Case Report Endovascular Stent Grafting of a Posterior Tibial Artery Pseudoaneurysm Secondary to Penetrating Trauma : Case Report and Review of the Literature Alessandro de Troia,1 Lukla Biasi,1 Luigi Iazzolino,1 Matteo Azzarone,1 Tiziano Tecchio,1 Cristina Rossi,2 and Pierfranco Salcuni,1 Parma, Italy
Endovascular treatment of posttraumatic pseudoaneurysms has become a viable less-invasive option when compared with open repair. In this study, we present a case of a posttraumatic pseudoaneurysm of the posterior tibial artery in a 34-year-old man treated with endovascular stent grafting. An extensive review of the literature has been performed.
Infrapopliteal posttraumatic pseudoaneurysm (PSA) is not a rare event in military facilities during periods of armed conflicts but is infrequently seen in the civilian health care system. PSA can occur as a consequence of penetrating or blunt injury, orthopedic injuries, sporting activities, or iatrogenic injuries.1 PSA usually presents with pain, swelling, or an expanding mass. It can be rarely associated with arteriovenous fistula2 and more frequently with distal ischemia or rupture. Posttraumatic PSA may be asymptomatic and have a subtle delayed presentation.3 Operative exposure and repair of these injuries can be challenging, and surgical management options include direct arterial or patch repair, graft interposition, and arterial ligation.1 Other techniques including duplex-guided compression, thrombin injection, coil embolization, and endovascular intervention have been described.4e6 1
Unit of Vascular Surgery, Department of Surgical Sciences, University Hospital of Parma, Parma, Italy. 2 Unit of Radiology, Department of Surgical Sciences, University Hospital of Parma, Parma, Italy.
Correspondence to: Alessandro de Troia, MD, Unit of Vascular Surgery, Department of Surgical Sciences, University Hospital of Parma, 43126, Italy; E-mail: [email protected] Ann Vasc Surg 2014; -: 1–5 http://dx.doi.org/10.1016/j.avsg.2014.02.013 Ó 2014 Elsevier Inc. All rights reserved. Manuscript received: August 6, 2013; manuscript accepted: February 4, 2014; published online: ---.
Trauma patients tend to be significantly younger than those presenting with iatrogenic PSAs, complicating elective endovascular procedures.7 Covered stents work by excluding the false lumen and promoting thrombosis within the PSA while permitting distal flow. This technique has generally been used in older patients who may not tolerate an open procedure. Stent grafting in a younger population with an infrapopliteal posttraumatic PSA represents a novel therapy that has yet to be fully investigated.8 In this study, we present a case of a young patient presenting with a symptomatic PSA of the posterior tibial (PT) artery treated with an endovascular stent and we review the current literature.
CASE REPORT A 34-year-old man was admitted to our unit for lower leg pain and pulsatile swelling, 8 days after a work injury, resulting from a penetrating metal fragment. Duplex scan ultrasonography (DSU) and computer tomography angiography (CTA) (Fig. 1) revealed the presence of a 31 26 mm PSA originating from the distal third of the right PT artery. The lesion was deemed suitable for endovascular stenting, and dual antiplatelet therapy (cardiaspirin and clopidogrel) had been commenced preoperatively. In the angio-suite, the right common femoral artery was punctured with anterograde approach and a 7F introducer (Terumo) inserted. PT artery catheterization 1
2 Case Report
Annals of Vascular Surgery
At 18-month follow-up, the patient was symptom free. Arterial duplex revealed stent graft and PT artery patency with triphasic tibial waveforms.
DISCUSSION
Fig. 1. Computer tomography angiography revealed the presence of a 31 26 mm PSA originating from the distal third of the PT artery.
Fig. 2. The 3 19 mm ePTFE-covered coronary stent graft (InSitu Direct Stent Technologies. Inc.) deployed at the site of the pseudoaneurysm.
procedure required a 190-cm 0.014-in microguide wire (Spartacore Abbot) and a 3 19 mm expanded polytetrafluorethylene (ePTFE)ecovered coronary stent graft (InSitu Direct Stent Technologies.Inc.) was deployed at the site of the PSA (Fig. 2). Completion angiography documented PSA complete exclusion with patent PT artery. The common femoral artery access site was percutaneously closed with a 6F Perclose ProGlide suturemediated closure system (SMC System Abbot). DSU documented triphasic PT signals at the ankle, and the patient was discharged on day 2. Dual antiplatelet therapy was recommended for 12 months.
