Only a few cases of infrapopliteal aneurysms are reported in the literature. These are commonly associated with trauma, infection, and iatrogenic injuries and mostly present as pseudoaneurysms. We report the case of a 44-year-old man with Behçet disease and an 8-cm tibioperoneal trunk aneurysm and discuss the management options of these aneurysms

Dakour Aridi, Hanaa

Dhaliwal, Jasninder Singh

Hamouda, Mohammed

Lee, Rachel Elizabeth

Malas, Mahmoud B

English

Only a few cases of infrapopliteal aneurysms are reported in the literature. These are commonly associated with trauma, infection, and iatrogenic injuries and mostly present as pseudoaneurysms. We report the case of a 44-year-old man with&nbsp;Behçet disease and an 8-cm tibioperoneal trunk aneurysm and discuss the management options of these aneurysms

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UC San DiegoUC San Diego Previously Published WorksTitleManagement of tibioperoneal trunk aneurysm in a patient with Behçet disease.Permalinkhttps://escholarship.org/uc/item/88j1b8g2JournalJournal of vascular surgery cases and innovative techniques, 4(1)ISSN2468-4287AuthorsHamouda, MohammedDakour Aridi, HanaaLee, Rachel Elizabethet al.Publication Date2018-03-01DOI10.1016/j.jvscit.2017.10.009 Peer reviewedeScholarship.org Powered by the California Digital LibraryUniversity of CaliforniaFrom thtory,AuthorCorrespReseaMedi(e-maThe edidisclomanu2468-4 2017is ancreathttps://Management of tibioperoneal trunk aneurysm in a patient withBehçet diseaseMohammed Hamouda, MBBS, Hanaa Dakour Aridi, MD, Rachel Elizabeth Lee, BA,Jasninder Singh Dhaliwal, MBBS, and Mahmoud B. Malas, MD, MHS, FACS, Baltimore, MdABSTRACTOnly a few cases of infrapopliteal aneurysms are reported in the literature. These are commonly associated with trauma,infection, and iatrogenic injuries and mostly present as pseudoaneurysms. We report the case of a 44-year-old manwith Behçet disease and an 8-cm tibioperoneal trunk aneurysm and discuss the management options of theseaneurysms. (J Vasc Surg Cases and Innovative Techniques 2018;4:15-8.)Behçet disease is an autoimmune disease characterizedby systemic vasculitis and a triple complex of symptoms:recurrent oral aphthous stomatitis, uveitis, and genital ul-cers. Inhabitants of Turkey and Far Eastern Asian countrieshave the highest prevalence of the disease.1 Although anarterial lesion secondary to Behçet disease is a rare mani-festation, an increased frequency of recurrence and life-threatening complications including ischemic bowelperforations, sudden rupture of large arterial or aortic an-eurysms, and cerebrovascular accidents bring challengesto providing treatment. Immunosuppressive therapy (eg,oral prednisolone) is administered to reduce the risk ofsuch outcomes.2 Medically treated aneurysmal lesionsrespond poorly, and in most cases, surgery is mandatory.3However, surgical intervention is challenging in these pa-tients compared with patients with normal vascularintegrity. The intense local inflammation may increasecomplications. In addition, arterial aneurysms in patientswith Behçet disease are at a high risk of rupture, and pa-tients are more likely to have multiple lesions at severalsites. The aim of this report was to highlight the manage-ment of a tibioperoneal trunk (TPT) aneurysm in a patientwith Behçet disease. The patient has consented to thispresentation.CASE REPORTHistory. A 44-year-old man presented to the vascular outpa-tient clinic for evaluation of an infrarenal abdominal aorticaneurysm and a right popliteal aneurysm. The patient wase Johns Hopkins Bayview Vascular and Endovascular Research Labora-Department of Surgery.conflict of interest: none.ondence: Mahmoud B. Malas, MD, MHS, FACS, Director of the Center ofrch Excellence and Surgical Trials, Johns Hopkins University School ofcine, 4940 Eastern Ave, Building A/5, Ste 547, Baltimore, MD 21401il: bmalas1@jhmi.edu).tors and reviewers of this article have no relevant financial relationships tose per the Journal policy that requires reviewers to