Aneurysm
of the dorsalis pedis artery: case report and literature review
(Portuguese
PDF version)
Marcelo
Iost Bausells1, Selma Regina de Oliveira Raymundo2,
Adinaldo Adhemar Menezes da Silva3, Marcelo Rocha
Casagrande1, Daniel Gustavo Miquelin1,
Luiz Fernando Reis4
1.
Resident doctor, Division of Vascular Surgery, Hospital de Base de
São José do Rio Preto.
2. Head professor of vascular surgery, Faculdade
de Medicina de São José do Rio Preto.
3. Professor of vascular surgery, Faculdade de Medicina
de São José do Rio Preto.
4. Physician, Division of Vascular Surgery, Hospital
de Base de São José do Rio Preto.
Correspondence:
Dr. Marcelo Iost Bausells
Rua Maranhão, 43/32
CEP: 01240-001- São Paulo - SP
Tel.: +55 (11) 3259.4441
E-mail: marcelobausells@hotmail.com
ABSTRACT
The
present article reports a case of a male child with aneurysm of
the dorsalis pedis artery. Diagnosis was confirmed by duplex scanning
and pathoanatomical examination. End-to-end anastomosis was performed.
Six months later, the lesion reappeared. A new duplex scan showed
integrity of the anastomosis and revealed another aneurysm immediately
close to this one. An angiographic study was performed and showed
complete plantar arch. The aneurysm was resected and the dorsal
foot artery was ligated. A pathological examination evidenced arterial
dissection after anastomosis. During a six-month follow-up period
after the second surgery, no recurrence was noted. Most of the published
case reports related to pseudoaneurysms. True aneurysms are relatively
rare. A discussion about the etiology, epidemiology and treatment
of this type of aneurysm is also presented.
Key-words:
aneurysm, artery, surgery.
Palavras-chave: aneurisma, artéria, cirurgia.
J
Vasc Br 2003;2(1):26-28
INTRODUCTION
True aneurysm
of the dorsalis pedis artery is a rare condition, especially among children.
It is usually associated with factors such as arteriosclerosis, collagen
disease and syphilis, among others. The present study describes the
case of a child with aneurysm of the left dorsalis pedis artery, which
had been free of disease or history of trauma. The epidemiology, etiology
and surgical treatment of the aneurysm are discussed and literature
reviewed.
CASE
REPORT
A 4-year-old male child was assessed by our division of vascular surgery
after being evaluated by pediatricians. The child presented with a pulsatile
mass for approximately two years. The mass was located on the dorsal
region of the left foot, next to the ankle, and was about 1 cm in diameter.
It was painless, with fibroelastic consistency, and with no inflammatory
signs at the site No rapid growth had been noticed in the last few months
and there was no previous history of trauma or related diseases at the
site. The child did not show characteristics of a syndrome.
After consultation,
a duplex scan was performed, which showed aneurysmal dilation of the
dorsalis pedis artery, with diameters of at most 4.9 mm x 8.9 mm, with
no signs of thrombi in them. The examination of the abdominal aorta
and of the iliac and visceral arteries was uneventful (Figures 1, 2,
3 and 4).
 Figure
1 - Preoperative duplex scanning.
Figure
2 - Duplex scan after first surgery.
Figure
3 - Arteriography after first surgery.
Figure
4 - Intraoperative aspect.
The child
was submitted to surgical treatment for aneurysm excision and end-to-end
anastomosis. The pathoanatomical examination confirmed the existence
of true aneurysm, which was 1.2 cm in length and 0.5 cm in diameter.
The surgical wound healed completely in the postoperative period. The
control duplex scan, carried out one month after the surgery, yielded
normal results.
Six months after the surgery, the pulsatile lesion reappeared under
the surgical scar. A new duplex scan revealed integrity of the end-to-end
anastomosis and dilation of the aneurysm after anastomosis, with a size
of 6.3 mm x 8.2 mm (Figures 5 and 6). A selective arteriography of the
left lower limb showed normal femoral, popliteal, and tibial arteries
and dilation of the dorsalis pedis artery, which extended from the tarsus
to the proximal half of the metatarsal bones. The plantar arch was unaffected,
with complete filling through both tibial arteries (Figures 7 and 8).