The recent development of endovascular technology and implementation with antiplatelet therapy has led to the use of stent grafts in the management of arterial injury and posttraumatic PSA.9 The use of stents and stent grafts to treat carotid, aortic, subclavian, innominate, iliac, brachial, and superficial femoral artery injuries has increased in the recent years.10,11 However, stent grafting for tibial injuries has been limited by the lack of availability of smalldiameter stent grafts. From an extensive review of the literature, 23 case reports of proximal and midsite PT artery posttraumatic PSA have been published in the past 46 years (Table I). Male patients are prevalent (70%); mean age is 41.3 years (range: 19e85 years). Until 2000, angiography was considered the gold standard for the diagnosis of vascular traumas of the lower limbs. In the past 13 years, angiography has been replaced by DSU associated with CTA, above all in the past few years, CTA is considered as being the most sensitive and specific diagnostic tool for vascular traumas of the lower limbs.33 Before 2000, 91% of cases were treated surgically, with a 27% amputation rate, but in the past 13 years, only 25% of cases have been treated with surgery, the remaining 75% undergoing treatment with endovascular techniques with no amputations needed (Fig. 3). Of the 23 cases reported, only 7 include references to the follow-up,19,21,22,26,30,32 (Table I): 2 surgical repairs,19,22 vein patch and great saphenous vein (GSV) interposed graft patent at 2 and 24 months respectively; 5 endovascular repairs21,26,30,32 (coil embolization, ultrasound-guided thrombin injection, and covered stent in 3 cases [Table I]), at follow-up ranging from 1 to 18 months; only the coil embolization procedure presented PT artery occlusion; all 3 covered stents were patent. Blunt tibial artery injury carries a higher risk for limb loss than injuries sustained from penetrating trauma; in fact, blunt injury, a pulseless extremity, the need for arterial repair, tibial arterial injury, and multiple long bone fractures may be considered predictors of amputation. The risk of limb loss increases with the number of tibial arteries injured. The management of acute limb-threatening ischemia after blunt arterial trauma has typically been achieved with open revascularization of the affected arterial tree; however, open reconstruction
Vol.
Table I. Case reports in the English literature Etiology
Diameter (mm)
Time of presentation days
Initial diagnostic modality
Tilney NL et al.12 Scudese VA et al.13 Cameron HS et al.14 Singh I et al.15 Byrnes G et al.16 Dreyfus U et al.17 Breen T et al.18 van Schil P et al.19 Guarniero R et al.20 Sanchez FW et al.21 Guiral J et al.22 Davis KA et al.23
1967 1968 1972 1972 1975 1980 1985 1990 1993 1994 1995 2000
n.d. M M n.d. n.d. F n.d. F n.d. F M M
n.d. 30 n.d. n.d. n.d. 48 n.d. 65 18 85 21 43
Fracture Fracture Fracture Facture Embolectomy Fracture Fracture Embolectomy Fixation (Ilizarov) Embolectomy Fracture Trauma
n.d. 100 n.d. n.d. n.d. n.d. 60 n.d. n.d. n.d. 60 17
n.d. 2 n.d. n.d. n.d. 126 n.d. 3 46 0 13 2
n.d. AGF AGF n.d. n.d. AGF AGF AGF AGF AGF AGF, DSU DSU
Dhal A et al.24 Neary WD et al.25
2001 2002
n.d. F
32 78
Fracture Embolectomy
10 n.d.
n.d. 7
AGF AGF, DSU
Corso R et al.26
2003
M
65
Embolectomy
115
1
Canbaz S et al.27 Georgiadis GS et al.3
2004 2006
F M
72 31
Embolectomy Cutting wound
40 80
5 60
DSU DSU, CTA, AGF
Chye Yew Ng et al.28 De Morais et al.29 Joglar et al.30
2006 2007 2010
M M M
20 22 39
Fracture Fixation (Ilizarov) Fracture
80 39 30
46 5 21
DSU DSU DSU
Singh PK et al.31 Marks JA et al.32
2011 2011
M M
30 19
Fracture Gunshot
100 56
450 8
DSU DSU, CTA
Salcuni
2013
M
34
Penetrating work injury
31
8
DSU, CTA
Ligation Ligation Suture of arterial injury Suture of arterial injury Ligation Ligation and excision Ligation Vein patch Ligation Coil embolization GSV interposed graft Ultrasound-guided thrombin injection Spontaneous thrombosis Ultrasound-guided thrombin injection Ultrasound-guided thrombin injection Vein patch Repaired with end-to-end anastomosis Coil embolization VGS interposed graft Covered stent 3 19 mm covered balloon-expandable stent graft (JOSTENT, Abbott Vascular) Coil embolization Covered stent 5 16 120 mm covered balloon-expandable iCast stent (Atrium Medical Corporation, Hudson, NH) Covered stent 3 19 mm ePTFEcovered coronary stent graft (InSitu Direct Stent Technologies.Inc. )
Follow-up months
O/P
n.d. n.d. n.d. n.d. n.d. n.d. n.d. 2 n.d. 12 24 n.d.
n.d. n.d. n.d. n.d. n.d. n.d n.d. P n.d. O P n.d.
n.d. n.d.
n.d. n.d.
6
P
n.d. n.d.
n.d. n.d.
n.d. n.d. 8
n.d. n.d. P
n.d. 1
n.d. P
18
P Case Report 3
AGF, angiography; M, male; F, female; n.d., not determined; P/O, patent/occlusion.
