Pseudoaneurysm of the posterior tibial artery after external fixation for leg fracture: case report and review of the literature

Abstracts

Este trabalho descreve um caso de pseudo-aneurisma da artéria tibial posterior devido ao uso de fixador externo para tratamento de fratura dos ossos da perna (técnica de Ilizarov), bem como as técnicas utilizadas para seu tratamento. A compressão guiada por ultra-som e a injeção de trombina guiada por ultra-som foram realizadas, sem sucesso. O tratamento definitivo do pseudo-aneurisma e reconstrução arterial foi conseguido através do tratamento cirúrgico clássico, usando enxerto interposto de veia safena magna homóloga invertida. As indicações, vantagens e desvantagens das técnicas de tratamento não invasivo (compressão guiada por ultra-som e injeção de trombina guiada por ultra-som) e as possíveis causas de sua incapacidade na obliteração do pseudo-aneurisma são discutidas. Também foi realizada a revisão de casos de pseudo-aneurisma da artéria tibial posterior na literatura médica, encontrando-se apenas um caso semelhante, entre 24 publicados.

Pseudo-aneurisma; artéria tibial posterior; compressão guiada por ultra-som; injeção de trombina guiada por ultra-som; ultra-som vascular; duplex ultra-som

CASE REPORT

Pseudoaneurysm of the posterior tibial artery after external fixation for leg fracture: case report and review of the literature

Domingos de Morais Filho^I; Ramzi Abdallah El Hosni Jr.^II; Carlos Alberto Morselli Diniz^III; Igor Schincariol Perozin^IV; Juliana Palmeira Gonçalves^IV; José Antônio Morselli Diniz^V

^IAssociate professor, Universidade Estadual de Londrina (UEL), Londrina, PR, Brazil. Member, SBACV

^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

^{Correspondence}

ABSTRACT

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.

Introduction

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).

Case report

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.

Discussion

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 cases^3-25 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.

Conclusion

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.

References

Manuscript received January 13, 2007, accepted March 14, 2007.

This study was performed at Hospital do Coração, Londrina, PR, Brazil.

