key: cord-1021540-h0tg0lte
authors: Bejko, Jonida; Sgorlon, Giada; Zanon, Chiara; Avruscio, Giampiero; Zanon, Antonio
title: True Aneurysm on Posterior Tibial Artery as Late Complication of SARS-CoV-2
date: 2021-10-10
journal: Ann Vasc Surg
DOI: 10.1016/j.avsg.2021.08.005
sha: 98aae841c6e6dcb4be6a61178b89732630eb066c
doc_id: 1021540
cord_uid: h0tg0lte

We describe the story of a 70 year-old Italian male that almost 4 months later respiratory infection by SARS-CoV-2 presented a rapid evolution of a true aneurism of the right posterior tibial artery (PTA).

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a global pandemic. The development of an acquired thrombophilia with activation of the coagulation cascade in response to the inflammatory process has been described. SARS-CoV-2 appears to have an affinity for vascular endothelium due to angiotensin-converting enzyme 2 receptors that seem to be downregulated, which may drive the proinflammatory/prothrombotic and vascular consequences. (1) We describe the story of a 70-year-old Italian patient who presented 4 months after COVID-19 infection with a true aneurysm of the posterior tibial artery (PTA).

A 70-year-old male was referred to the vascular outpatient clinic with history of a pulsatile lump behind his right ankle over the last two months. Apart from the presence of a lump, he denied any other complaints including any violent or repeated trauma. He also suffered from hypertension.

He was not taking any antiplatelet or anticoagulation medications and denied any use of tobacco.

He was hospitalized on April 2020, as the result of acute hypoxic respiratory failure due to community-acquired pneumonia, with positive results for SAR-CoV-2 infection in patient's reverse transcription-polymerase chain reaction (RT-PCR) test from nasopharyngeal swab. Doppler at that time had not revealed superficial or deep venous thrombosis or other abnormalities.

On At physical examination a 3×4 cm size lump just behind the right medial malleolus was identified, which was non-tender and pulsatile. The patient confirmed a rapid increase of the dimensions during the last month. The peripheral pulses were easily palpable on either side. There 

Aneurysms are more common in the proximal arteries such as femoral and popliteal arteries compared to distal small vessels. It is a rare pathology of the infra-popliteal region, where false aneurysms are more common and are usually associated with trauma (2). The true aneurysms of infrapopliteal region are extremely rare and most of them have been reported to be associated with trauma, collagen vascular pathology, fibromuscular dysplasia, inflammation, infection and atherosclerosis (2) . False aneurysms are more common in comparison to the true aneurysms even in infrapatellar blood vessels. The precise etiological factors are not identified, but trauma is suggested as possible causality. (2) Italy was the first western country to be stricken by the coronavirus pandemic. The most common COVID-19 symptoms of the disease at onset were fever, fatigue, dry cough, dyspnea, runny nose or other upper respiratory tract symptoms. Ageusia and anosmia were also found to be characteristic symptoms, albeit with more rare presentation, while gastrointestinal symptoms, focal neurological deficits as a result of strokes arising from thrombosis and thromboembolism, account for a minority of cases. Cutaneous manifestations with an array of morphologies have also been Since the initial reports, an increase in circulating D-dimer levels has been reported. The addition of systemic proinflammatory cytokines release as a consequence of endothelial inflammation, as well as the expression of the ACE2 receptors for SARS-CoV-2 on the membrane of the vascular muscle and endothelial cells, may help to explain why COVID-19 patients are also susceptible to arterial thrombosis, even in young non-arteriosclerotic individuals. (4) Vascular biomarkers confirm that COVID-19, a disease initially thought to be exclusively an interstitial pneumonia with varying degrees of severity, can also be considered a vascular disease. (4) In case reports published of PTA aneurysms, false and true, etiology suggested was trauma, infections or unknown. Degenerative changes lesions secondary to mycotic infection, polyarteritis nodosa are also described as responsible for true aneurysm. In our patient, we could not find any etiological factor, such as trauma, atherosclerosis or connective disorders. (2, 5) The only recent inflammatory event in our patient was the SARS-CoV-2 infection.

We are living an historical era due to the ongoing global pandemic, and we are all inclined to correlate situations without a certain causality to SARS-CoV-2. This patient is one of those cases in which we find no other etiological correlation with the recent onset of the PTA pseudoaneurysm.

On the other hand, however, the presence of lymphocytic infiltrate in the wall of the PTA, already highlighted as a histological finding in certain cases of vascular damage in SARS-CoV-2, and not reported in other cases of pseudoaneurysms in literature, can confirm our doubt. (6) Additionally, the negative bacteriology is important in determining this diagnosis, since mycotic aneurysms, which is on the differential, tend to be positive for bacteria in most cases.

The management options vary from conservative approach to surgical excision followed by reconstitution of PTA. Due to very limited number of published cases, a standard treatment has not been defined. Although ligation of posterior tibial artery may be performed, especially in emergency settings, surgical excision with posterior tibial artery reconstitution either by primary repair or by interposition vein graft is the preferred treatment. Endovascular embolization and percutaneous occlusion of aneurysm with various modalities are more commonly used in pseudoaneurysms and are associated with risk of limb ischemia. (2, 5) In this case, patient underwent surgical excision followed by end-to-end anastomosis. The anterior tibial and pedidis arteries were intact and one might question the need for operation in this report, however we believe that those aneurysms should be treated irrespective of symptomatology due to the risk of embolization, thrombosis and rupture leading to potential ischemia and amputation.

The vascular community should be aware of this new complication in critically ill patients with COVID-19. The finding in this patient is likely an infectious angiitis due to COVID 19, and surgery showed to be a valuable treatment option.

Excision of the true aneurysm followed by end-to-end anastomosis of PTA.

SARS-CoV-2, SARS-CoV, and MERS-CoV viral load dynamics, duration of viral shedding, and infectiousness: a systematic review and meta-analysis

Infrapopliteal Arterial Pseudoaneurysm Development Secondary to Blunt Trauma: Case Series and Literature Review

Covid-19 Bergamo Hospital Crisis Unit. Adaptations and Lessons in the Province of Bergamo

COVID-19 and Thrombotic or Thromboembolic Disease: Implications for Prevention, Antithrombotic Therapy, and Follow-Up: JACC State-of-the-Art Review

Spontaneous pseudoaneurysm of the posterior tibial artery successfully treated by open surgery: Case report and review of the literature. Medicine (Baltimore)

Endotheliitis in Coronavirus Disease 2019-Positive Patients After Extremity Amputation for Acute Thrombotic Events