DSU
Treatment
2014
Age
-, -
Sex
No.
Year
-,
Reference
4 Case Report
Fig. 3. The rate of surgery, endovascular treatment, and limb salvage between 2 periods: 1967e1999 and 2000e 2012.
in the setting of recent trauma, and after orthopedic reconstruction, is fraught with obstacles. Operative difficulty arises from lower extremity edema, the presence of operative hardware, and the presence of vasospasm in the injured vessels.34e37 Compartment syndrome (CS) is an important clinical entity requiring prompt diagnosis and management, as delayed treatment is associated with unacceptably high rates of disability and limb loss. After extremity trauma, w1% of patients will require a fasciotomy. The presence of vascular injury (particularly, combined arterial and venous injuries), of open fractures or of elbow or knee dislocations, is an independent predictor for the need for fasciotomy. Fasciotomy in arterial extremity injury treatment is associated with significantly improved limb outcomes.38,39 From the review of the current literature, CS associated to PT artery posttraumatic PSA has been documented in only 2 cases,13,32 both treated by means of fasciotomy. In the case reported, CS has been carefully investigated but not observed. The endovascular approach avoids the need of dissection of traumatized tissues preserving from iatrogenic injuries to surrounding structures and bearing lower risk of infection. The literature reports a rate of infection in revascularized posttraumatic lower limbs40e42 ranging from 11.1% to 52.7%, infection often being correlated with occlusion of the bypass and amputation. Expandable balloon stents in peripheral arteries susceptible to compression, tensile, and bending forces may deform and have a greater probability of stenosis. Moreover, studies evaluating infrapopliteal endovascular therapy in managing occlusive arterial disease have yielded insufficient data when compared with bypass surgery, and further studies are deemed necessary to establish its real role.43 In recent years, stents have been placed to treat infrapopliteal stenosis, revealing promising results by inhibiting restenosis and diminishing recurrent
Annals of Vascular Surgery
ischemia of the lower limbs and by repeated procedures of revascularization.44 Although endovascular strategies may allow for a less-invasive PSA thrombosis, the theoretical advantage of maintaining vessel patency must be taken into consideration. Infrapopliteal stents have been shown to not have inconsiderable reocclusion rates in atherosclerotic patients. Nevertheless, their use in a posttraumatic setting without impaired distal runoff seems justified, even for such peripheral lesions.43,44 Although there is no clear evidence as to the need for or effectiveness of antiplatelet therapy following extremity vascular injury and repair, their use is based on known mechanisms of action of these medications and extrapolation from similar regimens in patients having undergone vascular procedures for age-related vascular disease.45 In the reported case, the patient is a smoker, hence it was considered opportune to carry on the antiplatelet therapy after 12 months. In conclusion, endoluminal treatment of such lesions permits revascularization of a tibial vessel from a remote site, thereby minimizing the risk of iatrogenic neurovascular injuries. Posttraumatic PSA exclusion may be achieved by stent grafting preserving tibial artery patency, bearing in mind that most patients with these types of injuries are young with relatively healthy endothelium and lower longterm risk of occlusion. Surgery is reserved for cases of PSA where endovascular treatment has failed. REFERENCES 1. van Hensbroek PB, Ponsen KJ, Reekers JA, et al. Endovascular treatment of anterior tibial artery pseudoaneurysm following locking compression plating of the tibia. J Orthop Trauma 2007;21:279e82. 2. Spirito R, Trabattoni P, Pompilio G, et al. Endovascular treatment of a post-traumatic tibial pseudoaneurysm and arteriovenous fistula: case report and review of the literature. J Vasc Surg 2007;45:1076e9. 3. Georgiadis GS, Deftereos SP, Eleftheriadou E, et al. Delayed presentation of a posterior tibial false aneurysm. Surgery 2006;139:446e7. PubMed PMID: 16546512. 4. Fraser JD, Cully BE, Rivard DC, et al. Traumatic pseudoaneurysm of the anterior tibial artery treated with ultrasoundguided thrombin injection in a pediatric patient. J Pediatr Surg 2009;44:444e7. PubMed PMID: 19231554. 5. Singh D, Ferero A. Traumatic pseudoaneurysm of the posterior tibial artery treated by endovascular coil embolization. Foot Ankle Spec 2013;6:54e8. 6. Ferrero E, Ferri M, Carbonatto P, et al. Symptomatic aneurysm of a perforating peroneal artery after a blunt trauma. Ann Vasc Surg 2012;26:277.e1. 7. Rosa P, O’Donnell SD, Goff JM, et al. Endovascular management of a peroneal artery injury due to a military fragment wound. Ann Vasc Surg 2003;17:678e81. 8. Worni M, Scarborough JE, Gandhi M, et al. Use of endovascular therapy for peripheral arterial lesions: an analysis of
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28.