decline review of anyscript for which they may have a conflict of interest.287Published by Elsevier Inc. on behalf of Society for Vascular Surgery. Thisopen access article under the CC BY-NC-ND license (http://ivecommons.org/licenses/by-nc-nd/4.0/).doi.org/10.1016/j.jvscit.2017.10.009hypertensive and had a history of Behçet disease characterizedby orogenital ulcers and posterior uveitis with left eye blindness.The patient has been receiving steroid therapy since his diag-nosis 14 years ago and underwent a left 8  5-cm poplitealaneurysm repair 5 months before presentation in an outpatientsetting outside the United States. He is a current every-daysmoker of 100 pack-years.On physical examination, the patient had normal vital signs, aweight of 80 kg, a height of 176 cm, and a BMI of 25.8 kg/m2.Review of systems was positive for blurred vision and diffuserash. Physical examination of both legs showed no evidence ofinfection, cyanosis, or edema. Abdominal examination showedno palpable or pulsating masses. Lower extremity pulses were2þ and symmetric except for a prominent 4þ right popliteal ar-tery pulsation. Laboratory test results were within normal limits.Imaging. Lower extremity Doppler ultrasound examinationshowed a right below-knee popliteal artery aneurysmmeasuring 4.08  3.74  3.91 cm and a patent left above-kneepopliteal to proximal posterior tibial artery bypass with normalgraft velocity. It appeared that the left anterior tibial artery wasligated, and a collateral flow filled back into the peroneal artery.Ankle-brachial index was 1.2 on the right side and 1.12 on the leftside. Digital pressure was 139 mm Hg and 104 mm Hg, respec-tively. Duplex ultrasound of the abdominal aorta showed a3.4-cm saccular infrarenal aneurysm. Bilateral lower extremityand aortic angiography was performed and showed a normalright popliteal artery with a large 7-  8-cm saccular TPT aneu-rysm (Fig 1). A 3- to 4-cm saccular aneurysm in the mid to distalaorta was seen on the aortic angiogram.Operation. The risks and benefits of the TPT aneurysm repairwere discussed with the patient. These included the high risk ofaneurysm recurrence, given his vasculitis condition, and theimportance of lifetime anticoagulation to decrease the risk ofthrombosis and graft occlusion. He consented to the open repair.The patient was intubated and placed in the prone position.We made a gentle S-shaped incision extending from above tobelow the knee and identified the lesser saphenous vein, whichwas followed to the junction with the popliteal vein proximallyand then to about midcalf. All tributaries were doubly ligated.The popliteal artery was identified behind the knee and wasdissected free, with vessel loops placed around it. We followed15Fig 1. Preoperative angiographic image of the right lowerextremity showing a large 7-  8-cm saccular tibioper-oneal trunk (TPT) aneurysm.16 Hamouda et al Journal of Vascular Surgery Cases and Innovative TechniquesMarch 2018it down to the large TPT aneurysm extending 8 cm into thedeep calf muscle. The dissection was difficult and tedious andtook >3 hours. The aneurysm was completely freed up from allthe surrounding tissue with no bleeding (Fig 2, A). The posteriortibial and peroneal arteries were identified and controlled withthe vessel loop. The patient was given 5000 units of heparinintravenously. After the sac was opened, there was backbleed-ing from several small branches, which were suture ligatedwith a figure-of-8 5-0 Prolene from within the aneurysm. Thevein was transected proximally and distally and dilated gentlywith heparinized saline to approximately 5 mm in diameter.The vein was inverted, and two valves were identified andexcised. The proximal end of the vein was sewn to the poplitealartery below the knee. We were able to include the anteriortibial artery in the back wall of the anastomosis. The vein wascut to the proper length and was sutured to the posterior tibialartery distally (Fig 2, B). We did transect the aneurysm distallyand oversewed the TPT with two layers of nylon. At the