Endovascular interventions in technically challenging cases of post traumatic aneurysms and arteriovenous fistulas of limb arteries. Clinical cases

Abstract

Objective – to analyze current scientific data on the role of endovascular interventions in the management of technically challenging post-traumatic pseudoaneurysms (PTPA) and arteriovenous fistulas (AVF) of major extremity vessels resulting from gunshot wounds; to define the indications, benefits, and limitations of minimally invasive methods; to justify their role within hybrid strategies in comparison with conventional open reconstructions; and to present our case series of successful clinical observations.

Materials and methods. A systematic analysis of specialized literature dedicated to major extremity vessel injuries and their delayed complications was conducted. The review covers the experience of armed conflicts spanning from World War II to modern operations in Iraq and Afghanistan. We analyzed fundamental works (DeBakey, Rich), data from the Vietnam Vascular Registry involving 558 post-traumatic lesions, as well as contemporary epidemiological and multicenter studies (White, Clouse, DuBose) that highlight outcomes of endovascular management for vascular trauma. Special attention was paid to the comparative analysis of treatment strategies in anatomically complex (junctional) zones, where open surgery is associated with high operative trauma and increased risk of iatrogenic injuries.

Results. It was established that PTPAs and AVFs account for approximately 7% of all vascular injuries within the structure of combat trauma. Open reconstruction (resection with autogenous vein grafting) remains the priority for contaminated wounds, infected PTPAs, and lesions located within flexion zones in young patients. It was found that in proximal segments not affected by infection, covered stent-graft implantation achieves a technical success rate of over 90%, thereby radically minimizing dissection volume in anatomically complex zones. Embolization is positioned as an effective method for isolating branch lesions and providing adjuvant support for stenting. The main limitations of the endovascular approach include the risk of stent fracture in highly mobile segments and insufficient fixation zones. The feasibility of hybrid strategies in chronic high-flow AVFs with pronounced venous transformation is emphasized. The presented case series confirms the efficacy of the chosen algorithms in treating the consequences of gunshot wounds in both short- and mid-term periods.

Conclusions. Endovascular technologies are not a complete alternative to open vascular surgery, but they significantly expand the tactical arsenal in the management of extremity PTPAs and AVFs, particularly in cases of anatomically unfavorable lesion localization and high operative risk. The use of covered stent-grafts and selective embolization methods, with careful patient selection, ensures high technical success and stable clinical outcomes. The implementation of hybrid strategies allows for effective individualization of treatment tactics in the most complex cases with pronounced venous transformation. The choice of intervention (open, endovascular, or hybrid) must be based on a comprehensive assessment of the lesion’s angioarchitecture, the presence of an infectious process, the biomechanical characteristics of the affected segment, and the patient’s functional demands, which rules out the use of simplified, one-size-fits-all algorithms.