Ruptured Mycotic Infrapopliteal Aneurysm

Abstract

Aneurysms involving infrapopliteal arteries are rare. Ruptured infrapopliteal aneurysms are particularly uncommon and represent a surgical or endovascular emergency. A 57-year-old man presented with a 12-cm ruptured aneurysm of the tibioperoneal trunk 5 years after an episode of bacterial endocarditis. The patient was asymptomatic until he presented acutely with a rapid expansion in the size of the left leg. Computed tomography angiography confirmed presence of a large ruptured aneurysm with chronic destruction of the adjacent tibia. The surgical approach included operative exclusion of the aneurysm via medial leg incision. Proximal control was obtained of the superficial femoral artery, and once the aneurysm was opened and decompressed, the leg was exsanguinated with an elastic bandage and hemostasis was obtained with a tourniquet. The aneurysm was ligated from within the sac, and vascular continuity was restored with a reversed contralateral saphenous vein graft from the superficial femoral artery to the distal posterior tibial artery. This aneurysm was suspected to be mycotic, although no microorganisms were recovered. Review of English literature suggests this is the largest infrapopliteal aneurysm reported. We describe a unique surgical approach using extremity exsanguination and tourniquet for vascular control after aneurysm decompression to control hemorrhage, followed by successful restoration of arterial circulation.