Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 9  |  Issue : 1  |  Page : 105-107

Ruptured infective pseudoaneurysm of the posterior tibial artery causing repeated bleeding in a chronic venous ulcer


Department of Vascular and Endovascular Surgery, Yashoda Hospitals, Hyderabad, Telangana, India

Date of Submission25-Oct-2021
Date of Acceptance02-Nov-2021
Date of Web Publication23-Mar-2022

Correspondence Address:
Devender Singh
Department of Vascular and Endovascular Surgery, Yashoda Hospitals, Hyderabad, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_114_21

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  Abstract 


Bleeding from the chronic venous ulcer is usually from underling ruptured varicosities or due to opening of arteriovenous communications. Pseudoaneurysm of the tibial arteries in the chronic venous wounds leading to bleeding is an extremely rare complication. Massive bleeding sometimes is life-threatening. We present a case of ruptured infected pseudoaneurysm of the posterior tibial artery with a chronic venous ulcer, who presented in shock with repeated episodes of bleeding.

Keywords: Chronic venous ulcer, ligation, pseudoaneurysm, pulsatile bleeding


How to cite this article:
Singh D, Aryala S. Ruptured infective pseudoaneurysm of the posterior tibial artery causing repeated bleeding in a chronic venous ulcer. Indian J Vasc Endovasc Surg 2022;9:105-7

How to cite this URL:
Singh D, Aryala S. Ruptured infective pseudoaneurysm of the posterior tibial artery causing repeated bleeding in a chronic venous ulcer. Indian J Vasc Endovasc Surg [serial online] 2022 [cited 2022 May 28];9:105-7. Available from: https://www.indjvascsurg.org/text.asp?2022/9/1/105/340495




  Introduction Top


Bleeding from a chronic venous ulcer is usually due to underlying long-standing varicosities. But in a patient with a history of recurrent pulsatile bleeding to the extent of requiring multiple blood transfusions, one should suspect an underlying arterial cause. Infective chronic venous ulcers can result in pseudoaneurysm of the tibial arteries, though rare. We report a case of recurrent massive bleeding from the nonhealing wound over the right ankle region. He was found to have varicose veins and a bleeding ruptured pseudoaneurysm of the posterior tibial artery in the ulcer area and was managed.


  Case Report Top


A 70-year-old man presented in emergency with repeated episodes of bleeding from the nonhealing wound over the medial aspect of right ankle. The ulcer had been present for more than 5 years and was not managed properly. Proper medical attention was only soughed first time 2 weeks back when it suddenly started bleeding. He then had two more episodes of bleeding requiring blood transfusions. His Doppler scan was suggestive of multiple varicosities with significant saphenofemoral reflux, incompetent perforators in leg, and no deep vein thrombosis. He was managed conservative with compression and was advised to see a specialist after correction of his hemoglobin. As his hemoglobin continued to be on the lower side, in spite of multiple transfusions, he was advised to go to a higher center.

On arrival in emergency department, he again had bleeding from the wound and went into shock. He was tachycardic, hypotensive, grossly pale and noted to have pulsatile bleeding from the 5 cm × 4 cm, foul smelling pale wound over the right medial malleolus [Figure 1]. There were significant varicosities and hyperpigmentation over his right leg. His hemoglobin dropped to 4 gm%. He was resuscitated with fluids and blood, the wound was tightly dressed, and he was shifted to the operation theater. He first underwent endovenous radiofrequency of great saphenous vein and foam sclerotherapy for multiple varicosities [Figure 2]. After ablation, his wound was explored and found to have a ruptured pseudoneurysm of the posterior tibial artery [Figure 3]. In view of active infection of wound, a decision of ligation of the posterior tibial artery (away from active infection) was taken, confirming good flow in dorsalis pedis artery [Figure 4]. A piece of tissue from ulcer was sent for histopathological examination and culture. He was transfused 4 units of packed cell. Postoperatively, he showed good recovery; dorsalis pedis artery is well palpable, with good healthy wound granulation. His hemoglobin remained stable with no further bleeding from the wound. He was also investigated for any underlying vasculitis, which did not reveal any positive finding. His culture grew methicillin-resistant Staphylococcus aureus and was appropriately treated. Histopathological examination did not reveal any significant finding, and there was no evidence of any vasculitis or malignancy. The patient is doing well in the follow-up and is planned for four-layer bandage for the speedy healing of the wound. He has given his consent for the case presentation and publication.
Figure 1: Pulsatile bleeding from the nonhealing infected venous ulcer (right ankle)

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Figure 2: Dilated saphenofemoro junction (right groin) on color Doppler

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Figure 3: Pulsatile pseudoaneurysm of right posterior tibial artery

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Figure 4: Ruptured infected pseudoaneurysm of right posterior tibial artery

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  Discussion Top


Bleeding from the chronic venous ulcer is uncommon and is usually due to ruptured underlying varicosities.[1] Massive bleeding requiring blood transfusions is maybe due to arteriovenous communications in a chronic stasis ulceration.[2] A pseudoaneurysm of the tibial artery is an extremely rare cause.[3] Usual causes for a tibial artery pseudoaneurysm follow trauma or iatrogenic injuries.[4] In our case, there was no history of any trauma or procedure; however, there was evidence of infection which could be the possible cause for this pseudoaneurysm. Repeated episodes of pulsatile bleeding with a significant drop in hemoglobin should clinically suspect a pseudoaneurysm. Massive bleeding leading in shock can be life-threatening. A color Doppler or an angiography further confirms the diagnosis. We did not do an angiography, as the patient was in shock and made our diagnosis based on clinical findings and on table Doppler scan. Ligation of the pseudoaneurysm of the posterior tibial artery in the infective wound with a definitive procedure for the varicose veins remains the best procedure; however, it needs to be sure for the vascularity in foot with normal flow in rest of the arteries. Transcatheter microembolization has recently gained widespread acceptance in the treatment for the ruptured pseudoaneurysm at various sites within the body.[5] It can be utilized for tibial pseudoaneurysm, if all vessels are patent.

In conclusion, though pseudoaneurysm of the tibial artery is extremely rare in a chronic venous ulcer, the patient presenting with repeated episodes of massive bleeding should be considered in the diagnosis.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name 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.
Evans GA, Evans DM, Seal RM, Craven JL. Spontaneous fatal haemorrhage caused by varicose veins. Lancet 1973;2:1359-61.  Back to cited text no. 1
    
2.
Komai H, Kawago M, Juri M. Massive spouting bleeding from chronic stasis ulceration caused by arteriovenous communication of the lower extremity. J Vasc Surg 2006;44:658-9.  Back to cited text no. 2
    
3.
Parry DJ, Parikh A, Robertson I, Kessel D, Scott DJ. Arterial haemorrhage from a chronic venous ulcer – Pseudoaneurysm formation of the posterior tibial artery. Eur J Vasc Endovasc Surg 2000;20:489-91.  Back to cited text no. 3
    
4.
Skudder PA, Gelfand ML, Blumenberg RM, Fulco J. Tibial artery false aneurysm: Uncommon result of blunt injury occurring during athletics. Ann Vasc Surg 1999;13:589-91.  Back to cited text no. 4
    
5.
Yamakado K, Nakatsuka A, Tanaka N, Takano K, Matsumura K, Takeda K. Transcatheter arterial embolization of ruptured pseudoaneurysms with coils and n-butyl cyanoacrylate. J Vasc Interv Radiol 2000;11:66-72.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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