View Options - Click to expand
Print Options - Click to expand
E-Mail Options - Click to expand

Case Report: Pseudoaneurysm Causing Residual Limb Pain in a Transtibial Amputee

Gary A. Linassi, MB, FRCPC
Rodney S. Li Pi Shan, MD, FRCPC
Sherif S. El Maadawy, MD
Bruce B. Berscheid, MD, FRCPC
Huw G. Rees, MD, FRCSC

ABSTRACT

Pseudoaneurysm formation is a rare but known complication following amputation. We report the clinical and radiological findings in a 45-year-old man who presented with severe residual limb pain 1 month after an elective left transtibial amputation for chronic regional pain syndrome. The pain did not respond to high doses of opioids and prosthetic fitting was delayed. Duplex ultrasound imaging indicated the presence of a pseudoaneurysm in the anterior tibial artery. Pseudoaneurysm embolectomy using wire coils improved pain level and medications were reduced. Pseudoaneurysms can be a cause of intractable severe residual limb pain in patients after transtibial amputation. Treatment may involve embolectomy with wire coils.( J Prosthet Orthot . 2008;20:8–11.)

Determining the cause of residual limb pain in amputees can be very challenging. To appropriately investigate and treat pain in the residual limb, the prosthetist must identify the nature of pain (neuropathic, musculoskeletal, or somatic) before socket modification is undertaken. Amputees will experience pain at the residual site of amputation. Although common in prosthetic clinical practice, few studies describe its incidence or prevalence. Residual limb pain differs from phantom limb pain in that it is felt only in the residual limb and not in the absent limb.1 Phantom pain is usually neuropathic in character and originates from nervous tissue. Although residual limb pain can also have a neuropathic component, it usually originates in other tissues. It can be caused by inflamed bursae, localized soft-tissue inflammation,2 or bone pain. MRI can demonstrate additional causes of residual limb pain including scar formation, fat in atrophied muscles, soft tissue abscesses, osteomyelitis, and hematomas.3 Another rare cause of residual limb pain is complex regional pain syndrome.4

CASE DESCRIPTION

A 48-year-old man was referred to our consultation service for severe left residual limb pain (described as 12/10 in severity) that was not responding to high doses of opioid analgesia and pregabalin. An elective transtibial amputation was performed 1 month previously for symptoms related to complex regional pain syndrome—a complication of a motorcycle accident that occurred 17 years previously. His immediate postoperative recovery was uneventful. Two weeks after the amputation, he sought help for increasingly worsening nonneuropathic residual limb pain. He was admitted to hospital when the wound dehisced and bled ( Fig. 1 ). This provided temporary relief of his pain, but was subsequently followed by rapid worsening of his pain.

Physical examination revealed a tender residual limb with tense, indurated skin. The wound had dehisced and was healing by secondary intention. An area on its posteromedial aspect was extremely tender but not pulsatile. Range of motion was limited in flexion but otherwise normal. Sensation was normal.

Ultrasound imaging revealed a large, well-circumscribed mass measuring approximately 8.0 by 5.3 cm. Both solid and echogenic components with cystic areas were seen within it. There was increased flow centrally with large amounts of clot. Color Doppler-imaging revealed a classic to-and-fro flow pattern of blood5 that resembled a "ying-yang" sign of blood in the perivascular mass ( Fig. 2 ). The angiogram showed widely patent femoral, profunda femoris, and superficial femoral arteries. The anterior tibial artery had an abrupt cutoff approximately 2 cm distal to its origin where there was a filling of a sizeable pseudoaneurysm ( Figure 3 ).

Management included vessel embolization with three platinum coils ranging from 3 to 6 mm in size. After treatment, digital subtraction imaging revealed that the vessel was completely occluded and no further filling of the pseudoaneurysm was occurring ( Figure 4 ).

Because of the severity of pain, prosthetic evaluation was deferred pending further investigations which demonstrated the pseudoaneurysm formation. Subsequent to the repair procedure, the patient's pain levels decreased to 5/10 in severity and narcotic medications were reduced. The pain further diminished after several months of therapy. He was subsequently fitted with a patellar tendon bearing socket, neoprene sleeve, and Safe II foot. Early limb fluctuation attributed to the healing pseudoaneurysm was accommodated by various ply socks and enlarging the prosthesis. He is currently a functional prosthetic user experiencing no further pain symptoms.

