Endovascular rescue in a contaminated field: Managing penetrating intra-abdominal vascular trauma after a left lower quadrant gunshot wound

Abstract

Endovascular management of penetrating intra-abdominal vascular trauma is an evolving modality that may support hemodynamic stability, reduce operative time, and avoid open conduit-based reconstruction in contaminated fields. We present the case of a 24-year-old male with a gunshot wound to the left lower abdomen who was found to have multiple traumatic arteriovenous fistulas (AVFs) involving the right common iliac artery (CIA), inferior mesenteric artery (IMA), and inferior vena cava (IVC). The patient was hemodynamically stable on presentation and underwent exploratory laparotomy, which revealed enteric injuries with gross contamination and a stable retroperitoneal hematoma. Following bowel resection and damage control, a staged endovascular approach was pursued in a hybrid operating room. Covered stent placement in the right CIA and coil embolization of the IMA successfully excluded the identified AVFs. A contained IVC injury was managed non-operatively. Postoperative imaging demonstrated initial resolution; however, on postoperative day (POD) five, the patient developed a persistent AVF via collateral flow from the superior mesenteric artery through the middle colic artery to the distal IMA. This was successfully treated with repeat endovascular coil embolization. The patient required minimal transfusion, had no infectious complications, and was discharged on POD 16. At 1-year follow-up, imaging demonstrated durable exclusion of AVFs and stable remodeling of the IVC injury. This case highlights the feasibility and advantages of a staged hybrid approach in penetrating abdominal vascular trauma, particularly in contaminated operative fields. Endovascular techniques may reduce infectious risk, minimize blood loss, and allow for precise identification and treatment of complex vascular injuries, including those not apparent during open exploration. Early triage to hybrid operating environments and a high index of suspicion for delayed or collateralized AVFs are critical to optimizing outcomes.