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For the management of acute limb ischemia (ALI) and multilevel arterial occlusive disease, tibial bypass using the saphenous vein has been considered a mainstay due to the long-term durability in selected patients with acceptable saphenous veins and comorbid conditions. Traditionally, bypass using a varicose autogenous graft has been contraindicated due to the risk of late aneurysmal dilation and rupture. Here, we describe a patient who presented with ALI and received tibioperoneal trunk bypass using a varicose autogenous graft. The patient has been doing well during the 72-month follow-up without recurrent symptoms or revision. The follow-up images showed a favorably patent graft with mild aneurysmal changes at the valve cusp adjacent to the knee. If there are no other appropriate autologous veins for revascularization, a varicose autogenous vein graft may be a useful option for limb salvaging in selected patients with multilevel arterial occlusive diseases.

We present the case of a 68-year-old man with a tibioperoneal trunk mycotic pseudoaneurysm, a rarity in the modern age of antibiotics. We describe the patient's hospitalizations and workups that ultimately led to this diagnosis and our management with open ligation without bypass. This case highlights the importance of combining a thorough history and physical examination with laboratory and imaging data while keeping in mind a broad differential diagnosis.

Infrapopliteal artery aneurysms are rare, and tibioperoneal trunk aneurysms are even rarer. We herein report an unusual case of large tibioperoneal trunk pseudoaneurysm. The patient underwent successful endovascular exclusion of the pseudoaneurysm by coil embolization with stent assistance. The clinical features and management of tibioperoneal trunk aneurysms are also discussed in this article.

Arterial involvement in Behcet's disease is rare and the tibioperoneal trunk localisation is exceptional. We report the case of a young men with Behcet's disease and in whom the evolution to angiobehcet was unusual. The medical treatment and the therapeutic abstention were decided according to a bundle of argument.

We present a novel approach to endovascular thrombectomy using the Penumbra Indigo® Aspiration System with balloon assistance for a thromboembolic occlusion to the tibioperoneal trunk and tibial arteries causing acute limb ischemia. This technique allows for effective suction thrombectomy of distal vessels into a shorter, large-diameter aspiration catheter, thereby overcoming the limitations of the longer but smaller aspiration catheters.

Resumo Os aneurismas do tronco tibiofibular são raros e consistem principalmente em pseudoaneurismas. Os autores descrevem um caso incomum de pseudoaneurisma do tronco tibiofibular secundário a endocardite bacteriana diagnosticada e tratada vários anos antes. Após a exclusão de um processo infeccioso ativo, o paciente foi tratado com sucesso através do implante percutâneo de um stent recoberto. O tratamento endovascular, neste contexto, apresentou uma alternativa segura e eficaz.

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 Behcet disease and an 8-cm tibioperoneal trunk aneurysm and discuss the management options of these aneurysms.

Background This report presents a case of surgical retrieval of a Celt ACD® vascular closure device (VCD) situated in the tibioperoneal trunk, following a failed attempt at deployment. Existing literature mostly recommends an endovascular approach when attempting to retrieve embolised VCDs. Case presentation A 55 year old male presented with right sudden right lower limb pain and numbness 1 week following a successful left retrograde superficial femoral artery (SFA) angioplasty. Computed tomography (CT) angiogram revealed that the Celt ACD® VCD had embolised in the right tibioperoneal trunk. An endovascular approach was initially attempted to retrieve the VCD; however, this was unsuccessful due to the small diameter of the target artery. Due to the failure of the endovascular approach, surgical exploration of the right tibioperoneal trunk was undertaken, which led to the successful retrieval of the embolised VCD. Conclusion The case presented herein demonstrates the critical need for swift and decisive surgical exploration of patients with suspected embolisation of Celt ACD® devices in smaller distal arteries. Our experience has led to the recommendation that, due to the sharp edges of the Celt ACD® accompanied with the small diameter of the occluded vessels, surgical exposure and retrieval is the safest option if endovascular retrieval is unsuccessful.