end,there were palpable dorsalis pedis and posterior tibial pulsesin the foot, confirmed with triphasic Doppler signals that dissi-pated on clamping and were augmented when the bypasswas released. The patient was stable hemodynamicallythroughout the case and was transferred in stable condition tothe recovery room.Discharge and follow-up. The patient was dischargedhome after 3 days with an uneventful postoperative course.Follow up duplex ultrasound at 4 weeks, 12 weeks, 6 months,and 1 year showed widely patent right lower extremity bypass(Fig 3). The ankle-brachial index and toe pressure were normalbilaterally. The abdominal aortic aneurysm was stable in size.DISCUSSIONArterial complications occur in 25% to 30% of patientswith Behçet disease, with aneurysms occurring any-where throughout the body, either synchronously ormetachronously. Aneurysmal degeneration in this dis-ease is probably due to obliterative endarteritis of thevasa vasorum supplying the medium-sized and largevessels.4 These are more preferably treated with endovas-cular than with open repair.5-8 Endovascular proceduresare effective and safe, with acceptable complicationrates and good durability.2In this report, we present the case of a male patientwith Behçet disease who had undergone prior successfulleft TPT aneurysm resection and repair with above-kneepopliteal to posterior tibial bypass. The patient presentedwith a large right TPT aneurysm reaching 8 cm in diam-eter. There was no proximal or distal neck at which toplace the covered stent, and the aneurysm was very largewith no neck to coil. As a result, the patient was not acandidate for the endovascular approach.Tibioperoneal artery aneurysms are rare and are mostlydue to trauma, infection, and iatrogenic injuries.9 Aftercareful literature search, we identified eight cases of pa-tients with TPT aneurysms,4,9-14 only one of which was sec-ondary to Behçet disease.4 The aneurysm was 6.6 cm indiameter and was resected, followed by a below-kneepopliteal to distal posterior tibial artery bypass usingreversed ipsilateral great saphenous vein graft. Two ofthe other reported TPT aneurysms were due to athero-sclerosis,13,14 and the remaining five were of unspecifiedetiology.9-13 On the other hand, in 2011, Rico et al15 re-ported a case of a 41-year-old man with Behçet diseasewho presented with a ruptured tibioperoneal pseudoa-neurysm. The patient underwent emergent endovascularembolization with three 5-mm metallic coils.There is no consensus as to whether to perform bypasssurgery or endovascular stent placement for aneurysmrepair secondary to Behçet disease.16 The endovascularapproach is preferred in Behçet disease patients withsuitable anatomy (usually aortic aneurysms) because ofits relatively lower morbidity and mortality ratescompared with open surgical repair. However, in periph-eral aneurysms secondary to Behçet disease, the stentgrafts have a greater risk of complications, such asthrombosis and development of a pseudoaneurysm atthe site of the repair.3,17 On the other hand, possibleprocedure-related complications after open aneurysmexcision and bypass include acute graft occlusion,long-term restenosis, aneurysm recurrence, and fistulaFig 2. Intraoperative pictures of the (A) tibioperoneal trunk (TPT) aneurysm and (B) lower extremity bypass. Thearrow in (B) shows the vein conduit. The trocar is holding the tibial nerve.Fig 3. Follow-up duplex ultrasound examination of theright lower extremity. The right lower extremity bypass iswidely patent at 1 year postoperatively.Journal of Vascular Surgery Cases and Innovative Techniques Hamouda et al 17Volume 4, Number 1formation at the anastomotic site.4 The establishment ofremission before the surgical intervention hasbeen shown to decrease postoperative complications.Immunosuppressive therapy, such as oral prednisone,azathioprine, cyclosporine, and others, is given beforeand after surgery to prevent early and late postoperativecomplications.18 Some authors recommend using corti-costeroids combined with immunosuppressants for