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DepartmenCenter at Him
Correspondvascular SurgSaisho-Ko, Him
Ann Vasc SurDOI: 10.1016/� Annals of VPublished onli
A True Aneurysm of Posterior Tibial Artery
Hirohisa Murakami, Naoto Izawa, Shunsuke Miyahara, Tasuku Kadowaki, Naoto Morimoto,
Yoshihisa Morimoto, Keitaro Nakagiri, Masato Yoshida, and Nobuhiko Mukouhara,
Himeji, Japan
True aneurysms of tibial artery are uncommon. We report a case of a 47-year-old woman whosuffered from a distal embolism in the left toes. The surgical intervention involved an aneurys-mectomy and the interposition of the posterior tibial artery using the saphenous vein graft.She has been doing well 22 months after the operation.
Peripheral true aneurysms distal to the popliteal
artery are uncommon, and traumatic false aneu-
rysm is the most common etiology of intrapopliteal
aneurysms. We report a rare case of atherosclerotic
true aneurysm of the posterior tibial artery (PTA)
that was successfully treated surgically.
CASE REPORT
A 47-year-old woman presented to our hospital with pain
and paleness of the left toes and numbness on the left calf.
She had noticed a swelling on the medial calf and denied
any preceding trauma on her left leg. Her medical history
and the clinical examination did not suggest congenital
connective tissue disorders. Three-dimensional computed
tomographic scan images revealed a saccular aneurysm 3
cm in diameter in the left PTA (Fig. 1A).
Surgical intervention was performed with the medial
approach using systemic anesthesia. Therewas little adhe-
sion and inflammation around the aneurysm and it was
easily dissected. The aneurysm was about 20 � 30 mm2
in size at the bifurcated portion of the tibioperoneal trunk.
With an Esmarch tourniquet around the left thigh,
without clamping the PTA, the aneurysm was opened
and excised.
The PTA was reconstructed by interposition using an
autograft of the great saphenous vein, in which
t of Cardiovascular Surgery, Hyogo Brain and Hearteji, Himeji, Japan.
ence to: Hirohisa Murakami, MD, Department of Cardio-ery, Hyogo Brain and Heart Center at Himeji, 520eji, 670-0981, Japan, E-mail: hmurakami@hbhc.jp
g 2011; 25: 980.e1-980.e2j.avsg.2011.02.038ascular Surgery Inc.ne: May 30, 2011
anastomoses were performed in an end-to-end manner
using 7/0 polypropylene running suture.
Although histological examination revealed des-
tructed and disrupted elastic lamina in the smooth
muscle layer of the dilated aneurysmal wall being
replaced by the hyalinized collagen fibrous tissue, the
intima, tunica media, and adventitia were also present.
Therefore, a true aneurysm of the PTA was diagnosed.
Also, there were no signs of connective tissue disorder,
arteritis, necrotizing vasculitis, and infection (Fig. 2).
The postoperative course was uneventful. Postopera-
tive three-dimensional computed tomographic scan
showed the patent interposed graft (Fig. 1B). She has
been doing well 22 months after the operation.
DISCUSSION
Infrapopliteal aneurysms are uncommon, and most
aneurysms of the infrapopliteal arteries appear as
false and are associated with trauma, infection, or
iatrogenic injury.1-4 True aneurysms are extremely
rare. Recent review of previous reports in the
English literature described only 33 cases of true
aneurysms of infrapopliteal arteries, which revealed
only nine cases of atherosclerotic PTA aneurysms.3
Etiology of the 33 aneurysms includes atheroscle-
rosis in 20 cases and unknown in other cases. It is
supposed that some traumatic events, collagen
matrix alterations, inflammation, or other mecha-
nisms such as fibromuscular dysplasia might be
involved in the unknown etiology cases.2,3
The indication of surgical intervention for PTA
aneurysm commonly depends on the presence or
absence of symptoms. The symptomatic aneurysms
accompanying thrombus and distal emboli require
surgical intervention. Small and asymptomatic
980.e1
Fig. 2. Optical microscopy image of the aneurysmal wall
shows destruction of the elastic lamina and disrupted
smooth muscle layer of the dilated aneurysmal wall being
replaced by the hyalinized collagen fibrous tissue. A: adven-
titia, B: median, C: intima (Original magnification: �40;
MassoneGoldner stain plus Elastica van Gieson stain).
Fig. 1. (A) Three-dimensional computed tomographic
image reveals a saccular-shaped aneurysm of the posterior
tibial artery in the left leg. (B) Postoperative three-
dimensional computed tomographic image shows patent
posterior tibial artery partially interposed with the saphe-
nous vein graft.
980.e2 Case reports Annals of Vascular Surgery
aneurysms may be observed safely.4 Asymptomatic
large aneurysms are controversial; however, such
an aneurysm should be treated surgically because
some cases were reported to present with rupture
or leg ischemia.1
Arterial repair by interposition or bypass using
the vein graft is favorable. However, when the
not-involved infrapopliteal arteries are normal,
a simple ligation is permissible as a second option.
An alternative to open surgery is provided by an
endovascular device for excluding aneurysms by
means of stentegraft or coil embolization. There
are several reports on the treatment of anterior tibial
artery aneurysms for preventing rupture of pseu-
doaneurysms.5,6 In selected patients, endovascular
treatment of tibial artery aneurysms is a useful alter-
native to a surgical approach, although the role of
endovascular and percutaneous procedures has to
be assessed.7
CONCLUSIONS
We described a case of true aneurysm of the PTA. It
is a rare vascular lesion sometimes accompanying
distal embolism and thrombotic occlusion as the
sequelae. Open repair is favorable by interposition
or bypass with a saphenous vein graft.
REFERENCES
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popliteal artery aneurysms: report of two cases and literature
review. J Vasc Surg 1996;24:276-278.
2. Mahmood A, Salaman R, Sintler M, Smith SRG, Simms MH,
Vohra RK. Surgery of popliteal artery aneurysms: a 12-year
experience. J Vasc Surg 2003;37:586-893.
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Chiesa R. A true posterior tibial artery aneurysm: a case
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artery aneurysm in a young patient: surgical or endovascular
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