PMC8256240_01
The patient's right leg on arrival appears to be massively swollen and tense with
diminished sensation (a). Computed tomography angiography (b) showing a large hematoma
(empty white arrow in (c)) around the 26 x 28 mm ruptured popliteal aneurysm (white
arrow in (c)). Although the popliteal artery is patent (yellow arrow in C), the anterior
tibial artery proximal site is compressed (yellow arrowhead in C3) by the hematoma.
Digital subtraction angiography (d) and intravascular ultrasonography findings, showing
an intact popliteal artery (D1-4), popliteal artery with entry to the aneurysm (D2), and
compressed proximal anterior tibial artery (ATA) by the hematoma (D3). The red dot
circle is the artery wall. The red asterisk in D2 is the ruptured aneurysm. The blue
asterisk and dot circle in D3 is a hematoma. The proximal ATA is compressed by a
hematoma. White arrow: compressed ATA, White arrowhead: patent ATA (e).
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She was found to be in vital shock (84/40 mmHg, 120 beats/min) and her right leg was massively swollen and tense (Figure 1(a)). Emergent contrast-enhanced computed tomography (CT) revealed an rPAA (26 x 28 mm) (Figure 1(b) and (c)). Ansel Flexor sheath (COOK Medical, Bloomington, IN) was inserted from the right common femoral artery. Angiography showed an rPAA with hematoma (Figure 1(d) and (e)). Intravascular ultrasound (IVUS) was used to calibrate the vessel diameter and detect the aneurysm's entry site (Figure 1(d): D1-2). IVUS also confirmed that the proximal ATA was compressed by the hematoma (Figure 1(d): D3-4).
Four detachable coils inside the popliteal artery aneurysm (a, b) 5 x 50-mm stentgraft
placement to exclude the aneurysm (c). Interwoven nitinol stent from the proximal
anterior tibial artery to the distal part of the stentgraft (d). Final angiogram showing
aneurysm exclusion without endoleak (e: digital angiography, f: digital subtraction
angiography).
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fig2-20480040211027792
The proximal site of the anterior tibial artery (ATA) was compressed by the hematoma (Figure 2(c)). IVUS also confirmed that the proximal ATA was compressed by the hematoma (Figure 1(d): D3-4). Four coils (Interlock, Boston Scientific) were deployed inside the aneurysm (Figure 2(a) and (b)) to prevent possible endoleak after stentgraft implantation. Then, a 5 x 50-mm stentgraft (Gore  VIABAHN Endoprosthesis, W.L Gore&Associates, Inc., Flagstaff, AZ) was deployed to just ostial of the ATA to P3 segment to exclude the aneurysm (Figure 2(c)). Because a 5-mm stentgraft is relatively oversized for the ATA ostium, and the ATA proximal side was compressed by the hematoma, a 5 x 60-mm interwoven stent (IWS, Supera, Abbott Vascular, Chicago, IL) was placed from the proximal ATA to the distal part of the stentgraft (Figure 2(d)).