ABSTRACT

Peroneal pseudoaneurysm is a rarely seen as a complication due to a variety of treatment strategies. Continuous blood flow and decreased vascular wall support associated with pseudoaneurysm can cause rapid enlargement, compression of venous and nerve structures, rupture and mortality.
An 84-year-old female patient presented to the emergency department with sudden onset pain and paleness in the right lower extremity. Doppler ultrasound revealed thrombus in the right common femoral artery. The patient underwent emergency embolectomy. Doppler ultrasound due to continuing symptoms on postoperative day one showed 23x30 mm pseudoaneurysm of the distal third of the right peroneal artery. Left femoral artery was catheterised and the peroneal artery aneurysm was coil embolised successfully.
Timely diagnosis of complications and rapid treatment are essential in patients with recent vascular interventions. Palpable pulses and intact neurological examination do not rule out most of the complications which would require surgery for correction.

Introduction

Peroneal pseudoaneurysm is a rarely seen complication associated with a variety of treatment strategies. In this article, we present a case of iatrogenic peroneal pseudoaneurysm secondary to femoral embolectomy which was successfully treated with coil embolism.

Case

An 84-year-old female was admitted to the emergency department with a three-hour history of pain and paleness in the right lower extremity. Physical examination revealed absent distal pulses in the affected extremity. Motor and sensory examination was normal. Electrocardiography revealed a newly diagnosed atrial fibrillation. Doppler ultrasound (USG) and digital subsraction angiography were consistent with acute embolism of the right common femoral artery. Echocardiography did not show a cardiac thrombus.

An uncomplicated right femoral embolectomy was performed. Continued symptoms prompted another control Doppler USG despite palpable pulses and nonischemic clinical picture in the subsequent clinic follow-up. A pseudoaneurysm in the distal right peroneal artery was seen with patent anterior tibial artery, posterior tibial artery and popliteal artery. The left femoral artery was accessed to catheterise the right femoral artery; angiographic examination revealed multilobulated peroneal artery pseudoaneurysm (Figure 1). Coil embolisation of the distal peronal artery successfully stopped blood flow in the pseudoaneurysm, verified by a control angiography (Figure 2). The patient was discharged on postoperative day three without any further complications.

Figure 1

Figure 2

Discussion

Most of the peripheral artery pseudoaneurysms occur secondary to trauma. Diagnostic and therapeutic interventions are the commonest reasons for trauma (1). Infections and surgical procedures can also rarely lead to pseudoaneurysm formation (2). Continuous blood flow and decreased vascular wall support of a pseudoaneurysm can cause rapid enlargement, compression of venous and nerve structures, rupture and mortality (3).

Doppler USG is commonly used in the diagnosis of peripheral artery pseudoaneurysms due to ease of use. To-and-fro flow pattern and ying-yang sign are characteristic and lead to rapid diagnosis (4). Angiography is essential and the gold standard in pseudoaneurysms for evaluation of exact anatomic structure, distal flow and also endovascular treatment in the same session (5,6).

The anatomic structure of the involved artery, the perfusion and collateral circulation must be taken into account in the treatment. Simple ligation may be enough for pseudoaneurysms originating from arteries with ample collaterals like ulnar, tibial and peroneal arteries. Other approaches for preservation of arterial continuity are primary surgical repair, resection and end-to-end anastomosis, saphenous vein patch, stenting the pseudoaneurysm neck, coil embolisation (1) and compression with thrombin injection (7).

Pseudoaneurysms smaller than 20 mm can spontaneously regress and may be amenable to observation (8). Minimally invasive approaches should be the first choices if possible, necessary surgery should not be delayed due to increased morbidity (5,7).

Peroneal pseudoaneurysms secondary to trauma and surgical interventions are rarely seen. Here, we present a case of iatrogenic peroneal artery pseudoaneurysm secondary to embolectomy with a Fogarty catheter and successful treatment with coil embolisation instead of surgical repair.

Ethics

Informed Consent: Verbal informed consent was obtained from patients who participated in this study.

Peer-review: Externally peer-reviewed.

Authorship Contributions

Surgical and Medical Practices: İ.B., K.T., U.T., T.B. Concept: K.T., T.B., U.T. Design: K.T., T.B., U.T. Data Collection or Processing: K.T., T.B., U.T., Z.B., İ.B. Analysis or Interpretation: K.T., A.U, Z.B., İ.B. Literature Search: K.T., T.B., U.T. Writing: K.T., T.B., U.T., Z.B., İ.B.

Conflict of Interest: No conflict of interest was declared by the authors.

Financial Disclosure: The authors declared that this study received no financial support.