DISCUSSION

A pseudoaneurysm, also termed false aneurysm, forms when blood leaks from an artery into the surrounding tissue.6 It persists through a communication between the feeding artery and the surrounding blood filled cavity. The body of the aneurysm is initially composed of fibrous tissue. However, over a period of time, the surrounding tissue may mature resembling a vessel wall. As a consequence of arterial pressure, pseudoaneurysms tend to enlarge in size.7 Clinically, pseudoaneurysms can be associated with pain, a bruit and a pulsatile mass on palpation.8

Pseudoaneurysms are often missed and are commonly the result of an arterial injury9 especially from the femoral artery.10 They may form as a result of procedures which involve catheter puncture of an artery (incidence of 0.6%–6%11), from anastomoses of arterial bypass grafts or dialysis, after direct trauma to an artery,12,13 arterial wall infection, cardiac catheterization,14 and intravenous drug abuse.15 Complications can include rupture,16 nerve compression,17 and amputation.18 Lesions may be mistaken for an infection or abscess19 or may also simulate the presence of a mesenchymal tumor.20

A literature search of databases PubMed, CINAHL, and OVID encountered only two reports of pseudoaneurysm formation after transtibial amputation.21,22 They have also been found to complicate other amputations such as digital amputation,23 Lisfranc amputation,24 and rotationplasty.25

Radiographic examination may show a nonspecific tissue mass, later followed by rim calcification.26 Rarely, involvement of adjacent bone can occur.27 Ultrasonography is the most common method for diagnosis with a sensitivity of 94% and a specificity of 97%.28 Spectral waveforms and color Doppler show a characteristic to-and-fro flow pattern.29 Ultrasound is also useful for distinguishing between hematoma and aneurysm.30 Angiography is most sensitive for detection and diagnosis with contrast filling the aneurysm being a typical finding.31 MRI discriminates between hematoma and tumor. On spin-echo sequences, a persistent flow void into the aneurysm can be seen.32

Most pseudoaneurysms are small and undergo spontaneous thrombosis, which resolve over time without treatment.33 Spontaneous resolution is related to size ( < 1.8 cm in diameter)34 and whether the patient is using anticoagulation or antiplatelet therapy. Until recently, pseudoaneurysms were treated surgically by ligation and grafting.35 Recognized indications for surgical repair included a rapidly expanding or infected pseudoaneurysm, distal ischemia or neuropathy and failure of percutaneous treatment.36–38 Profuse bleeding may be encountered intraoperatively.39

Ultrasound-guided compression was first described by Fellmeth et al. in 199139 but has been superseded by the development of thrombin and coil embolization. Coil embolization was the preferred method by the interventional radiologist in this case. The technique involves filling the aneurysm with metallic coils to occlude flow.40 Recently, duplex guided thrombin injection has been proven safe and effective.41,42 Thrombin can be introduced transarterially or percutaneously with or without balloon occlusion. With this technique, an occlusion rate of 93% to 100% of the pseudoaneurysm can be achieved.

CONCLUSION

Pseudoaneurysm formation can cause significant pain after a transtibial amputation. This rare entity should be considered by the prosthetist in the differential for pain that does not conform to the neuropathic or musculoskeletal paradigm and does not resolve with prosthesis modification. It does not resemble neuropathic pain and should be considered in severe residual limb pain not responding to high doses of pain medication. Diagnosis can be made with standard Doppler ultrasound equipment. Preferred treatment can include coil or thrombin embolization.

Disclosure: The authors declare no conflict of interest.

Correspondence to: A. Gary Linassi, University of Saskatchewan, Department of Physical Medicine and Rehabilitation, 701 Queen Street, Saskatoon, Saskatchewan, Canada, S7K 0M7; e-mail:


GARY A. LINASSI, MB, FRCPC, is affiliated with the Department of Physical Medicine and Rehabilitation, University of Saskatchewan, Saskatoon, Saskatchewan, Canada.

RODNEY S. LI PI SHAN, MD FRCPC, is affiliated with the Department of Physical Medicine and Rehabilitation, University of Saskatchewan, Saskatoon, Saskatchewan, Canada.