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2014
the National Trauma Data Bank from 2007 to 2009. Ann Vasc Surg 2013;27:299e305. Parodi JC, Schonholz C, Ferreira LM, et al. Endovascular stent-graft treatment of traumatic arterial lesions. Ann Vasc Surg 1999;13:121e9. PubMed PMID: 10072450. Reuben BC, Whitten MG, Sarfati M, et al. Increasing use of endovascular therapy in acute arterial injuries: analysis of the National Trauma Data Bank. J Vasc Surg 2007;46:1222e6. de Troia A, Tecchio T, Azzarone M, et al. ‘‘Endovascular treatment of an innominate artery iatrogenic pseudoaneurysm following subclavian vein catheterization’’. Vasc Surg Endovasc 2011;45:78e82. Tilney NL, McLamb JR. Leg trauma with posterior tibial artery tear. J Trauma 1967;7:807e10. Scudese VA, Hamada K. Pseudoaneurysm of the posterior tibial artery complicating fracture of the tibia. Vasc Surg 1968;2:126e34. Cameron HS, Laird JJ, Carroll SE. False aneurysms complicating closed fractures. J Trauma 1972;12:67e74. Singh I, Gorman JF. Vascular injuries in closed fractures near junction of middle and lower thirds of the tibia. J Trauma 1972;12:592e8. Byrnes G, Mac Gowan WA. The injury potential of Fogarty balloon catheters. J Cardiovasc Surg (Torino) 1975;16:590e3. Dreyfus U, Fishman J. False aneurysm of the posterior tibial artery complicating fracture of the tibia and fibula. J Trauma 1980;20:186e7. Breen T, Brumback R. Posterior tibial artery pseudoaneurysm following tibial fracture. A case report. Orthopedics 1985;8:993e7. van Schil P, Vanmaele R, Moses F, et al. Pseudoaneurysm of the posterior tibial artery as an early complication after Fogarty catheter thrombectomy. Eur J Vasc Surg 1990;4:197e9. Guarniero R, Aguiar ET, Montenegro NB. [Vascular complications of the Ilizarov method]. Rev Hosp Clin Fac Med Sao Paulo 1993;48:17e21. Sanchez FW, Bertozzi G. Direct percutaneous embolization of a postembolectomy pseudoaneurysm. Cardiovasc Intervent Radiol 1994;17:155e7. 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;81:546e8. Davis KA, Mansour MA, Kang SS, et al. Pseudoaneurysms of the extremity without fracture: treatment with percutaneous ultrasound-guided thrombin injection. J Trauma 2000;49:818e21. Dhal A, Chadha M, Lal H, et al. Encounters with pseudoaneurysms in orthopaedic practice. Injury 2001;32:771e8. Neary WD, Tottle AJ, Earnshaw JJ. False aneurysm of the posterior tibial artery after femoral embolectomy. Eur J Vasc Endovasc Surg 2002;23:460e1. Corso R, Carrafiello G, Intotero M, et al. Large iatrogenic pseudoaneurysm of the posterior tibial artery treated with sonographically guided thrombin injection. AJR Am J Roentgenol 2003;180:1479e80. Canbaz S, Sunar H, Yuksel V, et al. Pseudoaneurysm of the posterior tibial artery as a complication of thrombectomy. J Cardiovasc Surg (Torino) 2004;45:87e8. Ng CY, Hendrix M, McKie S. Delayed onset tibial nerve axonotmesis and posterior tibial artery pseudoaneurysm caused by tibial diaphysis fracture. Injury Extra 2006;37: 158e62.
Case Report 5
29. de Morais Fihlos D, El Hosni RA, Morselli Diniz CA, et al. Pseudo-anuerisma de arteria tibial posterior p os-tratamento de fratura de perna come fixador externo: relato de caso e revisao da literatura. J Vasc Bras 2007;6:175e81. 30. Joglar F, Kabutey NK, Maree A, et al. The role of stent grafts in the management of traumatic tibial artery pseudoaneurysms: case report and review of the literature. Vasc Endovascular Surg 2010;44:407e9. 31. Singh PK, Banode P, Shrivastva S, et al. Pathological fracture of the fibula due to a late presenting posterior tibial artery pseudoaneurysm: a case report. J Bone Joint Surg 2011;93: e54. 32. Marks JA, Hager E, Henry D, et al. Lower extremity vascular stenting for a post-traumatic pseudoaneurysm in a young trauma patient. J Emerg Trauma Shock 2011;4:302e5. 33. Fox N, Rajani RR, Bokhari F, et al. Evaluation and management of penetrating lower extremity arterial trauma: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg 2012;73(Suppl. 4):S315e20. 34. Alvarez-Tostado J, Tulsyan N, Butler B, et al. Endovascular management of acute critical ischemia secondary to blunt tibial artery injury. J Vasc Surg 2006;44:1101e3. 35. Kauvar DS, Sarfati MR, Kraiss LW. National Trauma Databank analysis of mortality and limb loss in isolated lower extremity vascular trauma. J Vasc Surg 2011;53:1598e603. http://dx.doi.org/10.1016/j.jvs.2011.01.056. 36. Topal AE, Eren MN, Celik Y. Lower extremity arterial injuries over a six-year period: outcomes, risk factors, and management. Vasc Health Risk Manag 2010;6:1103e10. 37. Tan TW, Joglar FL, Hamburg NM, et al. Limb outcome and mortality in lower and upper extremity arterial injury: a comparison using the National Trauma Data Bank. Vasc Endovasc Surg 2011;45:592e7. 