Introduction: Extremity vascular injuries constitute the majority of combat vascular trauma and present a complex management challenge due to hemorrhage, ischemia, and associated musculoskeletal destruction.Methods: This is a retrospective multicenter review of 900 consecutive cases treated at Level II–IV military and civilian referral centers between 2022 and 2024. Major vascular injury was defined as injury to a named extremity vessel causing ischemia, major hemorrhage, or requiring operative vascular intervention.Results: Femoral–popliteal injuries accounted for 689/900 of the cases (76.6%). Combined arterial–venous injuries were present in 490/900 (54.4%). Complex trauma with bone, nerve, or combined trauma occurred in 711/900 (79.0%). Massive soft-tissue destruction occurred in 776/900 (86.3%). Interventions included vascular reconstructions (15.0%), temporary shunts (5.3%), and fasciotomies (35.8%). Primary amputation rate was 8.3% (75/900) and the secondary rate was 15.6% (140/900), yielding a 23.9% overall amputation rate, primarily driven by massive blast-induced soft-tissue destruction. Mortality was 1.7% (15/900). Chronic arterial insufficiency (17.7%) and thrombosis (13.7%) occurred long term.Conclusion: Modern combat extremity injuries highlight persistent limb-salvage challenges. Decreasing time to reperfusion is crucial. Key recommendations include: protocolization of damage-control strategies with clear indications for temporary shunts and fasciotomy; preferential use of autologous conduits in contaminated wounds; and early, aggressive soft-tissue management and infection control to reduce secondary amputations.
Axillary artery pseudoaneurysms following proximal humeral fractures are rare, particularly in elderly patients after low-energy trauma, and may present in a delayed manner, posing diagnostic challenges. We report a 76-year-old woman with a displaced proximal humeral fracture who returned four days later with severe anemia and extensive shoulder ecchymosis. Computed tomography angiography revealed a 35 × 20 mm axillary artery pseudoaneurysm within a large hematoma. The lesion was successfully excluded using a covered endovascular stent via femoral access, with post-procedure imaging confirming patency and complete pseudoaneurysm exclusion. The patient recovered uneventfully and was discharged two days later. This case highlights the need for high clinical vigilance in elderly patients and demonstrates that endovascular repair provides a safe, minimally invasive, and effective alternative to open surgery, expanding therapeutic options for combined orthopedic and vascular trauma.
Colo-vesical fistula is a condition characterized by an abnormal connection between the colon and the urinary bladder. Traumatic rectovesical fistulas (RVFs) are rare entities, most commonly resulting from penetrating trauma, including gunshot injuries. Symptoms shown by these patients are commonly pneumaturia and fecaluria, highly suggestive of a pathological communication between the bowel and the bladder. However, localization of the fistulous tract typically requires cross-sectional imaging. Herein, we report the case of a 29-year-old man admitted to our Emergency Department with a RVF resulting from a gunshot injury. Initial imaging studies were inconclusive, while the definitive diagnosis of traumatic RVF was established using abdominal computed tomography with an ultradelayed acquisition performed 35 minutes after contrast administration. Clinical symptoms remain a key guide in the diagnostic process, and when standard imaging fails to identify the fistulous tract, ultra-delayed imaging acquisitions should be considered to facilitate timely surgical management and improve patient outcomes.
Popliteal Artery Entrapment Syndrome (PAES) is a rare condition involving compression of the popliteal artery, affecting about 0.17% to 3.5% of the population. A young male athlete experienced worsening right foot pain and paleness of the area during exercise, leading to the diagnosis of Type I PAES due to an abnormal tendinous slip of the medial head of the gastrocnemius muscle. After surgical decompression, the athlete recovered smoothly and returned to sports within three months, reporting no symptoms at his one-year follow-up. Diagnosing PAES is challenging owing to non-specific symptoms like exercise-induced leg pain, often confused with common issues. This results in underdiagnosis and misclassification of PAES. Diagnosing PAES can be complex, particularly in young athletes, because its nonspecific symptoms are often overlooked. Enhanced clinical awareness and refined diagnostic strategies are crucial for timely recognition and improved patient outcomes.
Introduction: Lower limb vascular trauma is a time-critical emergency with a high risk of limb loss. Open surgical repair (OSR) has traditionally been the standard treatment, but endovascular therapy (ET) is increasingly utilized. This study aimed to compare the effectiveness and safety of ET versus OSR. Methods: A systematic review and meta-analysis of comparative observational studies was performed. Adult patients with traumatic lower limb arterial injuries involving the popliteal artery and/or superficial femoral artery were included. A random-effects model was used to calculate pooled risk ratios (RRs) with 95% confidence intervals (CIs). Statistical heterogeneity was assessed using the I² statistic. Results: Six retrospective cohort studies involving 9,503 patients were included. Of these, 1,315 patients underwent ET and 8,188 underwent OSR. ET was associated with a reduced risk of amputation compared with OSR (RR 0.67; 95% CI 0.50–0.91). Subgroup analyses demonstrated no significant difference in blunt (RR 0.90; 95% CI 0.59–1.37) or penetrating popliteal artery injuries (RR 0.84; 95% CI 0.21–3.34). ET significantly reduced the risk of compartment syndrome (RR 0.43; 95% CI 0.33–0.56) and the need for fasciotomy (RR 0.43; 95% CI 0.27–0.69). Conclusions: ET might provide limb salvage outcomes comparable to OSR while significantly reducing ischemia-related morbidity, particularly compartment syndrome and fasciotomy. These findings suggest that ET may be considered in selected patients, although the evidence remains limited.