To describe and assess the safety of a technique for the percutaneous retrograde access to either the P3 segment of the popliteal artery or the tibioperoneal trunk (TPT) through the anterior muscle compartment of the leg to treat distal femoropopliteal chronic total occlusion (CTO).After a failed antegrade attempt of endovascular recanalization of a femoropopliteal CTO, 41 symptomatic patients (29 men; mean age of 75.8 ± 8.4 years) underwent a percutaneous retrograde access by means of the puncture of the TPT in 15 cases (36.6%) and of the P3 tract of popliteal artery in 26 cases (63.4%). The puncture was performed on the anterolateral aspect of the proximal leg through the anterior muscle compartment with the patient in a standard supine position. Access to the vessel was obtained with a sheathless approach. After retrograde recanalization and guidewire rendezvous, the distal wire was retrieved proximally and a standard antegrade endovascular intervention was carried out.Retrograde access was achieved successfully in all patients. Recanalization was carried out in 16 cases (39.0%) with an endoluminal technique and in 25 cases (61.0%) in a subintimal fashion. Hemostasis was successfully attained in 31 patients (75.6%) by inflating a blood pressure cuff at the calf. In 11 cases (26.8%), the hemostasis was accomplished instead by means of a low-pressure ballooning as a bailout strategy for small residual bleedings. The transcutaneous oximetry at the 1-month follow-up from the procedure was significantly increased compared with the preprocedural values (10.4 ± 6.8 vs 42.4 ± 18.7 mm Hg; P .01). No early or late postoperative access-related complications were observed at a mean follow-up of 12.6 ± 9.5 months.After a failed antegrade approach, the anterolateral retrograde puncture of the P3 or of the TPT is a valuable and safe technique to treat femoropopliteal CTOs in selected patients, regardless the distal spread of the lesion to the popliteal artery.

True infrapopliteal aneurysms occur very rarely; the majority of reported cases are secondary to trauma or infection. We report the development of a tibioperoneal trunk aneurysm 6 months after atherectomy and angioplasty and describe subsequent open surgical repair via a great saphenous vein bypass graft.

Aneurysms of the tibioperoneal trunk and anterior tibial artery are extremely rare. There are only a few case reports of this entity, for which the majority are secondary to prior trauma or bacteremia and endocarditis. We describe a case of spontaneous pseudoaneurysms of the right anterior tibial artery and tibioperoneal trunk. The pseudoaneurysms were thrombosed on follow-up computed tomography angiography and the patient has been asymptomatic. The patient is being treated conservatively and remains asymptomatic at 1 year of follow-up.

Embryonic development of arteries of the lower limb results from the union of dorsal and ventral systems, explaining many variations at different levels. Some of these are important to recognize during the radiological exam because they can affect therapeutic management. These variations are most often bilateral and symmetrical predominating at the popliteal and subpopliteal levels. Lippert classified them into three types: normal level of popliteal arterial branching, high division of popliteal artery, hypoplastic or aplastic branching with altered distal supply. The length of the tibioperoneal trunk may also vary, rarely measuring more than 5 cm. We report a case combining three variations, two of them previously described in the literature and the third one not yet reported: our patient presented four arteries due to early bifurcation of the peroneal artery.

True aneurysms of the tibioperoneal trunk are rare. Given the scarcity of reports, the clinical presentation and treatment is not well defined. This is a case report of a 50-year-old male patient presenting with severe lower extremity swelling and compartment syndrome with neurological compromise secondary to a tibioperoneal trunk aneurysm. He was also noted to have discrete ipsilateral popliteal and dorsalis pedis artery aneurysms. Given the location and size of the aneurysm, the severe leg swelling, and venous hypertension, aneurysmorrhaphy or aneurysm sac excision with arterial reconstruction was prohibitively dangerous. Thus, following fasciotomies, a hybrid repair utilizing a saphenous vein superficial femoral to anterior tibial artery bypass along with coil embolization of the aneurysm sac was performed. The patient recovered full function of his leg and follow-up computed tomography angiogram demonstrated thrombosis and regression of the aneurysm sac with a patent bypass.

Mycotic aneurysms involving infrapopliteal arteries are rare. Ruptured infrapopliteal aneurysms are particularly uncommon and represent a surgical or endovascular emergency. We describe a case of 51-year-old male who presented with a 12-cm ruptured aneurysm of the tibioperoneal trunk 5 years after an episode of bacterial endocarditis. Our surgical approach included using extremity exsanguination and tourniquet to control hemorrhage during aneurysm ligation, followed by successful arterial reconstruction. Review of the English literature suggests that this is the largest ruptured infrapopliteal aneurysm reported.