38. Farber A, Tan TW, Hamburg NM, et al. Early fasciotomy in patients with extremity vascular injury is associated with decreased risk of adverse limb outcomes: a review of the National Trauma Data Bank. Injury 2012;43:1486e91. 39. Branco BC, Inaba K, Barmparas G, et al. Incidence and predictors for the need for fasciotomy after extremity trauma: a 10-year review in a mature level I trauma centre. Injury 2011;42:1157e63. 40. Velinovic MM, Davidovic BL, Lotina IS, et al. Complications of operative treatment of injuries of peripheral arteries. Cardiovasc Surg 2000;8:256e64. 41. Wani ML, Ahangar AG, Wani SN, et al. Peripheral vascular injuries due to blunt trauma (road traffic accident): management and outcome. Int J Surg 2012;10:560e2. 42. Siddique MK, Bhatti AM. A two-year experience of treating vascular trauma in the extremities in a military hospital. J Pak Med Assoc 2013;63:327e30. 43. Romiti M, Albers M, Brochado-Neto FC, et al. Meta-analysis of infrapopliteal angioplasty for chronic critical limb ischemia. J Vasc Surg 2008;47:975e81. 44. Karnabatidis D, Katsanos K, Siablis D. Infrapopliteal stents: overview and unresolved issues. J Endovasc Ther 2009; 16(Suppl 1):I153e62. 45. Coello PA, Bellmunt S, McGorrian C, et al., American College of Chest Physicians. Antithrombotic therapy in peripheral artery disease antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians. Evidence-based clinical practice guidelines. Chest 2012; 141(Suppl):e669Se90S.
Endovascular treatment of posttraumatic pseudoaneurysms has become a viable less-invasive option when compared with open repair. In this study, we present a case of a posttraumatic pseudoaneurysm of the posterior tibial artery in a 34-year-old man treated with endovascular stent grafting. An extensive review of the literature has been performed.
Infrapopliteal posttraumatic pseudoaneurysm (PSA) is not a rare event in military facilities during periods of armed conflicts but is infrequently seen in the civilian health care system. PSA can occur as a consequence of penetrating or blunt injury, orthopedic injuries, sporting activities, or iatrogenic injuries.1 PSA usually presents with pain, swelling, or an expanding mass. It can be rarely associated with arteriovenous fistula2 and more frequently with distal ischemia or rupture. Posttraumatic PSA may be asymptomatic and have a subtle delayed presentation.3 Operative exposure and repair of these injuries can be challenging, and surgical management options include direct arterial or patch repair, graft interposition, and arterial ligation.1 Other techniques including duplex-guided compression, thrombin injection, coil embolization, and endovascular intervention have been described.4e6 1
Unit of Vascular Surgery, Department of Surgical Sciences, University Hospital of Parma, Parma, Italy. 2 Unit of Radiology, Department of Surgical Sciences, University Hospital of Parma, Parma, Italy.
Correspondence to: Alessandro de Troia, MD, Unit of Vascular Surgery, Department of Surgical Sciences, University Hospital of Parma, 43126, Italy; E-mail: [email protected] Ann Vasc Surg 2014; -: 1–5 http://dx.doi.org/10.1016/j.avsg.2014.02.013 Ó 2014 Elsevier Inc. All rights reserved. Manuscript received: August 6, 2013; manuscript accepted: February 4, 2014; published online: ---.
Trauma patients tend to be significantly younger than those presenting with iatrogenic PSAs, complicating elective endovascular procedures.7 Covered stents work by excluding the false lumen and promoting thrombosis within the PSA while permitting distal flow. This technique has generally been used in older patients who may not tolerate an open procedure. Stent grafting in a younger population with an infrapopliteal posttraumatic PSA represents a novel therapy that has yet to be fully investigated.8 In this study, we present a case of a young patient presenting with a symptomatic PSA of the posterior tibial (PT) artery treated with an endovascular stent and we review the current literature.
CASE REPORT A 34-year-old man was admitted to our unit for lower leg pain and pulsatile swelling, 8 days after a work injury, resulting from a penetrating metal fragment. Duplex scan ultrasonography (DSU) and computer tomography angiography (CTA) (Fig. 1) revealed the presence of a 31 26 mm PSA originating from the distal third of the right PT artery. The lesion was deemed suitable for endovascular stenting, and dual antiplatelet therapy (cardiaspirin and clopidogrel) had been commenced preoperatively. In the angio-suite, the right common femoral artery was punctured with anterograde approach and a 7F introducer (Terumo) inserted. PT artery catheterization 1
2 Case Report
Annals of Vascular Surgery
At 18-month follow-up, the patient was symptom free. Arterial duplex revealed stent graft and PT artery patency with triphasic tibial waveforms.
