Pseudoaneurysm of Dorsalis Pedis Artery after Bunionectomy: Case Report and Review of Literature
Abstract:
The dorsalis pedis (DP) artery is a continuation of the anterior tibial artery that supplies the dorsum of the foot [1]. The DP artery is at the major site of various orthopedic and podiatric surgeries involving the foot. Although a rare event, aneurysms of the DP artery can occur with pseudoaneurysm being the most common complication [2]. We present an unusual case involving pseudoaneurysm of the DP artery status-post bunionectomy diagnosed using duplex ultrasound and treated with percutaneous thrombin injection.
The dorsalis pedis (DP) artery is a continuation of the anterior tibial artery that supplies the dorsum of the foot [1]. The DP artery is at the major site of various orthopedic and podiatric surgeries involving the foot. Although a rare event, aneurysms of the DP artery can occur with pseudoaneurysm being the most common complication [2]. We present an unusual case involving pseudoaneurysm of the DP artery status-post bunionectomy diagnosed using duplex ultrasound and treated with percutaneous thrombin injection.
A 56 year-old female, who had a bunionectomy in December 2007, was noted to have a mass at the dorsum of her left foot in January of 2008. The patient complained of localized pain and inability to wear shoes. The patient had no history of any allergies or bleeding tendencies. Her physical exam at presentation showed a recent 3 cm incision, with a pulsatile mass at the dorsum of the left foot, above the metacarpal bone, without cellulitis.
An arterial color duplex ultrasonography of the left foot evidenced mild, smooth
thickening along vessels with no hemodynamically significant stenosis. There was a large Pseudoaneurysm arising from the DP artery, measuring 2.9 × 2.3 cm with arterial flow. (Figure1).
Figure 1: Preoperative Arterial color duplex evidencing a pseudoaneurysm measuring 2.9 ×
2.3cm with arterial flow seen on the left foot.
Multiple attempts to achieve thrombosis by compression failed and the patient was admitted for treatment. The admission foot x-ray showed resected distal ends of the proximal phalanges of the 2nd, 3rd and 4th toes, distal end of the 2nd metatarsal, and previous surgery for Hallux Valgus. There was no evidence of fracture or osteomyelitis. (Figure 2).
Figure 2: Admission left foot X-ray
Under ultrasound guidance, a 21 gauge needle was positioned in the most superficial portion of the aneurysm and 400 units of Thrombin was injected under direct visualization showing thrombosis of the pseudoaneurysm. (Figure 3).
evidencing thrombosis of the pseudoaneurysm.
In our patient, the distal DP artery was patent before and after thrombin injection. The pseudoaneurysm repair improved the patient’s symptoms and there was no sign of digital ischemia after the procedure. At the
follow-up clinical examination, no neurosensory or motor deficits were present on exam. A Color Doppler sonography was performed, at one and three months, confirming the absence of flow in the pseudoaneurysmal cavity.
Dorsalis pedis pseudoaneurysms are extremely rare with few cases reported in the literature [3]. Most occur following traumatic injury that patients considered too minor to seek medical advice for, delaying diagnosis and treatment. Most cases are reported after foot and ankle sprain or surgical intervention [4, 5, 6] and they present as pulsatile swellings on the dorsum of the foot. Pseudoaneurysms form when an arterial lesion fails to seal, allowing arterial blood to flow into adjacent tissues and form a pulsatile hematoma with specific Doppler sonographic findings [7]. These lesions lack a fibrous wall and are contained by a surrounding shell of hematoma and the overlying soft tissue. They can present as a new thrill, bruit, or pulsatile hematoma with marked tenderness. Other differential diagnoses include contained hematoma, abscess and arteriovenous fistula.
Complications of pseudoaneurysms include local pain, skin ischemia, rupture, distal embolization and neuropathy [3]. In patients with a recent procedure the enlarging pseudoaneurysm may dehisce the wound with marked free arterial bleeding. The wearing of shoes in the patient with DPA pseudoaneurysm can be uncomfortable due to chronic irritation, which may also lead to eventual arterial thrombosis or rupture [8]. A focal neurological deficit, likely due to adjacent nerve compression, has been reported in DPA aneurysms, which resulted in restricted ankle dorsiflexion and paralysis of the deep peroneal nerve [8].
Pseudoaneurysm of Dorsalis Pedis Artery after Bunionectomy
Figure 3: (Post-Operative) Arterial color duplex
evidencing thrombosis of the pseudoaneurysm.
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Fall Ed. 2013 3.
There is also an increased risk of acute ischemia in the foot due to in situ thrombosis or thromboembolic occlusion of peripheral arterial branches [3,9].
Some authors have emphasized the value of repairing the DPA aneurysm to avoid future patient morbidity [3,8,9].
Ultrasound guided compression repair carries an overall complication rate of 3.6% and risk of rupture of 1% [3]. Contraindications to this technique include inaccessible site, limb ischemia, infection, large hematomas with overlying skin ischemia, compartment syndrome, and prosthetic grafts [3].
We describe a very rare case of DP artery pseudoaneurysm after bunionectomy. It illustrates the need for surgeons to be aware of this complication, especially with the increasing number of foot procedures by podiatric and orthopedic surgeons. Early intervention is needed to avoid severe complications such as dehiscence of the wound and free arterial bleeding. Increased awareness and careful hemostasis are essential to improve safety and outcome.
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