Posterior tibial artery aneurysm: a case report with review of literature
© Sagar and Button; licensee BioMed Central Ltd. 2014
Received: 9 April 2013
Accepted: 28 May 2014
Published: 16 June 2014
Aneurysms infra-patellar region are uncommon. Of them, true aneurysms are very rare and that of posterior tibial artery are extremely rare. The more common, pseudoaneurysms are commonly associated with trauma whereas the true ones are linked with either inflammatory or mycotic origins.
We reported another case of true aneurysm of posterior tibial artery without any evident aetiology. This was repaired with resection of aneurysm followed by interposition vein graft.
Through this report, we discussed the rarity, review of literature and management of this unusual condition.
Aneurysm is one of the common conditions that any vascular surgeon comes across frequently. Aneurysms are more common in the proximal arteries such as femoral and popliteal arteries compared to distal small blood vessels and their management options are well documented in English literature. However it is rare in the infra-popliteal region. Of them, false aneurysms are more common and are usually associated with trauma [1–5]. The true aneurysms of infrapopliteal region are extremely rare and most of them have been reported to be associated with either infection or inflammatory process [6–11]. Of the infra-popliteal blood vessels, the true dilatation of posterior tibial artery has been reported in the single digit numbers [12–14]. To add, we reported another case of true aneurysm of posterior tibial artery. We believe this to be the twelfth of such case reports in English literature. Along with its rarity, we also discussed the literature and its management options.
False aneurysms are more common in comparison to the true aneurysms of infrapatellar blood vessels. There have been only very few case reports of true aneurysms of posterior tibial artery published [13, 14]. The precise aetiological factors are not identified, but trauma, collagen vascular pathology, fibromuscular dysplasia, inflammation, infection and atherosclerosis were suggested.
The most common clinical presentations include asysmptomatic lump, distal embolism and aneurysm thrombosis. Paraesthesia secondary to such aneurysm is rare but reported in literature . Tshomba et al. reported 9% of cases presented with distal critical ischaemia of which two third ended up having midfood amputation, while only 3% of cases presented with rupture that resulted in acute compartment syndrome . Differential diagnoses of this aneurysm include tendon cyst, neurinoma, soft tissue tumour or pulsatile masses .
In our case, we could not find any aetiological factor for the aneurysm development. Out of eleven published case reports of true posterior tibial artery aneurysms, in four of them, aetiology was unknown [16, 17, 12, 9]. Two cases were reported secondary to degenerative changes [18, 13] and another three cases were secondary to mycotic infection [6, 11]. In one case, polyarteritis nodosa was responsible for such aneurysm  while in another case, histology was suggestive of syphilitic infection but immunostaining and culture isolation did not confirm the diagnosis .
The management options vary from conservative approach to surgical excision followed by reconstitution of posterior tibial artery. Due to very limited number of published cases, a standard treatment has not been defined. Therefore, the indications for treating these lesions are still a matter of debate, but symptomatic aneurysms, asymptomatic large aneurysms and those with laminated thrombus should be offered treatment . Yao and McCarthy observed asymptomatic aneurysm for seven years without any enlargement of aneurysm or any development of symptoms . Borozan also reported and suggested conservative approach in asymptomatic aneurysms . 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 embolisation and percutaneous occlusion of aneurysm with various modalities are more commonly used in pseudo-aneurysms and are associated with risk of limb ischaemia.
In this case, patient underwent surgical excision followed by interposition vein graft. Out of eleven published case reports, six patients had undergone surgical excision of posterior tibial artery aneurysm with interposition vein graft [9, 18, 6, 14, 11], while four patients had ligation of posterior tibial artery [16, 12, 19, 17]. One patient had surgical excision with primary end to end anastomosis of posterior tibial artery . In our patient, anterior tibial artery was intact and one might question the need for operation in this report, however we believe that infrapopliteal aneurysms should be treated irrespective of symptomatology due to the risk of embolization, thrombosis and rupture leading to potential ischaemia and amputation.
Although it is only twelfth reported case of true posterior tibial artery aneurysm, we recommend early diagnosis and treatment in the form of excision before it becomes symptomatic and complicated.
Patient’s formal written consent was obtained for publication of this case report.
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