SHERIF S. EL MAADAWY, MD, is affiliated with the Department of Physical Medicine and Rehabilitation, University of Saskatchewan, Saskatoon, Saskatchewan, Canada.

BRUCE B. BERSCHEID, MD FRCPC, is affiliated with Saskatoon Health Region, Saskatoon, Saskatchewan, Canada.

HUW G. REES, MD, FRCSC, is affiliated with Saskatoon Health Region, Saskatoon, Saskatchewan, Canada.

References:

  1. De Smet J, Charlton J, Meynadien J. Pain and rehabilitation from land mine injury. IASP [serial online] 2000;11:Article 20. Available at: www.nda.ox.ac.uk/wfsa/html/u11/u1120_02.htm .
  2. DiPersio M, Kirby RL. Four well documented cases of adventitious bursae on the distal anterior residual limbs of below-knee amputees [letter]. Am J Phys Med Rehabil 1995;74:249.
  3. Singson RD, Feldman F, Staron R, et al. MRI of postamputation neuromas. Skeletal Radiol 1990;19:259 –262.
  4. Isakov E, Susak Z, Korzets A. Reflex sympathetic dystrophy of the residual limb in below-knee amputees. Clin J Pain 1992;8: 270–275.
  5. Kurtz A, Middleton W, eds. Ultrasound: The Requisites. New York: Mosby; 1996.
  6. James, Brandie.Pseudoanerysm. Available at: test.cvtcollege.org/Ac_Programs/dms_vascular/studentbrandie.html .
  7. Parry DJ, Kessel D, Scot DJA. False aneurysm of the peroneal artery: an unusual complication of femoro-peroneal bypass grafting. Cardiovasc Surg 2002;10:54 –57.
  8. Dean RH, Yao JST, eds. Current Diagnosis and Treatment in Vascular Surgery . Boston: Appleton & Lange; 1995.
  9. Gantz ED, Sweet MB, Jakin I. False aneurysm mimicking an aggressive soft-tissue tumor. A case report. J Bone Joint Surg Am 1988;70:1090 –1092.
  10. Morgan R, Belli Anna-Maria. Current treatment methods for postcatherization pseudoaneurysms. J Vasc Interv Radiol. 2003; 14:697–710.
  11. Kresowik TF, Khoury MD, Miller BV, et al. A prospective study of the incidence and natural history of femoral vascular complications. J Vasc Surg 1991;12:328 –336.
  12. Bapuraj JR, Thingnam S, Rajak CL. Popliteal artery pseudoaneurysm following penetrating trauma. Australas Radiol 1999; 43:116 –118.
  13. Dickson JW. False aneurysm after intramedullary nailing of the femur. J Bone Joint Surg Br 1968;50:144 –145.
  14. Derom A. Ruptured pseudo-aneurysm of the popliteal artery after percutaneous transluminal angioplasty. Acta Chir Belg 2003;103:102–104, 2003.
  15. Manekeller S, Tolba RH, Schroeder S, et al. Analysis of vascular complications in intra-venous drug addicts after puncture of femoral vessels. Zentralbl Chir 2004;129:21–28.
  16. Wand JS, Zuckerman JN, Higginson DW. Delayed rupture of a false aneurysm following a femoral fracture. J Bone Joint Surg 1989;71:700.
  17. Robbs JV, Naidoo KS. Nerve compression injuries due to traumatic false aneurysms. Ann Surg 1984;200:80–82.
  18. Cheema MA, Shafique A. Presentation and management of pseudoaneurysms of femoral artery. J Coll Physicians Surg Pak 2005;15:3:162–164.
  19. Marcove RC, Lindeque BG, Silane MF. Pseudonaneurysm of the popliteal artery with unusual arteriographic presentation. A case report. Clin Orthop 1988;234:142–144.
  20. Erler K, Ozdemir M, Oguz E, Basbozkurt M. Does false aneurysm behave like a sarcoma? Distal femoral arterial false aneurysm simulated a malignant mesenchymal tumor. Arch Orthop Trauma Surg 2004;124:60–63.
