Case Report

Vascular
2016, Vol. 24(1) 109–112
! The Author(s) 2015
Aneurysms of the foot arteries Reprints and permissions:
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DOI: 10.1177/1708538115599093
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Abdullah Alhaizaey1,2,3, Mohamad A Hussain1,2,
Badr Aljabri3 and Mohammed Al-Omran1,2,3

Abstract
Aneurysms of the foot arteries are uncommon but can lead to devastating complications such as acute foot ischemia or
arterial rupture if left untreated. In this case series, we present four cases of aneurysms of the foot: one true dorsalis
pedis artery aneurysm and three cases of post-traumatic plantar artery pseudoaneurysms with arteriovenous fistulas. All
four patients were successfully managed with surgical excision of the aneurysm with or without arteriovenous fistulas
ligation. Our case series is followed by discussion on the etiology, clinical presentation and management strategy of
patients with aneurysms of the foot arteries.

Keywords
Foot aneurysm, pseudoaneurysm, plantar artery pseudoaneurysm, arteriovenous fistula

distally (Figure 1(b)). To assess distal foot circulation

Introduction
Aneurysms of arteries of the foot have been reported as
either true aneurysms or pseudoaneurysms. True aneur-
ysms tend to occur in the elderly with atherosclerosis as
the underlying etiology. Pseudoaneurysms of the foot
arteries, on the other hand, mostly occur in younger
patients secondary to trauma to either the dorsum or
plantar surface of the foot.
In this report, we present four cases of aneurysms of
the foot: one true dorsalis pedis artery (DPA) aneurysm
and three cases of post-traumatic plantar artery pseu-
doaneurysms with arteriovenous fistulas (AVFs). This
case series is followed by a discussion on the etiologies,
clinical presentations and management options for
aneurysms of the foot arteries. Patient consent for pub-
lishing was obtained.
Case 1: True dorsalis pedis
artery aneurysm
A 60-year-old man presented with a three-year history
of an enlarging pulsatile mass located on the dorsal
aspect of the right foot (Figure 1(a)). Clinical examin-
ing revealed no signs of toe ischemia. A pre-operative
arterial duplex ultrasound (DUS) confirmed a
2.6  2.0 cm aneurysm of the right DPA with normal
right foot toe pressures. The patient was recommended
surgical resection of the aneurysm. The saccular-shaped
aneurysm was exposed and controlled proximally and
prior to aneurysm resection, a trial of intraoperative
clamping of the DPA was carried out distal and prox-
imal to the aneurysm. This revealed decreased Doppler
signals in the digital arteries. The aneurysm was
resected, and the vessel was reconstructed via an end-
to-end anastomosis (Figure 1(c)). Histology demon-
strated a true aneurysm given all three layers (intima,
media and adventitia) of the arterial wall were affected.1
The patient had an uncomplicated post-operative
course and remained well at 6-month, 12-month and
2-year follow-up visits.
Case 2: Post-traumatic medial
plantar artery pseudoaneurysm
A 28-year-old woman presented with a six-month his-
tory of pain and swelling on the plantar surface of the
foot. She reported a history of trauma to the foot that
1
Division of Vascular Surgery, Li Ka Shing Knowledge Institute of St.
Michael’s Hospital, Toronto, Ontario, Canada
2
The Department of Surgery, University of Toronto, ON, Canada
3
The Department of Surgery, King Saud University, Riyadh, Kingdom of
Saudi Arabia
Corresponding author:
Mohammed Al-Omran, Division of Vascular Surgery, St. Michael’s
Hospital, 30 Bond Street, Suite 7-074, Bond Wing, Toronto, Ontario,
M5B 1W8, Canada.
Email: alomranm@smh.ca
110
Figure 1. A 60-year-old man with a true dorsalis pedis artery (DPA) aneurysm. (a) Pulsatile mass visible on the dorsum of the right
foot. (b) DPA aneurysm excluded prior to surgical resection. (c) Reconstructed DPA with end-end anastomosis.
resulted from stepping on a piece of glass one year prior
to the presentation. A deep lacerated wound at that
time required multiple interrupted sutures to control
the bleeding. The foot was edematous with prominent
subcutaneous veins visible in the distal third of the leg.
A pulsatile mass with palpable thrill was present on the
plantar surface of the foot. Radiographic work-up
included magnetic resonance angiography (MRA) of
the foot, which revealed a 3.0  3.0 cm medial plantar
artery pseudoaneurysm deep to the abductor hallucis,
flexor hallucis longus and plantar fascia with an asso-
ciated AVF (Figure 2). The patient underwent success-
ful surgical excision of the medial plantar artery
pseudoaneurysm and ligation of AVF with resolution
of foot edema and venous dilatation. She remained
asymptomatic at 6-month, 12-month and 2-year
follow-up visits.
Cases 3 and 4: Post-traumatic lateral
plantar artery pseudoaneurysms
A 26-year-old woman and an 18-year-old man pre-
sented with a new onset painful mass on the plantar
surface of the foot. Both of these patients reported a
background history of trauma to the plantar surface of
the foot six and eight months prior to presentation,
respectively. Both patients had undergone local
wound exploration and primary repair of the laceration
with interrupted stitches as initial management. On
clinical assessment, a pulsatile mass on the plantar sur-
face of the foot was visible with a palpable thrill in both
patients. Both patients underwent uneventful surgical
excision of the lateral plantar artery pseudoaneurysm
with AVF ligation (Figure 3), and remained asymptom-
atic at 6-month, 12-month and 2-year follow-up visits.
Discussion
The etiology of foot aneurysms can be divided into
two broad categories: true aneurysms and
Vascular 24(1)
pseudoaneurysms. True foot aneurysms tend to occur
in the elderly with atherosclerosis as the underlying eti-
ology. These patients usually present with a painless
pulsatile mass in the dorsum of the foot much like