Objective: We evaluated feasibility and outcomes of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) for non-compressible torso hemorrhage in a resource-limited setting. Methods: This retrospective-prospective cohort study included 23 trauma patients undergoing REBOA at a tertiary center in Thailand (2012–2024). Primary endpoints were 24-hour and 28-day survival. Results: Patients presented with profound shock (median systolic blood pressure 60 mmHg) and severe neurological impairment (median Glasgow Coma Scale 7); 43.5% received prehospital cardiopulmonary resuscitation. REBOA increased systolic blood pressure by 39.8±20.7 mmHg, achieving 82.6% return of spontaneous circulation. The 24-hour and 28-day survival rates were 26.1% and 21.7%, respectively—superior to historical resuscitative thoracotomy outcomes (2–8.5%). Multivariate analysis identified Glasgow Coma Scale 9–12 as the strongest survival predictor versus 3–8 (odds ratio 23.33, 95% confidence interval 1.95–279.43, P = 0.013). No limb ischemia occurred; acute kidney injury developed in 21.7%. Conclusions: REBOA achieved favorable survival in critically ill patients without hybrid operating rooms or 24/7 interventional radiology. Glasgow Coma Scale score emerged as the key prognostic indicator, suggesting optimal efficacy when deployed before complete cardiovascular collapse. REBOA represents a feasible option in resource-limited trauma centers.
Vascular injuries in modern warfare are frequently complex and contaminated and are associated with a high risk of secondary complications. Erosive bleeding after vascular reconstruction represents a limb- and life-threatening condition. We report a case of combined gunshot and shrapnel injury to both upper extremities in a soldier, initially treated with temporary vascular shunting and subsequent autovenous reconstruction. The postoperative course was complicated by erosive bleeding at the graft site, requiring urgent reoperation and staged wound management. Limb perfusion was successfully preserved. This case illustrates the importance of shunting, repeated surgical assessment, aggressive infection control and staged reconstruction strategies in contaminated combat-related vascular injuries.
This article describes the case of a 45-year-old female patient who had been treated with radiotherapy for vaginal cancer and who developed actinic cystitis with frequent episodes of severe hematuria, requiring repeated blood transfusions. The patient was treated with selective embolization of the vesical arteries. The procedure was successful, and the patient has been in follow-up for six months without other hematuria episodes, nor needing further blood transfusions or hospital admissions. A review of technical aspects regarding bladder embolization and possible complications related to this procedure is also provided.
Background: A pseudoaneurysm (PSA) is a focal arterial dilation caused by blood leakage from a vessel, forming a localized hematoma enclosed by a fibrin wall. Unlike true aneurysms, PSAs lack involvement of all vessel wall layers. Rare in peripheral arteries, they cause life-threatening complications if untreated. Case Report: We report a case of a 42-year-old male who developed a left brachial artery PSA following surgical removal of a titanium elastic nail. The patient presented with a 6-month history of a pulsatile swelling. Imaging revealed a fusiform PSA with partial thrombotic occlusion. Surgical excision was performed, and the brachial artery reconstructed with a great saphenous vein interposition graft. Conclusions: Brachial artery PSAs are uncommon and result from trauma or surgical intervention. Treatment involves open surgical repair with vein grafting. Alternative approaches, including endovascular stent grafting and coil embolization, may be viable. Early diagnosis and tailored management are essential to prevent complications.
Background: Marfan syndrome is autosomal dominant with ocular, cardiovascular, and musculoskeletal manifestations. It is caused by mutation that encodes the fibrin gene on chromosome 15. Case Presentation: A 54-year-old man presented to our center with a sudden onset of severe headache followed by a gradual loss of consciousness. His medical history was significant for Marfan syndrome. We found a spontaneous subdural hematoma in the left frontoparietotemporal area. The patient underwent emergency surgical intervention consisting of excision of the acute lesion and decompressive craniectomy in the left frontoparietal-temporal area. A postoperative brain computed tomography scan was conducted, which revealed a reduced midline shift and a subdural hematoma drainage. Laboratory investigations and intensive treatment were continued; however, the patient’s clinical condition deteriorated progressively. Conclusion: This case underscores the rare occurrence of spontaneous acute subdural hematoma in the setting of Marfan syndrome, which calls for prompt recognition and surgical intervention.