  21. Selby JB Jr, Bittner GM, Tegtmeyer CJ, Tribble CG. Balloon occlusion of a pseudoaneurysm in a below the knee amputation residual limb. Am J Roentgenol. 1989;153:625– 627.
  22. Bunt TJ, Malone JM, Karpman RR. Iatrogenic tibial pseudoaneurysm following below-knee amputation. Am J Surg. 1990;56: 546–547.
  23. Hentz V, Jackson I, Fogarty D. Case report: false aneurysm of the hand secondary to digital amputation. J Hand Surg Am 1978;32:199 –200.
  24. Lieberman JR, Goldstock LE, Jacobs RL. Pseudoaneurysm of the dorsalis pedis artery after Lisfranc amputation. Foot Ankle 1991; 12:123–124.
  25. Blewitt N, Pooley J, Berridge D, Chamberlain JC. Pseudoaneurysm of the superficial femoral artery. An unusual complication following rotationplasty. Clin Orthop Relate Res 1994;306: 171–174.
  26. Hatem SF, Petersilge CA, Park JK. Pseudoaneurysm of the left superficial femoral artery. AJR 1997;160:283–292.
  27. Hall RF, Watt DH. Osseous changes due to a false aneurysm of the proper digital artery: a case report. J Hand Surg Am 1986; 11:440–442.
  28. Coughlin BF, Pausshter DM. Peripheral pseudoaneurysms: evaluation with duplex US. Radiology 1988;168:339–342 [Abstract].
  29. Abu-Yousef MM, Weise JA, Shamma AR. The "to-and-fro" sign: duplex Doppler evidence of femoral artery pseudoaneurysm. Am J Roentgenol 1988;150:632– 634.
  30. Fitzgerald EJ, Bowsher WG, Ruttley M. False aneurysm of the femoral artery: computed tomographic and ultrasound appearances. Clin Radiol 1986;37:585–588.
  31. Otsuka T, Yonezewa M, Kamiyama F, et al. Popliteal pseudoaneurysm simulating soft tissue sarcoma: complication of osteochondroma resection. Int J Clin Oncol 2001;6:105–108.
  32. Hatem SF, Petersilge C, Park J. Pseudoaneurysm of the left superficial femoral artery. AJR 1997;169:283–292.
  33. Kresowik TF, Khoury MD, Miller BV, et al. A prospective study of the incidence and natural history of femoral vascular complications. J Vasc Surg 1991;13:328 –336.
  34. Kent K, McArdle CR, Kennedy B, et al. A prospective study of the clinical outcome of femoral pseudoaneurysm and arteriovenous fistulas induced by arterial puncture. J Vasc Surg 1993;17: 125–133.
  35. Vancabeke M, Heiderich B, Bellens B, Putz P. Pseudoaneurysm of the ulnar artery following use of an external fixator. Acta Orthop Scand 1999;70:522–523.
  36. O'Sullivan GJ, Ray SA, Lewis JS, et al. A review of alternative approaches in the management of iatrogenic femoral pseudoaneurysms. Ann R Coll Surg Engl 1999;81:226 –234.
  37. Sharma NK, Chin KF, Modgill VK. Pseudoaneurysms of the femoral artery: recommendation for a method of repair. J Royal Coll Surg Edinb 2001;46:195–197.
  38. Waller DA, Sivananthan UM, Diament RH, et al. Iatrogenic vascular injury following arterial cannulation: the importance of early surgery. Cardiovasc Surg 21993;1:251–252.
  39. Fellmeth BD, Roberts AC, Bookstein JJ, et al. Postangiographic femoral artery injuries: nonsurgical repair with US-guided compression. Radiology 1991;178:671– 675.
  40. Ramakantan R, Shah P. Steel coil embolization of a posttraumatic aneurysm of the superficial femoral artery. Injury 1990;21:410–411.
  41. Owen RJT, Haslam PJ, Elliott ST, et al. Percutaneous ablation of peripheral pseudoaneurysms using thrombin: a simple and effective solution. Cardiovasc Intervent Radiol 2000;23:441– 446.
  42. Matson MB, Morgan RA, Belli AM. Percutaneous treatment of pseudoaneurysms using fibrin adhesive. Br J Radiol 2001;74: 690–694.