• 1. Katsamouris AN, Steriopoulos K, Katonis P, et al. Limb arterial injuries associated with limb fractures: clinical presentation, assessment and management. Eur J Vasc Endovasc Surg. 1995;9:64-70.
• 2. Polak WG, Pawlowski S, Skora J, et al. Vascular complications after the treatment with Ilizarov external fixators. Vasa. 2001;30:138-40.
• 3. Scudese VA, Hamada K. Pseudoaneurysm of the posterior tibial artery complicating fracture of the tibia. Vasc Surg. 1968;2:126-34.
• 4. Cameron HS, Laird JJ, Carroll SE. False aneurysms complicating closed fractures. J Trauma. 1972;12:67-74.
• 5. Byrnes G, Mac Gowan WA. The injury potential of Fogarty balloon catheters. J Cardiovasc Surg (Torino). 1975;16:590-3.
• 6. Dreyfus U, Fishman J. False aneurysm of the posterior tibial artery complicating fracture of the tibia and fibula. J Trauma. 1980;20:186-7.
• 7. Breen T, Brumback R. Posterior tibial artery pseudoaneurysm following tibial fracture. A case report. Orthopedics. 1985;8:993-7.
• 8. O'Holleran TP, Claussen BF. Posterior tibial arterio-venous fistula and false aneurysm. Nebr Med J. 1985;70:202-3.
• 9. 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.
• 10. van Schil P, Vanmaele R, Moses F, De Maeseneer M, De Bock L. Pseudoaneurysm of the posterior tibial artery as an early complication after Fogarty catheter thrombectomy. Eur J Vasc Surg. 1990;4:197-9.
• 11. Edwards P, Kurth L. Posterior tibial pseudoaneurysm after calcaneus fracture: a case report. Foot Ankle. 1992;13:93-5.
• 12. Guarniero R, Aguiar ET, Montenegro NB. Complicações vasculares no método de Ilizarov. Rev Hosp Clin Fac Med Sao Paulo. 1993;48:17-21.
• 13. Sanchez FW, Bertozzi G. Direct percutaneous embolization of a postembolectomy pseudoaneurysm. Cardiovasc Intervent Radiol. 1994;17:155-7.
• 14. Mulier T, Molenaers G, Fabry G. A false aneurysm complicating a subcutaneous Achilles tendon lengthening. J Pediatr Orthop B. 1995;4:114-5.
• 15. Guiral J, Vazquez P, Ortega M. [False aneurysm of the posterior tibial artery complicating fracture of the tibia and fibula]. Rev Chir Orthop Reparatrice Appar Mot. 1995;81:546-8.
• 16. Nierenberg G, Hoffman A, Engel A, Stein H. Pseudoaneurysm with an arteriovenous fistula of the tibial vessels after plantar fasciotomy: a case report. Foot Ankle Int. 1997;18:524-5.
• 17. Parry DJ, Parikh A, Robertson I, Kessel D, Scott DJ. Arterial haemorrhage from a chronic venous ulcer--pseudoaneurysm formation of the posterior tibial artery. Eur J Vasc Endovasc Surg. 2000;20:489-91.
• 18. Davis KA, Mansour MA, Kang SS, et al. Pseudoaneurysms of the extremity without fracture: treatment with percutaneous ultrasound-guided thrombin injection. J Trauma. 2000;49:818-21.
• 19. Wollstein R, Wolf Y, Sklair-Levy M, Matan Y, London E, Nyska M. Obliteration of a late traumatic posterior tibial artery pseudoaneurysm by duplex compression. J Trauma. 2000;48:1156-8.
• 20. Dhal A, Chadha M, Lal H, Singh T, Tyagi S. Encounters with pseudoaneurysms in orthopaedic practice. Injury. 2001;32:771-8.
• 21. Neary WD, Tottle AJ, Earnshaw JJ. False aneurysm of the posterior tibial artery after femoral embolectomy. Eur J Vasc Endovasc Surg. 2002;23:460-1.
• 22. Corso R, Carrafiello G, Intotero M, Solcia M. Large iatrogenic pseudoaneurysm of the posterior tibial artery treated with sonographically guided thrombin injection. AJR Am J Roentgenol. 2003;180:1479-80.
• 23. Canbaz S, Sunar H, Yuksel V, Duran E. Pseudoaneurysm of the posterior tibial artery as a complication of thrombectomy. J Cardiovasc Surg (Torino). 2004;45:87-8.
• 24. Aiyer S, Thakkar CJ, Samant PD, Verlekar S, Nirawane R. Pseudoaneurysm of the posterior tibial artery following a closed fracture of the calcaneus. A case report. J Bone Joint Surg Am. 2005;87:2308-12.
• 25. Georgiadis GS, Deftereos SP, Eleftheriadou E, Zacharouli D, Lazarides MK. Delayed presentation of a posterior tibial false aneurysm. Surgery. 2006;139:446-7.
• 26. Abisi S, Chick C, Williams I, Hill S, Gordon A. Endovascular coil embolization for large femoral false aneurysms: two case reports. Vasc Endovascular Surg. 2006;40:414-7.
• 27. Ghersin E, Karram T, Gaitini D, et al. Ultrasonographically guided thrombin injection of iatrogenic pseudoaneurysms in unusual sites. J Ultrasound Med. 2003;22:809-16.
• 28. Engelhorn CA, Morais Filho D, Barros FS, Coelho NA. Guia prático de ultra-sonografia vascular. Rio de Janeiro: Di Livros. 2007. p. 155-7.
• 29. Fellmeth BD, Roberts AC, Bookstein JJ, et al. Postangiographic femoral artery injuries: nonsurgical repair with US-guided compression. Radiology. 1991;178:671-5.
• 30. Cope C, Zeit R. Coagulation of aneurysms by direct percutaneous thrombin injection. AJR Am J Roentgenol 1986;147:383-7.
• 31. Kang SS, Labropoulos N, Mansour MA, et al. Expanded indications for ultrasound-guided thrombin injection of pseudoaneurysms. J Vasc Surg. 2000;31:289-98.
• 32. Khoury M, Rebecca A, Greene K, et al. Duplex scanning-guided thrombin injection for the treatment of iatrogenic pseudoaneurysms. J Vasc Surg. 2002;35:517-21.
• 33. Sackett WR, Taylor SM, Coffey CB, et al. Ultrasound-guided thrombin of injection iatrogenic femoral pseudoaneurysms: a prospective analysis. Am Surg. 2000;66:937-40.

Publication Dates

• Publication in this collection
  20 Sept 2007
• Date of issue
  June 2007

History

• Received
  13 Jan 2007
• Accepted
  14 Mar 2007