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Patient initials or identifier number
Relevant clinical history and physical exam
A 21 year-old man complained intermittent claudication for months. He had history of recurrent oral ulcer, terminal ileum ulcer(Image 1) and peripheral vascular occlusive disease and received percutaneous angioplasty one year ago. Right popliteal aneurysmal formation was found at that time. (Image 2&3). The physical examination showed oral aphthous, cold of right lower limb and impalpable posterior tibia artery and dorsal pedis artery and a pusutile mass overt right popliteal fossa.
Relevant test results prior to catheterization
Protein C: in normal range
Protein S: in normal range
Anti-thrombin III: in normal range
Anti-nuclear antibody: negative
Anti-neutrophil cytoplasmic antibody: negative
Anti-phospholipid antibody: negative
Lipid profile: normal
Erythrocyte sedimentation rate: 45
Ankle/Brachial index of right limb: 0.6
Relevant catheterization findings
Superficial femoral artery: Ostium to middle chronic total occlusion (CTO) with distal reconstruction via collaterals from profound femoris. (Image_I)
SFA_distal to TP trunk: CTO
Anterior tibia artery: proximal CTO, patent of distal ATA and dorsal pedis artery (Image_II)
Posterior tibia artery: Proximal CTO without stump (Image_II)
Peroneal artery: Proxima CTO, middle to distal: patent (Image_II an Image_III)
The Terumo destination sheath 7fr x 65 cm delivered to CFA via retrograde approach. Antegrade V-18 and Astato 8-20 wire could puncture to the SFA proximal cap but failed to entry the distal true lume. Retrograde punctue was peformed via angio-guiding and retrograde V-18wire could advance to SFA-Middle and then antegrade Astato 8-20 wire could kiss the retrograde V-18 wire and go done to distal SFA. The SFA flow was good after POBA with Pacific 4.0 mm x 15 cm up to 10 atm. The tibia-fibular trunk CTO wired by Victory 18 gm and dilated to 3.0 mm. The TP trunk and peroneal artery flow was reconstructed. ATA CTO was wired by Regalia XS and performed kissing balloon technique (Pacific 3.0 mm x 15 cm up to 6 atm over ATA-P, 2.5 x 20 mm BC up to 12 atm Peroneal ostium and both up to 4 atm). Final SFA, ATA and peroneal flows were good (Image I). Left CFA puncture site was closed via 8fr angio seal device. A 2 weeks after PTA, a pseudoaneurysm 4 cm in diameter was noted and failed to probe compression. Surgical resection with PTFE graft interposition (Due to intima injury) were performed. One week after surgery, another 2 pulsatile mass was noted over middle SFA and popliteal fossa. Pseudoaneurysm proved by CTA (Image_II). Combined his oral ulcer history and multiple pseudoaneurysm, Behcet disease was diagnosed and Endoxan pulse therapy was applied. He then received covered stent implantation for SFA lesion via distal SFA surgical cut down (Image_III). There was no further complication.
Pseudoaneurysm is a specific manifestation of Behcet disease. We believed the pseudoaneurysm in this patient caused by vascular puncture and vessel injury when wiring the chronic total occlusion site. Careful evaluation the patient history in young patient with peripheral vascular occlusive disease is essential to early recognized of Behcet disease. A pre-operation immune suppression agent warranted for preventing vascular complication. In patient with Behcet disease and pseudoaneurysm, combined with surgical cut down of healthy vessel and covered stent implantation is a alternative choice and may reduce the incidence of further diseased vessel injury and pesudoaneurysm formation.