Iatrogenic posterior tibial (PT) artery pseudoaneurysms are rarely described in the current literature. However, with increasing use of pedal access for endovascular procedures, access site complications such as pseudoaneurysms will inevitably occur with more frequency. The case herein describes a pedal access site pseudoaneurysm in the PT that was successfully managed by direct ultrasound-guided thrombin injection.
Key words: Iatrogenic posterior tibial artery pseudoaneurysm
A 75-year-old man with a long history of diabetes and hypertension presented to our clinic with Rutherford stage 4 chronic limb ischemia and bilateral rest pain. Pre-operative non-invasive testing showed non-compressible vasculature with mostly monophasic waveforms in the infrapopliteal vessels. Diagnostic lower extremity arteriography performed via the right radial artery showed diffuse severe disease of all tibial arteries, with subtotal occlusions in the posterior, anterior, and peroneal tibial arteries. Given the extent of the patient symptomatology and the distal nature of the tibial stenoses, a decision was made to attempt revascularization via the pedal approach. Ultrasound-guided access was obtained in the distal segment of the left posterior tibial (PT)artery, approximately one inch proximal to the medial malleolus. A 6 French Slender sheath was inserted (Terumo), and a .014-inch Command ES wire (Abbott) was used to cross the left PT and tibioperoneal trunk stenoses into the left superficial femoral artery. Directional atherectomy was performed using a SilverHawk SX-C catheter (Medtronic), followed by 2.5 mm percutaneous transluminal angioplasty balloon catheter inflation throughout the PT. Significant improvement in stenosis reduction was noted, and the procedure was concluded with permissive hemostasis using a TR Band (Terumo).
Two days after the procedure, the patient presented for follow-up with complaints of localized pain and mild swelling of his left leg. An arterial ultrasound showed no significant abnormalities, and the patient was sent home with non-steroidal anti-inflammatory drugs and a plan for close follow-up. One week later, the patient presented for his scheduled visit with worsening pain and swelling. On physical examination, there were new, tender ecchymoses noted in the region of the access site, along the inner sole of the foot, and in the area of the first three toes (Figure 1). Color Doppler ultrasound of the left leg showed a large pseudoaneurysm involving the PT (Figure 2). An attempt at ultrasound-guided compression yielded partial success, with thrombus involving only a small portion of the pseudoaneurysm. A decision to try ultrasound-guided thrombin injection was subsequently made.
Ultrasound-guided passage of a 25-gauge needle into the superficial portion of the pseudoaneurysm was performed using real-time ultrasonography (Figure 3). A total of 0.4 mL of 1000 units/mL (400 units) of recombinant thrombin was injected with near immediate thrombosis of the dominant sac (Figure 4). A second component of the pseudoaneurysm, located more centrally, was identified near the neck. There was no clear window, except through the dominant sac. Using a longer, 22-gauge needle, access was gained into the more central lesion, and an additional 0.3 mL (300 units) of thrombin was injected, causing thrombosis in the region.
The patient was placed in the supine position for 4 hours after the procedure. Follow-up ultrasound scans at 5, 15, 30, 60, 120, and 240 minutes after the procedure showed good distal flow in the left posterior tibial artery, with stable thrombosis of the sac, after which the patient was discharged home. Forty-eight hours later, follow-up ultrasound demonstrated a widely patent PT artery with no flow in the pseudoaneurysm (Figure 5). At 3-month follow-up, there was complete resolution of pain, swelling, and bruising, and the PT showed good flow on color Doppler ultrasound (Figure 6).
True aneurysms in the infrapopliteal region are exceedingly rare. Pseudoaneurysms, or “false aneurysms,” are more common than true aneurysms in the tibial region, and are often a result of trauma or surgical procedures. There are very few reports of pseudoaneurysms as complications of percutaneous catheterization involving the tibial vessels, and, as a result, there is no standard management protocol. In contrast, numerous case reports/series exist for management of iatrogenic femoral artery pseudoaneurysms. Access-related pseudoaneurysms of the femoral artery can be managed by ultrasound-guided manual compression, thrombin injection, and/or surgical intervention. In this report, we presented a case of an iatrogenic PT pseudoaneurysm managed by ultrasound -guided injection of recombinant topical thrombin (Recothrom, Mallinckrodt Pharmaceuticals).
Retrograde endovascular percutaneous access via the PT is a relatively new technique when compared to the femoral artery approach. The literature shows a possible advantage in the management of chronic infrainguinal occlusions via retrograde tibial approaches, especially when antegrade femoral approaches fail.1 However, this specific discussion is beyond the scope of this article.
Infrapopliteal aneurysms are rare. Of those described, false aneurysms are more likely.2 There are several reports of tibial artery pseudoaneurysms after direct trauma, fractures of the lower limb, and orthopedic procedures.3 They are conventionally managed with open surgery, but recent trials of endovascular management are emerging .4
Ultrasound-guided compression has reduced the need for surgical intervention when introduced to the management of pseudoaneurysms. However, several limitations, including high failure rates and patient discomfort, have limited the use of ultrasound-guided compression. In contrast, duplex-guided thrombin injections have been more successful in terms of the speed of thrombosis of the false lumen and patient comfort.5
Recothrom, or recombinant thrombin, is a topical thrombin used to aid in hemostasis. Off-label use has been described in pseudoaneurysms, as has the use of non-recombinant thrombin. A study by Malgor and colleagues examined the use of recombinant thrombin in the management of arterial pseudoaneurysms and showed good outcomes with no subsequent surgical intervention needed.6 Similarly, a case report by Corso and colleagues describes successful injection and treatment of an 11.5 cm iatrogenic pseudoaneurysm in the PT with a bovine thrombin solution, using a total of 6000 units.7
Pseudoaneurysms in the infrapopliteal region are very rare. A high index of suspicion is necessary if a patient presents with access-site pain and swelling after a pedal endovascular approach. The use of recombinant thrombin in the management of iatrogenic pseudoaneurysms, though not without risk, could be considered as a possible alternative approach to treating infrainguinal pseudoaneurysms.
Disclosure: The authors report no financial relationships or conflicts of interest regarding the content herein.
Manuscript submitted May 27, 2019; manuscript accepted June 11, 2019.
Address for correspondence: Rami Sartawi MD, OMNY Vein and Cardiovascular, 1041 Third Avenue, Suite 201, New York, NY 10065. Email: email@example.com
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