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Table of Contents
CASE REPORT
Year : 2021  |  Volume : 4  |  Issue : 3  |  Page : 95-97

Treatment of posttraumatic infrapopliteal pseudoaneurysm with a physician-modified covered stent


Department of Vascular Surgery, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China

Date of Submission03-Jan-2021
Date of Decision23-Jan-2021
Date of Acceptance28-Jan-2021
Date of Web Publication31-Aug-2021

Correspondence Address:
Dr. Dong-Lin Li
Department of Vascular Surgery, The First Affiliated Hospital, School of Medicine, Zhejiang University, 79# Qingchun Road, Hangzhou 310003
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2589-9686.325189

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  Abstract 


Infrapopliteal pseudoaneurysms can occur after trauma. In recent years, endovascular repair has been increasingly used to treat infrapopliteal pseudoaneurysms. Nevertheless, there has been no covered stent specifically for small peripheral vessels. Here, we report a case of a 65-year-old male with a pseudoaneurysm of the anterior tibial artery which was managed with a physician-modified covered stent. 6 months after the procedure, the mass had completely disappeared and the vascular anatomy of the calf is well preserved.

Keywords: Covered stent, infrapopliteal pseudoaneurysm, physician modified


How to cite this article:
Zhou X, Qiu CY, Li DL, Zhang HK. Treatment of posttraumatic infrapopliteal pseudoaneurysm with a physician-modified covered stent. Vasc Invest Ther 2021;4:95-7

How to cite this URL:
Zhou X, Qiu CY, Li DL, Zhang HK. Treatment of posttraumatic infrapopliteal pseudoaneurysm with a physician-modified covered stent. Vasc Invest Ther [serial online] 2021 [cited 2021 Dec 6];4:95-7. Available from: https://www.vitonline.org/text.asp?2021/4/3/95/325189




  Introduction Top


The pathogenesis of pseudoaneurysms is characterized by localized rupture of the arterial wall. Traditional surgical repair of infrapopliteal artery needs operative exploration with either direct repair, ligation, or interposition grafting of the injured artery.[1] Nowadays, the endovascular approach for peripheral arterial lesions with covered stents represents a less traumatic anatomic reconstruction of such lesions.[2] Several reports showed that treatment of infrapopliteal pseudoaneurysm with covered stents has get satisfactory results.[1],[2],[3] However, the application of covered stents to the management of infrapopliteal pseudoaneurysm has been limited by the lack of availability of small-diameter covered grafts.[1]

Herein, we report a case of posttraumatic infrapopliteal pseudoaneurysm receiving endovascular treatment with a physician-modified covered stent.


  Case Report Top


A 65-year-old farmer was admitted to the hospital with right lower leg pain and pulsatile swelling. Two weeks ago, he injured his right leg when doing farm work and received debridement in the local hospital. With frequent serosanguineous discharge from the wound, the patient required emergency surgery. A computed tomography angiography (CTA) examination of the lower extremity artery revealed a pseudoaneurysm originating from the right anterior tibial artery. He recived a right leg angiogram which confirmed the presence of a anterior tibial artery pseudoaneurysm [Figure 1]a. Due to the unavailability of small-diameter covered stent, we plan to proceed to an endovascular intervention using a modified covered stent. We inflated a 3.5 mm × 29 mm coronary balloon expandable bare stent in vitro and then cut the two ends of the balloon to make it a tube [Figure 1]d. A second balloon expandable bare stent (3.5 mm × 33 mm) was inserted into the tube and the first inflated bare stent. We compressed the first inflated bare stent to make it fixed to the second stent with the tube in the middle of the two stents [Figure 1]e and Supplementary Video 1]. Under anesthesia, this physician-modified covered stent was advanced through a 6F-guiding catheter and was deployed at the site of the pseudoaneurysm. Multiple angiographic views confirmed the complete exclusion of the pseudoaneurysm [Figure 1]b, and the patient recovered smoothly. Over the next few weeks, the patient underwent several debridements [Figure 1]f and a free flap grafting procedure [Figure 1]g.
Figure 1: Angiogram confirming the presence of a pseudoaneurysm (black arrow, left) secondary to trauma of the anterior tibial artery (a, white arrow, right). After stent placement, the pseudoaneurysm was completely excluded (b, black arrow, right). Computed tomography angiography scan showed complete patency of the anterior tibial artery 6 months after the procedure (c, white arrow, right). We deployed a 3.5 mm × 29 mm coronary stent in vitro and cut the two ends of the balloon to make it a tube (d). A second balloon expandable bare stent (3.5 mm × 33 mm) was inserted into the tube and the first inflated bare stent. We compressed the first inflated bare stent to make it fixed to the second stent with the tube in the middle of the two stents (e). Over the next few weeks, the patient underwent several debridements (f) and a free flap grafting procedure (g)

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Six months after the procedure, the patient was completely symptom free, with complete disappearance of the mass. CTA examination confirmed complete patency of the anterior tibial artery, successful exclusion of the pseudoaneurysm [Figure 1]c. These findings remain unchanged 22 months postoperatively. This study was approved by the institution review board, and the patient gave his consent to publish the present report.


  Discussion Top


Iatrogenic injuries are the most common causes of infrapopliteal pseudoaneurysms such as ankle arthroscopy and knee arthroplasty,[4] followed by trauma, such as sharp or blunt injury.[1],[4],[10] Some connective tissue diseases, such as Behcet's disease, Ehlers–Danlos syndrome, also lead to spontaneous rupture of arteries to form pseudoaneurysms.

