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

1. M€onig SP, Walter M, Sabine Sorgatz S, Erasmi H. True infra-

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.

3. Tshomba Y, Papa M, Marone EM, Kahlberg A, Rizzo N,

Chiesa R. A true posterior tibial artery aneurysm: a case

report. Vasc Endovasc Surg 2006;40:243.

4. Kanaoka T, Matsuura H. A true aneurysm of the posterior

tibial artery: a case report. Ann Thorac Cardiovasc Surg

2004;10:317-318.

5. Golledge J, Velu R, Quigley F. Use of a covered stent to treat

two large false aneurysms of the anterior tibial artery. J Vasc

Surg 2008;47:1090.

6. Larena-Avellaneda A, Debus ES, Daum H, Kindel M, Gross-

Fengels W, Imig H. Mycotic aneurysms affecting both lower

legs of a patient with Candida endocarditis. Endovascular

therapy and open vascular surgery. Ann Vasc Surg 2004;18:

130-133.

7. Barbano B, Gigante A, Zaccaria A, et al. True posterior tibial

artery aneurysm in a young patient: surgical or endovascular

treatment? BMJ Case Rep 2009 (in press). doi:10.1136/bcr.

04.2009.1812.