DISCUSSION
Fig. 1. Computer tomography angiography revealed the presence of a 31 26 mm PSA originating from the distal third of the PT artery.
Fig. 2. The 3 19 mm ePTFE-covered coronary stent graft (InSitu Direct Stent Technologies. Inc.) deployed at the site of the pseudoaneurysm.
procedure required a 190-cm 0.014-in microguide wire (Spartacore Abbot) and a 3 19 mm expanded polytetrafluorethylene (ePTFE)ecovered coronary stent graft (InSitu Direct Stent Technologies.Inc.) was deployed at the site of the PSA (Fig. 2). Completion angiography documented PSA complete exclusion with patent PT artery. The common femoral artery access site was percutaneously closed with a 6F Perclose ProGlide suturemediated closure system (SMC System Abbot). DSU documented triphasic PT signals at the ankle, and the patient was discharged on day 2. Dual antiplatelet therapy was recommended for 12 months.
The recent development of endovascular technology and implementation with antiplatelet therapy has led to the use of stent grafts in the management of arterial injury and posttraumatic PSA.9 The use of stents and stent grafts to treat carotid, aortic, subclavian, innominate, iliac, brachial, and superficial femoral artery injuries has increased in the recent years.10,11 However, stent grafting for tibial injuries has been limited by the lack of availability of smalldiameter stent grafts. From an extensive review of the literature, 23 case reports of proximal and midsite PT artery posttraumatic PSA have been published in the past 46 years (Table I). Male patients are prevalent (70%); mean age is 41.3 years (range: 19e85 years). Until 2000, angiography was considered the gold standard for the diagnosis of vascular traumas of the lower limbs. In the past 13 years, angiography has been replaced by DSU associated with CTA, above all in the past few years, CTA is considered as being the most sensitive and specific diagnostic tool for vascular traumas of the lower limbs.33 Before 2000, 91% of cases were treated surgically, with a 27% amputation rate, but in the past 13 years, only 25% of cases have been treated with surgery, the remaining 75% undergoing treatment with endovascular techniques with no amputations needed (Fig. 3). Of the 23 cases reported, only 7 include references to the follow-up,19,21,22,26,30,32 (Table I): 2 surgical repairs,19,22 vein patch and great saphenous vein (GSV) interposed graft patent at 2 and 24 months respectively; 5 endovascular repairs21,26,30,32 (coil embolization, ultrasound-guided thrombin injection, and covered stent in 3 cases [Table I]), at follow-up ranging from 1 to 18 months; only the coil embolization procedure presented PT artery occlusion; all 3 covered stents were patent. Blunt tibial artery injury carries a higher risk for limb loss than injuries sustained from penetrating trauma; in fact, blunt injury, a pulseless extremity, the need for arterial repair, tibial arterial injury, and multiple long bone fractures may be considered predictors of amputation. The risk of limb loss increases with the number of tibial arteries injured. The management of acute limb-threatening ischemia after blunt arterial trauma has typically been achieved with open revascularization of the affected arterial tree; however, open reconstruction
Vol.
Table I. Case reports in the English literature Etiology
Diameter (mm)
Time of presentation days
Initial diagnostic modality
Tilney NL et al.12 Scudese VA et al.13 Cameron HS et al.14 Singh I et al.15 Byrnes G et al.16 Dreyfus U et al.17 Breen T et al.18 van Schil P et al.19 Guarniero R et al.20 Sanchez FW et al.21 Guiral J et al.22 Davis KA et al.23
1967 1968 1972 1972 1975 1980 1985 1990 1993 1994 1995 2000
n.d. M M n.d. n.d. F n.d. F n.d. F M M
n.d. 30 n.d. n.d. n.d. 48 n.d. 65 18 85 21 43
Fracture Fracture Fracture Facture Embolectomy Fracture Fracture Embolectomy Fixation (Ilizarov) Embolectomy Fracture Trauma
n.d. 100 n.d. n.d. n.d. n.d. 60 n.d. n.d. n.d. 60 17
n.d. 2 n.d. n.d. n.d. 126 n.d. 3 46 0 13 2
n.d. AGF AGF n.d. n.d. AGF AGF AGF AGF AGF AGF, DSU DSU
Dhal A et al.24 Neary WD et al.25
2001 2002
n.d. F
32 78
Fracture Embolectomy
10 n.d.