how the patient presented in our first case.1 However,
more serious presentations such as ruptured aneurysm
and acute ischemia of the forefoot have also been
reported.2,3 Pseudoaneurysms of the foot arteries, on
the other hand, generally occur secondary to a trau-
matic injury, and are therefore more likely to be
underreported.
To determine the rates of all primary foot aneurysms
and pseudoaneurysms reported in literature, we con-
ducted a computerized literature in MEDLINE (up to
1 October 2014) using the following keywords: foot
artery, dorsalis pedis artery, posterior tibial artery,
plantar artery, foot, aneurysm and pseudoaneurysm.
No limitations were set for article type, publication
date, language, gender or age group. We found 41
total cases of foot aneurysms reported in literature;
18/41 (44%) of the patients had true foot aneurysms,
whereas 26/41 (56%) had pseudoaneurysms of the foot
arteries with or without AVFs. Only 7/26 (27%) of the
pseudoaneurysms involved the plantar artery of the
foot.4–9
Locations of foot artery pseudoaneurysms depend
on the type and mechanism of injury sustained. For
instance, pseudoaneurysms of the anterior tibial
artery and its lateral malleolar branches tend to occur
following an injury to the vessels during passage
of an arthroscope for ankle arthroscopy.10–12
Pseudoaneurysms of plantar arteries, on the other
hand, generally occur due to trauma to the plantar sur-
face of the foot, often secondary to a local injury.
Most traumatic plantar artery pseudoaneurysms
occur in the lateral plantar artery, as it is more super-
ficial and larger than medial plantar artery.
Furthermore, the medial plantar artery is protected
by the abductor hallucis, flexor hallucis longus and
quadrates plantar muscles making injury to this artery
Alhaizaey et al.
Figure 2. A 28-year-old woman with traumatic lateral plantar artery pseudoaneurysm with arteriovenous fistula (AVF). (I)
Pseudoaneurysm controlled proximally with a vessel loop. (IIa) Arrow showing the arterial origin of the pseudoaneurysm and (IIb)
arrow showing the venous communication with the pseudoaneurysm.
Figure 3. An 18-year-old man with traumatic medial plantar
artery pseudoaneurysm deep in the plantar bursa with AVF.
uncommon and more difficult to treat surgically. Two
out of the three cases of plantar artery pseudoaneur-
ysms presented in this report involved injuries to the
more commonly affected lateral plantar artery.
Clinical presentation of patients with foot aneurysms
is diverse, and includes: asymptomatic, pulsatile mass
that may grow in size over time, foot swelling second-
ary to venous hypertension caused by an AVF, acute
foot ischemia or rupture. Three out of the four cases of
foot aneurysms presented in our report were symptom-
atic; the two patients with a lateral plantar artery pseu-
doaneurysm presented with persistent foot pain, which
111
was likely associated with increasing size of the pseu-
doaneurysm. The patient with a medial plantar artery
pseudoaneurysm, on the other hand, presented with
symptoms secondary to venous hypertension (foot
edema, dilated foot and leg veins) caused by the asso-
ciated AVF.
Several potential management strategies should be
considered during the preoperative assessment of foot
aneurysms, including: percutaneous embolization of
the aneurysm, intact ligation and surgical excision of
the aneurysm with reconstruction. Which strategy is
selected depends on several factors, such as the vascular
anatomy of the foot, presence or absence of collateral
arteries, and if there is an associated AVF. Preoperative
imaging with MRA, computed tomography angiog-
raphy (CTA) or catheter-directed angiography can
delineate the vascular anatomy of the foot and help
guide management.
From an anatomical perspective, the ‘‘classic’’ anas-
tomosis between the medial and lateral plantar arteries
is present in only about 20% of individuals and 5% of
individuals have no junction between dorsalis pedis and
lateral plantar arteries.13 Individuals with good collat-
eral circulation of the foot evidenced by the presence of
these vascular anastomoses can likely tolerate embol-
ization or ligation of the aneurysm without the need for
reconstruction. However, if the foot perfusion is inad-
equate, arterial reconstruction is mandatory – this was
the case in our first reported patient who exhibited
inadequate toe perfusion after excluding the aneurysm
from the foot circulation as documented by poor
Doppler signals in all digital arteries. Furthermore,
the presence of an associated AVF mandates open sur-
gical resection,14 as was the case in the second, third
and fourth presented patients.
Risk of perioperative complications during surgical
excision of foot aneurysms is low. However, the
112
space-occupying effect of a plantar pseudoaneurysm
may damage the adjacent nerves if not released prop-
erly, which can lead to tarsal tunnel syndrome.9 Other
potential complications include arterial/graft throm-
bosis or distal embolism causing acute ischemia if vas-
cular reconstruction is required. No study has directly
compared the outcomes of endovascular and surgical
therapy for foot aneurysms, and current evidence for
the treatment approach to foot aneurysms is limited to
small case series.
Conclusion
Although aneurysms of arteries of the foot are rare,
they can lead to complications such as venous hyper-
tension, rupture and acute ischemia if left untreated.
Furthermore, the continual emergence of technological
leaps in the form of endovascular techniques affords a
greater diversity of therapeutic options available for the
management of foot aneurysms. A better understand-
ing of the various etiologies, clinical presentations and
treatment strategies through cases such as those pre-
sented in this report can help clinicians with early diag-
nosis and management of this rare clinical problem.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
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