A second
surgery, which consisted of excision of the lesion and ligation of the
dorsalis pedis artery, was performed (Figures 9, 10 and 11). The pathoanatomical
examination showed dissecting aneurysm in the anastomosed segment of
the artery.
We observed
appropriate perfusion of the foot in the postoperative period. The follow-up
until six months after the surgery did not show recurrence of the lesion.
DISCUSSION
Arterial
aneurysms result from two basic mechanisms: (1) intrinsic, due to structural
fragility of the vessel wall, and (2) due to mechanical stress of the
arterial wall. Several pathological processes are associated with arterial
aneurysms, among which, we have Marfan syndrome, Ehlers-Danlos syndrome,
syphilis, diabetes, infections, trauma, atherosclerosis and fibrodysplasia.
The aorta is the most frequently affected artery, followed by femoral
and popliteal arteries. Aneurysms are clinically characterized by a
pulsatile mass, and may present or not thrill or murmur. Arteriography,
computed tomography, magnetic resonance, and ultrasonography are routinely
used to confirm the diagnosis, check the extension of the problem and
relationships with other anatomical structures.
The aneurysms of the dorsalis pedis artery are rarely reported, but
we believe they occur quite often. Of the 15 case reports found in the
literature, most were concerned with pseudoaneurysms1-5
in children, usually related to trauma or orthopedic surgery.
Few of the reported cases relate to true aneurysms. Herrmann 7
described aneurysm in a 42-year-old patient and associated it with arteriosclerosis.
The lesion was excised, with end-to-end anastomosis of the artery.
Wu 8 reported aneurysm of the dorsalis pedis
artery in a 52-year-old male patient, who was submitted to resection
of the lesion and ligation of the arterial stumps. The pathoanatomical
examination revealed true aneurysm, with mural thrombus and thin arterial
walls.
Fitzpatrick9
and Morettini et al. 10 reported another
two cases, described as idiopathic and isolated, respectively. Both
patients presented risk factors for arteriosclerosis.
McKee & Fisher6 described a case of
a 71-year-old, diabetic and hypertensive woman, in whom the aneurysm
was excised after ligation of the dorsalis pedis artery. The histopathological
exam revealed epithelioid hemangioma.
Some studies suggest that if aneurysm is observed at this site, other
sites should be inves tigated by careful clinical examination and imaging
exams. Immunoelectrophoresis, anti-smooth muscle antibody and antinuclear
antibody panels and serology for syphilis should be requestedm.9,10
A histopathological exam of the vessel wall and a microbiological exam
of the surgical specimen are crucial for the investigation of mycotic
aneurysm.
Clinical conduct, with periodical reassessments of the lesion, was adopted
in some cases. Most cases required surgical intervention, which consisted
of excision of the lesion followed by end-to-end anastomosis of the
artery,1,2,7,10 in order
to preserve vascular integrity, ensuring normal development in children
and adolescents at risk of developing atherosclerosis. However, the
definitive ligation of the artery is another treatment option that can
be carried out safely.
In the reported case, as it involved a child, we decided for arterial
repair on the first surgery, as recommended by the literature; such
procedure was also adopted due to the easy approximation of the proximal
and distal stumps of the artery it allows. Our decision for permanent
ligation of the artery on the second surgery was rather based on technical
aspects than on the possibility of recurrence of the disease, since
the histopathological exam showed dissection of the arterial wall next
to the anastomosis as reason for recurrence of the disease.
The imaging exams did not show other aneurysms or vascular abnormalities.
The preoperative exams and the pathoanatomical exams did not detect
the etiology of the disease, and the lesion was considered to be a true
aneurysm of the dorsalis pedis artery, with idiopathic nature.
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Herrmann M. Pedal aneurysms [letter]. Eur J Vasc Endovasc Surg 1996;11:250.
8.Wu
KK. True aneurysm of dorsalis pedis artery mimicking a soft tissue
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