n.d. 7
AGF AGF, DSU
Corso R et al.26
2003
M
65
Embolectomy
115
1
Canbaz S et al.27 Georgiadis GS et al.3
2004 2006
F M
72 31
Embolectomy Cutting wound
40 80
5 60
DSU DSU, CTA, AGF
Chye Yew Ng et al.28 De Morais et al.29 Joglar et al.30
2006 2007 2010
M M M
20 22 39
Fracture Fixation (Ilizarov) Fracture
80 39 30
46 5 21
DSU DSU DSU
Singh PK et al.31 Marks JA et al.32
2011 2011
M M
30 19
Fracture Gunshot
100 56
450 8
DSU DSU, CTA
Salcuni
2013
M
34
Penetrating work injury
31
8
DSU, CTA
Ligation Ligation Suture of arterial injury Suture of arterial injury Ligation Ligation and excision Ligation Vein patch Ligation Coil embolization GSV interposed graft Ultrasound-guided thrombin injection Spontaneous thrombosis Ultrasound-guided thrombin injection Ultrasound-guided thrombin injection Vein patch Repaired with end-to-end anastomosis Coil embolization VGS interposed graft Covered stent 3 19 mm covered balloon-expandable stent graft (JOSTENT, Abbott Vascular) Coil embolization Covered stent 5 16 120 mm covered balloon-expandable iCast stent (Atrium Medical Corporation, Hudson, NH) Covered stent 3 19 mm ePTFEcovered coronary stent graft (InSitu Direct Stent Technologies.Inc. )
Follow-up months
O/P
n.d. n.d. n.d. n.d. n.d. n.d. n.d. 2 n.d. 12 24 n.d.
n.d. n.d. n.d. n.d. n.d. n.d n.d. P n.d. O P n.d.
n.d. n.d.
n.d. n.d.
6
P
n.d. n.d.
n.d. n.d.
n.d. n.d. 8
n.d. n.d. P
n.d. 1
n.d. P
18
P Case Report 3
AGF, angiography; M, male; F, female; n.d., not determined; P/O, patent/occlusion.
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Fig. 3. The rate of surgery, endovascular treatment, and limb salvage between 2 periods: 1967e1999 and 2000e 2012.
in the setting of recent trauma, and after orthopedic reconstruction, is fraught with obstacles. Operative difficulty arises from lower extremity edema, the presence of operative hardware, and the presence of vasospasm in the injured vessels.34e37 Compartment syndrome (CS) is an important clinical entity requiring prompt diagnosis and management, as delayed treatment is associated with unacceptably high rates of disability and limb loss. After extremity trauma, w1% of patients will require a fasciotomy. The presence of vascular injury (particularly, combined arterial and venous injuries), of open fractures or of elbow or knee dislocations, is an independent predictor for the need for fasciotomy. Fasciotomy in arterial extremity injury treatment is associated with significantly improved limb outcomes.38,39 From the review of the current literature, CS associated to PT artery posttraumatic PSA has been documented in only 2 cases,13,32 both treated by means of fasciotomy. In the case reported, CS has been carefully investigated but not observed. The endovascular approach avoids the need of dissection of traumatized tissues preserving from iatrogenic injuries to surrounding structures and bearing lower risk of infection. The literature reports a rate of infection in revascularized posttraumatic lower limbs40e42 ranging from 11.1% to 52.7%, infection often being correlated with occlusion of the bypass and amputation. Expandable balloon stents in peripheral arteries susceptible to compression, tensile, and bending forces may deform and have a greater probability of stenosis. Moreover, studies evaluating infrapopliteal endovascular therapy in managing occlusive arterial disease have yielded insufficient data when compared with bypass surgery, and further studies are deemed necessary to establish its real role.43 In recent years, stents have been placed to treat infrapopliteal stenosis, revealing promising results by inhibiting restenosis and diminishing recurrent
Annals of Vascular Surgery
ischemia of the lower limbs and by repeated procedures of revascularization.44 Although endovascular strategies may allow for a less-invasive PSA thrombosis, the theoretical advantage of maintaining vessel patency must be taken into consideration. Infrapopliteal stents have been shown to not have inconsiderable reocclusion rates in atherosclerotic patients. Nevertheless, their use in a posttraumatic setting without impaired distal runoff seems justified, even for such peripheral lesions.43,44 Although there is no clear evidence as to the need for or effectiveness of antiplatelet therapy following extremity vascular injury and repair, their use is based on known mechanisms of action of these medications and extrapolation from similar regimens in patients having undergone vascular procedures for age-related vascular disease.45 In the reported case, the patient is a smoker, hence it was considered opportune to carry on the antiplatelet therapy after 12 months. In conclusion, endoluminal treatment of such lesions permits revascularization of a tibial vessel from a remote site, thereby minimizing the risk of iatrogenic neurovascular injuries. Posttraumatic PSA exclusion may be achieved by stent grafting preserving tibial artery patency, bearing in mind that most patients with these types of injuries are young with relatively healthy endothelium and lower longterm risk of occlusion. Surgery is reserved for cases of PSA where endovascular treatment has failed. REFERENCES 1. van Hensbroek PB, Ponsen KJ, Reekers JA, et al. Endovascular treatment of anterior tibial artery pseudoaneurysm following locking compression plating of the tibia. J Orthop Trauma 2007;21:279e82. 