Spontaneous rupture of the lumbar artery is a rare and potentially life-threatening complication, particularly in anticoagulated patients. Its diagnosis is challenging due to nonspecific symptoms and rapid progression. We present the case of a 78-year-old woman, without prior arterial disease, who developed atrial fibrillation during hospitalization and was started on enoxaparin (1 mg/kg every 12 hours). She subsequently developed hemodynamic instability, prompting urgent imaging. An initial ultrasound showed a right flank hematoma, and a computed tomography angiogram confirmed a retroperitoneal hematoma due to lumbar artery rupture. The patient received aggressive resuscitation and hemodynamic support, followed by successful catheter embolization, which stabilized her condition. This case highlights the importance of considering spontaneous lumbar artery rupture in anticoagulated patients presenting with unexplained hemodynamic instability. Early diagnosis and timely endovascular intervention can be life-saving and improve outcomes.
Background: Spontaneous Spinal Epidural Hematoma (SSEH) is a rare emergency in the general population. It is an even rarer entity in the pediatric population. Case Description: We report two cases: a 15-month-old boy with SSEH, who was presenting with irritability, acute pain, and a 3-year-old girl who presented with left-sided Horner’s syndrome and pain in the left upper extremity. Both patients were misdiagnosed upon admission. At 10 months and 2 months, respectively, after surgery, decompressive surgery was recommended as soon as possible, but this is normally carried out 12 to 24 hours after onset. Conclusion: The clinical presentation of SSEH is atypical and highly difficult to diagnose in children, especially in infants and toddlers. SSEH should always be included in the differential diagnosis when children present with acute back and neck pain, irritability, and uncontrolled crying.
Background: Endovascular repair of the aorta has been established as the treatment of choice for patients with closed traumatic aortic injury, and its implementation has resulted in better clinical outcomes for patients. Our objective was to describe a case series of patients with closed traumatic aortic injury who received endovascular management. Methods: We carried out a retrospective review of the experience accumulated over 5 years in a level IV center in Colombia of the management of closed traumatic aortic injury with endovascular treatment. We found four patients with different aortic injuries described as grade II or III. Endovascular management was performed during the first 48 hours after admission to the emergency room; hospital survival was 100%, and there was no record of complications after the procedure. Conclusions: Endovascular repair is the treatment of choice for closed traumatic aortic injury, including scenarios of hemodynamic instability. This is the first case series published from Colombia.
Background: Cardiogenic cerebral embolism (CCE) accounts for approximately 20% of ischemic strokes and presents with severe neurological deficits and high mortality rates. The safety and effectiveness of current therapeutic strategies remain under evaluation. This systematic review aims to assess the safety profiles of current therapies, including thrombolysis, endovascular thrombectomy, anticoagulants, and antiplatelets, in patients with CCE. Methods: A systematic search was conducted in Web of Science, Scopus, and PubMed for studies published up to May 2024. Articles were screened using the Rayyan intelligence tool, and their quality was assessed using the JBI critical appraisal tool. The review included randomized controlled trials (RCTs) and observational studies evaluating the safety and outcomes of different CCE treatment modalities. Results: Ten studies met the inclusion criteria. Endovascular thrombectomy demonstrated improved functional outcomes with a reduced risk of mortality, although symptomatic intracranial hemorrhage (sICH) rates were comparable to other therapies. Intravenous thrombolysis with alteplase was associated with increased sICH risk but reduced 90-day mortality. Direct oral anticoagulants (DOACs), including apixaban and edoxaban, showed a favorable safety profile with no significant increase in intracranial bleeding. Antiplatelet therapy, particularly low-dose tirofiban, demonstrated reduced in-hospital mortality without increasing hemorrhagic risk. Conclusion: While current therapies for CCE improve outcomes, their safety profiles vary. Endovascular thrombectomy appears effective for severe cases, whereas DOACs provide a safe alternative for long-term anticoagulation. Further large-scale trials are needed to refine treatment guidelines and minimize hemorrhagic risks.
Background: Acute Respiratory Distress Syndrome (ARDS) is a severe complication of ischemia-reperfusion injury (IRI), characterized by acute hypoxemic respiratory failure and high mortality. Acute limb ischemia (ALI) can trigger systemic inflammation leading to ARDS. This study introduces a swine model of ARDS secondary to ALI. Methods: Two Yorkshire swine were used in this study. Animals were anesthetized and subjected to nine hours of hindlimb ischemia via arterial occlusion. The limb was then reperfused and animals monitored through physiological parameters, computed tomography imaging, lung ultrasounds and histology. Data was then analyzed using GraphPad Prism and Analyze software for statistical and imaging evaluation. Results: Baseline measurements confirmed normal vasculature and stability, access was obtained and occlusion delivered. Following nine hours of hindlimb ischemia, reperfusion led to progressive respiratory decline, with worsening oxygenation, decline in the Horowitz index, elevated lactate and potassium levels, and imaging showing early signs of lung injury. Post-mortem analysis confirmed lung congestion, consistent with ARDS. Conclusions: The study demonstrates a novel, easily performed, cost-effective and replicable swine model of ARDS using hindlimb IRI. This model mimics physiological and sterile conditions seen in a clinical setting and serves as a valuable tool for studying ARDS. It also allows for investigation of the systemic inflammatory cascade triggered by peripheral ischemia, mirroring human ARDS cases that occur with distal injuries. Future studies with larger sample sizes and extended critical care periods are recommended to validate the technique and enhance its relevance for experimental applications.