atleast 2 years postoperatively to decrease the risk ofrecurrent aneurysms.16,19CONCLUSIONSTibioperoneal aneurysms are a rare manifestation ofBehçet disease. Cases should be evaluated on an individ-ual basis, and management depends mainly on the loca-tion, anatomy, and size of the aneurysm. Close follow-upis recommended to monitor for disease progressionand recurrence as well as to detect postoperativecomplications.REFERENCES1. Zouboulis CC. Epidemiology of Adamantiades-Behçet’sdisease. Ann Med Interne (Paris) 1999;150:488-98.2. Normayah K, Mazri YM, Suib I, Zainal AA. Behçet’s diseasewith vascular complications. Med J Malaysia 2004;59:547-9.3. Kim WH, Choi D, Kim JS, Ko YG, Jang Y, Shim WH. Effec-tiveness and safety of endovascular aneurysm treatment inpatients with vasculo-Behçet disease. J Endovasc Ther2009;16:631-6.4. Al-Jubouri S, Al-Jubouri M, Kamal D. Aneurysm of the tibio-peroneal trunk: case report. Ann Vasc Dis 2013;6:651-4.5. Balcioglu O, Ertugay S, Bozkaya H, Parildar M, Posacioglu H.Endovascular repair and adjunctive immunosuppressivetherapy of aortic involvement in Behçet’s disease. Eur J VascEndovasc Surg 2015;50:593-8.6. Goksel OS, Torlak Z, Çınar B, Sahin S, Karatepe C, Eren E.Midterm results with endovascular approach to abdominalaortic pathologies in Behçet’s disease. Ann Vasc Surg2012;26:277.e5-9.7. Kwon TW, Park SJ, Kim HK, Yoon HK, Kim GE, Yu B. Surgicaltreatment result of abdominal aortic aneurysm in Behçet’sdisease. Eur J Vasc Endovasc Surg 2008;35:173-80.8. Nitecki SS, Ofer A, Karram T, Schwartz H, Engel A,Hoffman A. Abdominal aortic aneurysm in Behçet’s disease:new treatment options for an old and challenging problem.Isr Med Assoc J 2004;6:152-5.9. Ferrero E, Viazzo A, Robaldo A, Ferri M, Piazza S, Cumbo P,et al. True giant aneurysm of the tibio-peroneal trunk: casereport and review of the literature. Vasc Endovascular Surg2011;45:372-3.10. Ventarola DJ, Labropoulos NN, Landau DS, Tassiopoulos AK,Loh SA. Tibioperoneal trunk aneurysm resulting in compart-ment syndrome with associated aneurysms of the poplitealand dorsalis pedis arteries. Ann Vasc Surg 2016;35:207.e11-6.11. Cappendijk VC, Mouthaan PJ. A true aneurysm of thetibioperoneal trunk. Case report and literature review. Eur JVasc Endovasc Surg 1999;18:536-7.18 Hamouda et al Journal of Vascular Surgery Cases and Innovative TechniquesMarch 201812. Faccenna F, Alunno A, Felli MM, Castiglione A, Izzo P,Gossetti B, et al. Tibioperoneal true aneurysm: case reportand literature review. G Chir 2011;32:379-83.13. Mönig SP, Walter M, Sorgatz S, Erasmi H. True infrapoplitealartery aneurysms: report of two cases and literature review.J Vasc Surg 1996;24:276-8.14. Katz SG, Kohl RD, Razack N. Bilateral infrapopliteal arteryaneurysms. Ann Vasc Surg 1992;6:168-70.15. Rico JV, Pedrajas FG, González IC, Segura Iglesias RJ. Urgentendovascular treatment of a ruptured tibioperoneal pseu-doaneurysm in Behçet’s disease. Ann Vasc Surg 2011;25:385.e11-4.16. Liu Q, Ye W, Liu C, Li Y, Zeng R, Ni L. Outcomes of vascularintervention and use of perioperative medications for non-pulmonary aneurysms in Behçet disease. Surgery 2016;159:1422-9.17. Kwon Koo B, Shim WH, Yoon YS, Kwon Lee B, Choi D,Jang Y, et al. Endovascular therapy combined withimmunosuppressive treatment for pseudoaneurysms inpatients with Behçet’s disease. J Endovasc Ther 2003;10:75-80.18. Kalko Y, Basaran M, Aydin U, Kafa U, Basaranoglu G,Yasar T. The surgical treatment of arterial aneurysms inBehçet disease: a report of 16 patients. J Vasc Surg2005;42:673-7.19. Tascilar K, Melikoglu M, Ugurlu S, Sut N, Caglar E, Yazici H.Vascular involvement in Behçet’s syndrome: a retrospectiveanalysis of associations and the time course. Rheumatology(Oxford) 2014;53:2018-22.Submitted Aug 30, 2017; accepted Oct 28, 2017.

Management of tibioperoneal trunk aneurysm in a patient with Behçet disease.

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Management of tibioperoneal trunk aneurysm in a patient with Behçet disease.

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