Infrapopliteal Arterial Pseudoaneurysm Development Secondary to Blunt Trauma: Case Series and Literature Review

Abstract

Objectives: Infrapopliteal arterial pseudoaneurysms (IAP) following blunt trauma with associated orthopedic injuries are uncommon, often present in a delayed fashion, and encompass a diagnostic and therapeutic dilemma. Herein, we present a series of IAPs that were diagnosed following blunt trauma and their management. Methods: Case series consisting of 3 patients and a review of the international literature. Results: Our case series included 3 patients presenting with IAPs following blunt trauma with associated orthopedic injuries. They were all identified in a delayed manner (>3 weeks) after the orthopedic injuries were treated. All patients presented with pain and a pulsatile mass while one concurrently had neurologic deficits. The pseudoaneurysms were diagnosed by duplex ultrasound and confirmed by angiography to be originating from the tibioperoneal trunk, anterior tibial, and posterior tibial arteries respectively. Two patients were treated with surgical excision. Of these, one required an arterial bypass procedure while the other underwent direct ligation only. The third patient was treated by endovascular coiling. A literature review from 1950 to the present found 51 reported cases of IAP resulting from blunt trauma. Ninety percent of trauma-related infrapopliteal injuries occurred in men with a mean delay in diagnosis of 5.6 months (median 1.8 months) after injury. Since 1950, management has shifted from primarily ligation to incorporating minimally invasive endovascular techniques when appropriate. Conclusions: Infrapopliteal artery pseudoaneurysms are rare following blunt skeletal trauma. A delay in diagnosis often occurs and can result in major morbidity and extensive surgical intervention. We recommend a high index of suspicion and a thorough vascular examination in patients with lower extremity skeletal trauma to help identify and treat these injuries early and effectively.

True Aneurysm on Posterior Tibial Artery as Late Complication of SARS-CoV-2

“…Degenerative changes lesions secondary to mycotic infection, polyarteritis nodosa are also described as responsible for true aneurysm. In our patient, we could not find any etiological factor, such as trauma, atherosclerosis or connective disorders 2 , 5 The only recent inflammatory event in our patient was the SARS-CoV-2 infection.…”

“…Aneurysms are more common in the proximal arteries such as femoral and popliteal arteries compared to distal small vessels. It is a rare pathology of the infra-popliteal region, where false aneurysms are more common and are usually associated with trauma 2 . The true aneurysms of infrapopliteal region are extremely rare and most of them have been reported to be associated with trauma, collagen vascular pathology, fibromuscular dysplasia, inflammation, infection and atherosclerosis 2 .…”

“…It is a rare pathology of the infra-popliteal region, where false aneurysms are more common and are usually associated with trauma 2 . The true aneurysms of infrapopliteal region are extremely rare and most of them have been reported to be associated with trauma, collagen vascular pathology, fibromuscular dysplasia, inflammation, infection and atherosclerosis 2 . False aneurysms are more common in comparison to the true aneurysms even in infrapatellar blood vessels.…”

“…False aneurysms are more common in comparison to the true aneurysms even in infrapatellar blood vessels. The precise etiological factors are not identified, but trauma is suggested as possible causality 2 …”

“…Although ligation of posterior tibial artery may be performed, especially in emergency settings, surgical excision with posterior tibial artery reconstitution either by primary repair or by interposition vein graft is the preferred treatment. Endovascular embolization and percutaneous occlusion of aneurysm with various modalities are more commonly used in pseudo-aneurysms and are associated with risk of limb ischemia 2 , 5 …”