A 21 y/o female presented to the trauma bay with
a right anterior mid-thigh gunshot wound and associated small stable hematoma
in the anterior right thigh. Vital signs were stable. No active bleeding was present. Strong distal pulses were present. Strength and sensation were intact, however
the patient complained of RLE paresthesias.
Right femur x-ray revealed retained missile posterior mid thigh, but no
fracture.
Hard signs of arterial injury include active
bleeding, expanding hematoma, bruit or thrill over wound, absent distal pulses,
and ischemia of extremity. Presence of a
hard sign is highly predictive of arterial injury. Should proceed to OR without additional
imaging.
Soft signs of arterial injury include decreased
pulses, proximity to vasculature, hematoma, neurologic deficit, and history of
blood loss. Soft signs of injury warrant
further investigation for arterial injury.
Our patient had multiple soft signs – hematoma,
proximity, and neurologic deficit. CT
angiography was obtained and revealed a superficial femoral arteriovenous
fistula. The patient was taken to the
operating room and the superficial femoral arteriovenous fistula was explored
after proximal and distal control was obtained.
The involved vein was resected and primarily repaired. The involved artery was resected and repaired
as well. The patient was discharged home
on the fourth postoperative day.
In cases of arteriovenous fistulas secondary to
trauma, most sources recommend early operative repair. Case reports of endovascular stenting for
traumatic injuries to extremities are emerging with acceptable patency results
and decreased morbidity, including less iatrogenic peripheral nerve injuries.
References:
1. Davidovic
et al. Post-traumatic AV fistulas and pseudoaneurysms. J Cardiovasc Surg 1997;
38:645-51.
2. Erkut B,
Karapolat S, Kaygin MA, Unlu Y. Surgical treatment of post-traumatic
pseudoaneurysm and arteriovenous fistula due to gunshot injury. Ulus Travma
Acil Cerrahi Derg 2007;13: 248-50.
3. Stewart
et al. Use of Stent Grafts in Lower Extremity Trauma. Annals of Vascular
Surgery 2011; 264.
X-ray
showing retained missile right thigh and no fracture.
CT
angiography showing contrast flow between artery (anterior, top of image) and
vein (posterior, bottom of image, tip of cursor).
from Dr. LIndsay Petersen
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