Background: Percutaneous treatment strategies of peripheral artery disease have rapidly increased over the last decade leading to significant improvement in walking distance but at the cost of access-related complications after endovascular approaches. Femoral pseudoaneurysms are most commonly found in this context and different strategies for successful complication management are available. However, pseudoaneurysms of small peripheral vessels like the tibial vessels are rarely seen and treatment approaches are not well-defined and therefore standard protocols are lacking.

Case presentation:

Here, we report on a 65-years-old man with a history of symptomatic peripheral artery disease. Angiography confirmed the occlusion of the P1-segment of the left popliteal artery and a short occlusion of the tibioperoneal trunk. Retrograde vascular access via the posterior tibial artery was established and the popliteal artery was treated with drug-coated-balloon-angioplasty and stenting, the tibioperoneal trunk underwent drug-coated-stent-angioplasty. Five days after discharge the patient presented in our emergency department with painful swelling of the left calf. Ultrasonography detected a large pseudoaneurysm of the posterior tibial artery. Due to its unfavorable localization ultrasound-guided and angiographically controlled, minimally-invasive thrombin injection seemed and achieved complete resolution of the pseudoaneurysm. The patient was discharged with a dual antithrombotic medication of rivaroxaban 15 mg per day and clopidogrel 75 mg per day. Follow-up duplex-ultrasonography after three and six months showed patency of the stents with lasting improvement of blood flow in tibioperoneal vessels on the left side and resolution of the pseudoaneurysm.

Conclusions: The presented case highlights the advantage of a minimally-invasive approach that is easily accessible and feasible in the case of rare tibial artery pseudoaneurysms. Ultrasound- and angiographically guided thrombin injection was well tolerated, safe and effective in our patient similar to pseudoaneurysms of common femoral arteries. Therefore, minimally-invasive thrombin injection should be considered as a first-line treatment strategy.