Mycotic aneurysm affecting the tibioperoneal trunk is very rare. Only a few articles have reported bilateral mycotic aneurysms of the tibioperoneal trunk in the English literature. A 46-year-old man was suffering from consecutive bilateral mycotic aneurysms involving the tibioperoneal trunks after mitral-valve replacement for infective endocarditis. Each aneurysm was treated separately by a surgical approach, which included resection of the aneurysm, debridement of infectious tissue and arterial reconstruction using reversed saphenous vein graft. There was no recurrence of infection, and the graft remains patent. This is the first case of bilateral arterial reconstructions successfully performed for the tibioperoneal trunks.

Summary We report the case of a 43 years-old man with a acute limb ischaemia due to the thrombosis of a tibioperoneal trunk aneurysm secondary to arterialfibroplasia. We review the literature, diagnostic methodology is discussedandthe different therapeutic options are revised.

Introduction: Pseudoaneurysms of the tibioperoneal trunk are rare and can be limb threatening. There are various treatment options to seal pseudoaneuryms both percutaneously and via open surgery. Case report: Description of the case of a large tibioperoneal trunk pseudoaneurysm that has been successfully treated by coil embolization in a patient with a previous endocarditys. Conclusion: Endovascular treatment of pseudoaneurysm should be considered as an alternative treatment option to open surgery. © 2010 Wiley-Liss, Inc.

The best treatment strategy for below the knee bifurcation disease is not known. We present first two cases with successful implantation of dedicated coronary bifurcation sirolimus eluting stent BiOSS Lim (Balton, Poland) in complex bifurcation and trifurcation lesions of tibioperoneal trunk. Both implantations were uncomplicated with sustained short-term result at 30-day control Duplex ultrasound and remarkable clinical improvement. Our report demonstrates feasibility and short-term effectiveness of implantation of dedicated coronary bifurcation stent in below-the-knee bi- and tri-furcations.

An acute occlusion of the tibio-peroneal trunk, due to gunshot wound injury in a young woman is presented. Delineation of the injury was determined during wound exploration. The wounded vessel was resected and arterial reconstruction was achieved by contralateral non-reversed greater saphenous vein graft interposition pretreated with blind valvulotomy. A large venous tributary allowed a bifurcated graft to be constructed. This case describes the technique of bifurcated non-reversed venous grafting, which has not been reported in an acute trauma scenario. The advantages of the method are discussed.

Calf vessel continuity with an intact pedal arch is an important factor in femorodistal (FD) bypass for critical ischaemia. Pulse generated runoff (PGR) was used in combination with the pedal arch patency test of Roedersheimer to determine preoperatively calf vessel and pedal arch patency. Three pedal arch groups were identified; complete (two calf vessels in continuity), incomplete (one vessel) and occluded (no vessels). One hundred non-reversed FD grafts were performed for critical ischaemia (63 men and 37 women), median age 72 (range 43-89 years). Sixteen grafts were to the above knee popliteal artery, 36 to the distal popliteal, three to the tibioperoneal trunk and 45 to a single calf vessel. There were 25 complete, 64 incomplete and 11 occluded pedal arches. The overall primary patency rate was 73%, nine grafts were successfully revised giving a secondary patency rate of 83.5%. The secondary graft patency rates for the above knee popliteal, below knee popliteal, tibioperoneal and single calf vessel grafts were 100, 92, 66 and 66% respectively. The 1 year graft patency rates for grafts to a complete, incomplete and occluded pedal arch were 88, 75 and 9% respectively (Lee-Desu p0.01). Similar results were obtained for limb salvage; 100, 84 and 24% respectively (p0.01). These results confirm the value of PGR in the preoperative assessment of patients with critical ischaemia. In reconstructions to the popliteal artery, PGR derived pedal arch status does not appear to influence the outcome. By contrast PGR derived pedal arch status in an excellent predictor of success following reconstructions to a single calf vessel.(ABSTRACT TRUNCATED AT 250 WORDS)

This report describes the use of transcollateral retrograde revascularization in two patients after failed recanalization of the tibioperoneal trunk in one and superficial femoral artery occlusion in the other. Retrograde recanalization was successfully achieved via a distal branch of the profunda femoris artery in the first case and a medial genicular branch in the second. After successful retrograde recanalization, the guide wire was snared in both cases and angioplasty/stent placement was performed in an antegrade fashion.

