preferred diagnostic examination to identify PA over the past years has been VUS. In our review, angiography was the diagnostic examination in 10 out of 12 cases (83.33%) published prior to 1994 (Table1) and VUS in nine out of 13 cases (69.23%) described since 1995. VUS diagnostic criteria include visualization of a homogeneous mass with uniform density in B-mode examination, adjacent to an artery (which forms the PA sac), presence of circular blood flow inside it (in color and Doppler mode) and presence of communicating ostium, through which a bidirectional flow in Doppler mode is demonstrated28 (Figure 1).
Until 1991, treatment of PA was usually surgical, when Fellment29 reported the benefits of the ultrasound-guided compression technique (USGC) for PA. However, USGC has unsatisfactory results in patients with PA larger than 3-4 cm in diameter, and some patients do not tolerate the discomfort caused by this procedure. Possible complications of USGC are PA widening or rupture, vaso-vagal reactions, deep venous thrombosis, atrial fibrilation and angina.19,29 The USGC technique consists of compression at the level of the PA ostium, using an ultrasound transducer until occlusion of the PA in a single session or in compression sessions of up to 45 min. This procedure, however, demands much time to be performed, is painful for the patient, little effective for those under anticoagulation therapy and can be extenuating for the ultrasonographer. After a successful procedure, the patients should rest for about 6 hours with a compressive bandage for 24 to 48 hours. USGC is contraindicated in cases of PA in deeper location (deep femoral artery), limb ischemia, infection, compressive syndrome or large hematomas with skin ischemia.
The USGTI technique originally described by Cope & Zeita30 in 1986 was not widely used due to its possible morbidity potential. Its use was redefined with the publication of prospective studies showing the benefits of the technique in patients with PA of the common femoral artery.31 The USGTI, which was initially used in patients who presented much discomfort at compression, has a PA resolution rate ranging from 90-96% of patients32 when used for the treatment of PA located in the common femoral artery. In the first attempts, complications were described as a consequence of thrombin extravasation or thrombus migration for distal areas of the limb due to compression inefficacy, exceeding volume of injected thrombin or its large dilution.
The USGTI technique involves compression on the PA ostium with the transducer and thrombin injection inside the PA sac. The correct position of the injection needle inside the aneurysmal sac can also be confirmed by the transducer. Thrombin has a fast action, providing the formation of fibrin network in a few seconds, with mean PA thrombosis time of 12 seconds (ranging from 3 to 90 seconds),31-33 which requires monitoring of needle location and injection volume, due to risk of embolic events. At first, thrombin was used at large doses that predisposed to complications, but it was later verified that thrombin at low doses could have the same effect on the PA.31-33
Although there is no consensus or protocol regulating thrombin injection as to the relationship between thrombin volume and PA size, injection volume is determined by PA total coagulation, with immediate confirmation by ultrasonography.
It is recommended to perform the USGTI procedure at a hospital prepared for it, by a skilled vascular ultrasonographer and with immediate support in case there is any problem during intervention, due to risk of PA distal embolization.
After the procedure is over, patients should rest for 6 hours. An evaluation after 48 hours and 1 week is needed to assure there has been no recurrent PA or distal arterial embolization. Patients should be advised about cares concerning any allergic reaction.
In our review, the most frequent treatment (or resolution) of cases was ligation (in 12 cases or 48%), considering that there are three leg arteries and that ligation of one of them does not imply alteration of perfusion. Thrombin injection (USGTI) was successfully performed in three cases (12%)18,21,22 and compression (USGC) in only one case.19 In our case, PA evolution time (at least 2 weeks) and extensive laceration of the arterial wall could justify lack of success in both less invasive treatments (USGC and USGTI).
There is also a risk of anaphylactic reaction, but it is less frequent due to better drug depuration. Finally, there is the financial benefit of USGTI, since the surgical procedure for PA removal has a higher cost than this technique, besides presenting the risks common to surgeries.31-33
In our case, since the vascular lesion occurred at the distal portion of the leg, it could have been associated with removal of fixation wires from the left tibia and not with the fracture itself, considering that it occurred at the middle third of the tibia. Failure of treatments using noninvasive techniques for PA obliteration (USGC and USGTI) can serve as a warning to colleagues working with PA treatment, especially in cases of slower evolution and in cases in which there is possibility of extensive laceration of the arterial wall.
Facility and effectiveness of noninvasive treatment of peripheral artery PA, especially USGTI, are well known. However, in some cases, PA obliteration does not occur. Because PA of the PTA is rare, it is even more necessary to study and understand it. Although not being able to obliterate PA through USGC or USGTI, surgical treatment was successful, confirming that arterial laceration required a more aggressive treatment.
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Domingos de Morais Filho
Av. Bandeirantes, 403
CEP 86010-020 Londrina, PR, Brazil
Manuscript received January 13, 2007, accepted March 14, 2007.
This study was performed at Hospital do Coração, Londrina, PR, Brazil.