Infrapopliteal pseudoaneurysms are extremely rare, and although there are various treatments for pseudoaneurysms, not all of them are suitable for the management of infrapopliteal lesions. The reason for this is the unique anatomical characteristics of the infrapopliteal artery: the diameter is thin and the location is deep. Open surgery at this site is invasive, while ultrasound-guided compression or thrombin injection alone can also be difficult to seal completely.

The recent development and application of endovascular technology has been applied to the management of arterial injury and posttraumatic pseudoaneurysms.[5],[6] Seven reported case reports described the successful use of stent grafts to treat posttraumatic pseudoaneurysms of the anterior tibial artery [Table 1].[1],[2],[3],[7],[8],[9],[10] Moreover, this group of patients was followed up for up to 15 months, and no in-stent restenosis or fracture was found.
Table 1: Posttraumaticinfrapoplitealpseudoanerysms,reviewoftheliterature

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Nevertheless, there are no small-diameter covered stents specifically designed for use in the tibial artery. The stent grafts used in the reported cases are Jostent Graft, Symbiont, Graftmaster RX covered stent, and BeGraft which were developed and approved for coronary intervention.[1],[2],[3],[7],[8],[9],[10] Although not specifically reported from a theoretical point of view, the existing biomechanical differences between coronary and tibial district are significant, and this could somehow affect the outcome of nondedicated devices.[8] Besides, due to many manufacturers do not produce them, the acquisition of stent grafts is difficult. As a center hospital for vascular interventional therapy, our cath lab is not routinely equipped with these covered stents, which are more difficult to get in other regions. Moreover, in the treatment of carotid pseudoaneurysm and coronary perforation, there are some precedents for using physician-modified covered stent such as autologous vein graft and stent graft made of 3M film. At the same time, self-made and modified stents are often used in the treatment of aortic dissection and thoracic aortic aneurysm to cope with different conditions, and all of them have good long-term patency rate. Moreover, the balloon used in the physician-modified covered stent is a semi-compliant balloon. The material of this ballon is generally polytetrafluoroethylene (PTFE) which used in the PTFE Symbiot. Compared with other materials, PTFE is less prone to collapse, crushing, and occlusion.

From long-term treatment effects, this physician-modified covered stent can reconstruct damaged arteries and isolate the pseudoaneurysm well. After follow-up for 21 months, no stent restenosis and rupture were found. Therefore, this stent graft may provide a reasonable choice for the treatment of posttraumatic pseudoaneurysms of the anterior tibial artery in case of emergency. During the application of self-made stent grafts, there are some problems, the fluency of stent transmission to the specified position is not quiet good, and due to a known high risk of thrombosis when underdeployed, this stent had to be aggressively balloon dilated.

Moreover, in this case, the patient had a large infected wound, which need emergency intervention. Our endovascular approach avoided the dissection of these traumatized tissues, iatrogenic injury to surrounding structures, release of the tamponade on the hematoma, and carried less risk of infection. Meanwhile, we adopted the vacuum sealing drainage (VSD) to make the wound better recover. Moreover, there was a concern that, despite endovascular management, the patient would require evacuation of the associated lower leg hematoma.

In conclusion, advanced techniques were needed for endovascular treatment of infrapopliteal pseudoaneurysms. We successfully performed the physician-modified covered stent technique to treat a posttraumatic infrapopliteal pseudoaneurysms. This technique was a feasible option for such circumstance.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Spirito R, Trabattoni P, Pompilio G, Zoli S, Agrifoglio M, Biglioli P. Endovascular treatment of a post-traumatic tibial pseudoaneurysm and arteriovenous fistula: Case report and review of the literature. J Vasc Surg 2007;45:1076-9.  Back to cited text no. 1
    
2.
De Roo RA, Steenvoorde P, Schuttevaer HM, Den Outer AJ, Oskam J, Joosten PP. Exclusion of a crural pseudoaneurysm with a PTFE-covered stent-graft. J Endovasc Ther 2004;11:344-7.  Back to cited text no. 2
    
3.
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.  Back to cited text no. 3
    
4.
Kashir A, Kiely P, Dar W, D'Souza L. Pseudoaneurysm of the dorsalis pedis artery after ankle arthroscopy. Foot Ankle Surg 2010;16:151-2.  Back to cited text no. 4
    
5.
Chrencik MT, Caraballo B, Yokemick J, Pappas PJ, Lal BK, Nagarsheth K. Infrapopliteal arterial pseudoaneurysm development secondary to blunt trauma: Case series and literature review. Vasc Endovascular Surg 2020;54:367-74.  Back to cited text no. 5
    
6.
Parodi JC, Schönholz C, Ferreira LM, Bergan J. Endovascular stent-graft treatment of traumatic arterial lesions. Ann Vasc Surg 1999;13:121-9.  Back to cited text no. 6
    
7.
van Hensbroek PB, Ponsen KJ, Reekers JA, Goslings JC. Endovascular treatment of anterior tibial artery pseudoaneurysm following locking compression plating of the tibia. J Orthop Trauma 2007;21:279-82.  Back to cited text no. 7
    
8.
Brunoro M, Baldassarre V, Sirignano P, Mansour W, Capoccia L, Speziale F. Endovascular treatment of an anterior tibial artery pseudoaneurysm secondary to penetrating trauma in a young patient: Case report and literature review. Ann Vasc Surg 2019;60:479.e5-0000.  Back to cited text no. 8
    
9.
Biagioni RB, Burihan MC, Nasser F, Biagioni LC, Ingrund JC. Endovascular treatment of penetrating arterial trauma with stent grafts. Vasa 2018;47:125-30.  Back to cited text no. 9
    
10.
Jones A, Kumar S. Successful stenting of iatrogenic anterior tibial artery pseudoaneurysm. EJVES Short Rep 2016;30:4-6.  Back to cited text no. 10
    


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