Management of critical limb ischemia (CLI) requires a combined treatment approach: optimal medical therapy and revascularization procedures are both essential for favorable outcome. With the development of endovascular interventions these new modalities took the primary role in limb revascularization, especially in CLI patients, where the culprit lesion is often located below the knee (BTK) level, making the surgical procedure unfeasible. In our present case report, we demonstrate a successful percutaneous recanalization of a surgically non-treatable tibioperoneal trunk occlusion. The procedure was performed with dual access from anterograde and retrograde transpedal approach, and modified “V stenting” technique was used. We describe feasibility of bail out stenting using retrograde posterior tibial artery access after failed retrograde guidewire externalization. Our report discusses the feasibility, safety, and efficacy of the retrograde approach applying 4F compatible devices. © 2012 Wiley Periodicals, Inc.

Intraoperative balloon dilation (with or without laser assistance) was performed on 30 lesions in 20 patients in whom proposed bypasses distal to the tibioperoneal trunk were revised to more proximal bypasses (above- or below-knee femoropopliteal) following successful dilation. Only 3 patients overall required subsequent amputation—at one month, nine months, and one year postoperatively, respectively. There were 3 deaths from unrelated causes; all had patent grafts at time of death. Two patients were lost to follow-up. This experience reinforces the beneficial adjunctive role of intraoperative balloon dilation in patients who require long bypasses, allowing less extensive reconstructive procedures to be performed and consequently yielding better long-term results than surgery alone.

The purpose of this study was to analyze the variations in branching of the popliteal artery by reviewing femoral arteriograms. Between 2004 and 2006, digital subtraction angiographies of both lower extremities were performed in 621 patients. We reviewed these 1242 arteriograms retrospectively in order to analyze the branching pattern of the popliteal artery. Of the 1242 extremities, 1108 extremities (89.2%) had normal branching pattern of the popliteal artery. The remaining 134 extremities (10.8%; 65 right, 69 left) in 105 patients (66 men, 39 women; 76 unilateral, 29 bilateral) showed seven variant branching patterns: hypoplastic or aplastic posterior tibial artery (PT) (n = 63, 5.1%); hypoplastic or aplastic anterior tibial artery (AT) (n = 21, 1.7%); trifurcation (n = 19, 1.5%); high origin of AT (n = 15, 1.2%); hypoplastic or aplastic PT and AT (n = 10, 0.8%); high origin of PT (n = 5, 0.4%); and anterior tibioperoneal trunk (n = 1, 0.1%). When the branching pattern of the popliteal artery is normal in one extremity, there is a 13% probability the other side will be a variant pattern. When the branching pattern is variant in one extremity, there is a 28% probability the opposite side will also contain a variation. Variations in branching of the popliteal artery are not uncommon. Awareness of these variations is important for evaluation of the lower extremity arteriograms and has clinical implications for vascular surgeons and interventional radiologists.

Anatomic and histologic studies of vein valves were made on 50 adult cadav ers (100 lower extremities). In the deep and superficial venous trunks, big valves were found mostly with two cuspids. At the inlets of their branches, small valves monocuspid in shape were commonly found. There was no valve in the common iliac vein, and the percentages of the other veins containing valves were: external iliac 42%, common femoral 51%, deep femoral 88%, superficial femoral 100%, popliteal 93%, tibioperoneal trunk 26%, and all the deep veins in the lower leg, including tibial and peroneal 100%. The valves in the deep venous trunk are much stronger than those in the long saphenous vein. They can resist a retrograde pressure of 180 to 420 and 100 to 260 mmHg respectively. The clinical value of this study concerning the staged arteriovenous reversal in the treatment of severely ischemic limbs and the etiology of the primary incompetence of the deep veins of the lower extremity are discussed.

Stent placement in a tibial artery for suboptimal angioplasty results has had a high rate of restenosis and occlusion due to neointimal hyperplasia. Drug-eluting stents may provide a new therapeutic option in this situation. We describe the use of a Cypher drug-eluting stent after suboptimal angioplasty result in a claudicant with a severe tibioperoneal trunk lesion and single-vessel runoff to the foot with 6-month follow-up.

A young woman with an iatrogenic coagulation defect related to a mechanical mitral valve prosthesis developed a pseudoaneurysm of the tibioperoneal trunk after a minor blunt injury. The importance of minor blunt trauma in such cases and the surgical approach are reviewed.