Vascular injuries due to trivial trauma are rare and infrapopliteal vascular injuries
in this subset of injuries are even less common in the absence of crush injuries and
bony fractures.
A 52-year-old gentleman, an agriculture laborer, sustained an injury to his left leg
when he accidentally banged against a wooden log. There was a wound in his distal
left leg, which was sutured at a nearby hospital on the day of injury. The postoperative
period was uneventful until he noticed bleeding from the wound on day 5 after injury,
which was managed with pressure bandage and ligation of bleeders. He experienced repeated
episodes of bleeding on the 42nd and 45th day post injury. He had undergone ligation
of the bleeders repeatedly on outpatient basis at the same hospital before presenting
to us with an ill-defined pulsatile swelling of ∼5 × 6 cm in size beneath the 6 cm
long infected sutured wound in the distal left leg ([Fig. 1]). There was purulent discharge and the viability of the sutured skin was precarious.
Arterial Doppler showed a pseudoaneurysm of the left anterior tibial artery with good
distal flow in both the anterior and posterior tibial arteries. On exploration, a
4 × 6 cm pseudoaneurysm of the anterior tibial artery was seen ([Fig. 2A]). Pseudoaneurysm was excised and the anterior tibial artery was ligated proximally
and distally after ascertaining distal vascularity. The infected skin was debrided
and there was a defect of 6 × 5 cm exposing the underlying tendons. Hence a peroneus
brevis muscle flap resurfaced with skin graft was used to cover the defect ([Fig. 2B]). Postoperatively and at follow-up of 6 months, he was asymptomatic and the flap
had settled well ([Fig. 3]).
Fig. 1 Presenting clinical picture showing sutured wound with necrosis of surrounding skin
in the distal leg (arrowhead pointing toward the foot).
Fig. 2 (A) Intraoperative picture showing pseudoaneurysm (marked by arrow) of the anterior
tibial artery (marked by star) dissected out from surrounding tissues. (B) Intraoperative picture after the excision of pseudoaneurysm with defect covered
with peroneus brevis flap that was resurfaced with skin graft afterwards.
Fig. 3 Six-month follow-up picture showing the well settled muscle flap and skin graft.
Infrapopliteal pseudoaneurysms are less common and the true incidences of such injuries
leading to pseudoaneurysms are not exactly known.[1] Anterior tibial artery pseudoaneurysms were reported in 43% of the cases.[2] Most common symptoms at the time of diagnosis was swelling, pain, and bleeding.[3] Herald bleed usually harbinger torrential threatening bleeds.[4] When such herald bleeds occur, the history should be revisited and the vascular
injury and sequel should be investigated. Neglected pseudoaneurysms that get infected
leads to necrosis of the overlying skin and adds to the complexity of treatment. Debriding
surgically the skin and soft tissue to healthy planes under good tourniquet control
sooner addresses the infection. The pseudoaneurysm needs to be tackled either by reconstruction
of vessels, which is risky in presence of infection, or ligating the ends of the vessel
after ascertaining the distal vascularity. Endovascular procedure is also a possible
option in these situations. Finally, the reconstruction of skin and soft tissue by
local flaps is necessary. Muscle flaps do better in eradicating infection by filling
cavities and thus reducing dead spaces.[5] Free flaps must be used judiciously in the presence of infection and compromised
vessels. High index of suspicion should be there among the professionals treating
trauma conditions for early diagnosis and treatment. Infected pseudoaneurysms add
complexity to the treatment.