2. Spirito R, Trabattoni P, Pompilio G, et al. Endovascular treatment of a post-traumatic tibial pseudoaneurysm and arteriovenous fistula: case report and review of the literature. J Vasc Surg 2007;45:1076e9. 3. Georgiadis GS, Deftereos SP, Eleftheriadou E, et al. Delayed presentation of a posterior tibial false aneurysm. Surgery 2006;139:446e7. PubMed PMID: 16546512. 4. Fraser JD, Cully BE, Rivard DC, et al. Traumatic pseudoaneurysm of the anterior tibial artery treated with ultrasoundguided thrombin injection in a pediatric patient. J Pediatr Surg 2009;44:444e7. PubMed PMID: 19231554. 5. Singh D, Ferero A. Traumatic pseudoaneurysm of the posterior tibial artery treated by endovascular coil embolization. Foot Ankle Spec 2013;6:54e8. 6. Ferrero E, Ferri M, Carbonatto P, et al. Symptomatic aneurysm of a perforating peroneal artery after a blunt trauma. Ann Vasc Surg 2012;26:277.e1. 7. Rosa P, O’Donnell SD, Goff JM, et al. Endovascular management of a peroneal artery injury due to a military fragment wound. Ann Vasc Surg 2003;17:678e81. 8. Worni M, Scarborough JE, Gandhi M, et al. Use of endovascular therapy for peripheral arterial lesions: an analysis of
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29. de Morais Fihlos D, El Hosni RA, Morselli Diniz CA, et al. Pseudo-anuerisma de arteria tibial posterior p os-tratamento de fratura de perna come fixador externo: relato de caso e revisao da literatura. J Vasc Bras 2007;6:175e81. 30. Joglar F, Kabutey NK, Maree A, et al. The role of stent grafts in the management of traumatic tibial artery pseudoaneurysms: case report and review of the literature. Vasc Endovascular Surg 2010;44:407e9. 31. Singh PK, Banode P, Shrivastva S, et al. Pathological fracture of the fibula due to a late presenting posterior tibial artery pseudoaneurysm: a case report. J Bone Joint Surg 2011;93: e54. 32. Marks JA, Hager E, Henry D, et al. Lower extremity vascular stenting for a post-traumatic pseudoaneurysm in a young trauma patient. J Emerg Trauma Shock 2011;4:302e5. 33. Fox N, Rajani RR, Bokhari F, et al. Evaluation and management of penetrating lower extremity arterial trauma: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg 2012;73(Suppl. 4):S315e20. 34. Alvarez-Tostado J, Tulsyan N, Butler B, et al. Endovascular management of acute critical ischemia secondary to blunt tibial artery injury. J Vasc Surg 2006;44:1101e3. 35. Kauvar DS, Sarfati MR, Kraiss LW. National Trauma Databank analysis of mortality and limb loss in isolated lower extremity vascular trauma. J Vasc Surg 2011;53:1598e603. http://dx.doi.org/10.1016/j.jvs.2011.01.056. 36. Topal AE, Eren MN, Celik Y. Lower extremity arterial injuries over a six-year period: outcomes, risk factors, and management. Vasc Health Risk Manag 2010;6:1103e10. 37. Tan TW, Joglar FL, Hamburg NM, et al. Limb outcome and mortality in lower and upper extremity arterial injury: a comparison using the National Trauma Data Bank. Vasc Endovasc Surg 2011;45:592e7. 38. Farber A, Tan TW, Hamburg NM, et al. Early fasciotomy in patients with extremity vascular injury is associated with decreased risk of adverse limb outcomes: a review of the National Trauma Data Bank. Injury 2012;43:1486e91. 39. Branco BC, Inaba K, Barmparas G, et al. Incidence and predictors for the need for fasciotomy after extremity trauma: a 10-year review in a mature level I trauma centre. Injury 2011;42:1157e63. 40. Velinovic MM, Davidovic BL, Lotina IS, et al. Complications of operative treatment of injuries of peripheral arteries. Cardiovasc Surg 2000;8:256e64. 41. Wani ML, Ahangar AG, Wani SN, et al. Peripheral vascular injuries due to blunt trauma (road traffic accident): management and outcome. Int J Surg 2012;10:560e2. 42. Siddique MK, Bhatti AM. A two-year experience of treating vascular trauma in the extremities in a military hospital. J Pak Med Assoc 2013;63:327e30. 43. Romiti M, Albers M, Brochado-Neto FC, et al. Meta-analysis of infrapopliteal angioplasty for chronic critical limb ischemia. J Vasc Surg 2008;47:975e81. 44. Karnabatidis D, Katsanos K, Siablis D. Infrapopliteal stents: overview and unresolved issues. J Endovasc Ther 2009; 16(Suppl 1):I153e62. 45. Coello PA, Bellmunt S, McGorrian C, et al., American College of Chest Physicians. Antithrombotic therapy in peripheral artery disease antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians. Evidence-based clinical practice guidelines. Chest 2012; 141(Suppl):e669Se90S.
