Multistage endovascular treatment of a post-traumatic arteriovenous fistula and pseudoaneurysm of the anterior tibial artery аfter a mine-blast injury

Full Text

BACKGROUND

Contemporary armed conflicts are characterized by a substantial number of combat casualties sustaining mine-blast injuries, which typically involve complex combined injuries to major vessels [1, 2]. Among the most serious delayed complications are traumatic arteriovenous fistulas and pseudoaneurysms, which disrupt regional hemodynamics and carry the risk of life-threatening events, including rupture and thromboembolism [3, 4]. Although open surgery has historically been considered the gold standard, such interventions in the setting of pronounced post-traumatic fibrosis are associated with significant tissue trauma and prolonged hospitalization [5]. Endovascular techniques, including embolization and stent-grafting, allow minimization of procedural morbidity [6, 7]; however, multi-level lesions may necessitate a staged therapeutic approach [8].

In this report, we describe a successful experience of multistage endovascular treatment for a complex combined injury of the anterior tibial artery.

CASE DESCRIPTION

Patient Profile

A 27-year-old male sustained a mine-blast injury to the left lower leg with a comminuted fracture of the leg bones in October 2023. Primary wound care and immobilization were performed at a general multidisciplinary hospital at the pre-hospital stage. Despite fracture consolidation, the patient experienced persistent severe pain and refractory edema of the left lower leg over the ensuing months. The absence of clinical improvement with conservative management prompted referral to the Federal Research and Clinical Center of Specialized Medical Care and Medical Technologies of the Federal Medical and Biological Agency of Russia in February 2024 for comprehensive evaluation.

DIAGNOSTIC FINDINGS

At initial examination, the patient’s general condition was satisfactory. Local assessment revealed dense edema of the left lower leg, hyperkinetic pulsation, and a palpable pulsating mass in the popliteal fossa. Duplex ultrasonography (DUS) raised suspicion of an arteriovenous fistula between the popliteal artery and popliteal vein. To achieve precise topographic characterization and delineate the dimensions and anatomical relationships of the pathological formation, contrast-enhanced computed tomography angiography (CTA) of the lower-extremity arteries was performed on March 1, 2024. The study demonstrated avulsion of the anterior tibial artery (ATA) from the popliteal artery, a saccular pseudoaneurysm measuring 27×48×47 mm, and an arteriovenous fistula between the pseudoaneurysm cavity and the popliteal vein (Fig. 1). Signs of venous hypertension were identified, including dilatation of the popliteal and superficial femoral veins and prominent subcutaneous venous collaterals in the leg and thigh.

 

Fig. 1. Computed tomography angiography of the lower limb arteries, 3D reconstruction: pseudoaneurysm (arrow).

 

DIAGNOSIS

The following clinical diagnosis was established: «Sequelae of mine-blast injury to the left lower leg. Post-traumatic avulsion of the anterior tibial artery from the popliteal artery with formation of a pseudoaneurysm. Arteriovenous fistula between the pseudoaneurysm and the left popliteal vein».

TREATMENT

To precisely characterize the arterial supply to the pseudoaneurysm and the anatomy of the arteriovenous fistula, superselective angiography was performed on March 7, 2024. This revealed the ATA with a diameter of 4 mm and retrograde blood flow; a defect at the ostium of the ATA from the popliteal artery supplying the pseudoaneurysmal cavity; avulsion of the ATA ostium from the popliteal artery; and pronounced early arteriovenous shunting through the fistula into the popliteal vein (Fig. 2).

 

Fig. 2. Intraoperative superselective angiography: contrast filling of the aneurysm cavity (green arrow) by retrograde blood flow from the anterior tibial artery (arrows).

 

Stage 1 (June 21, 2024): Combined Endovascular Intervention

Endografting of the popliteal artery with a covered stent-graft was performed to exclude the popliteal artery defect at the ATA ostium, combined with coil embolization of the ATA trunk to prevent retrograde filling of the pseudoaneurysmal cavity via the ATA (Fig. 3). For embolization of the ATA ostium, the catheter was advanced through the posterior tibial artery, then distally along the plantar artery to the plantar arch, followed by passage of a microcatheter and a soft-tip guidewire through the plantar arch, continuing into the deep plantar branch and then into the dorsal artery of the foot. The guidewire thus described a loop: posterior tibial artery → plantar artery → plantar arch → dorsal pedal artery. The guidewire was then advanced retrogradely from the distal ATA to its proximal segment. The procedure was completed with deployment of microcoils (Fig. 4).

 

Fig. 3. Intra-procedure stage demonstrating the advancement of a guidewire across the plantar arterial arch; anatomical landmarks are marked with arrows.

 

Fig. 4. Endoprosthesis implantation stage. Angiogram after stent-graft placement in the popliteal artery. Embolization of the anterior tibial artery trunk with microcoils (arrows).

 

Following the first operative stage, DUS demonstrated a reduction in the size of the aneurysmal cavity (2.0×2.2 cm), however, continued filling of the cavity through collateral branches of the popliteal artery and tibioperoneal trunk was observed. The endograft was patent without evidence of endoleak. Given the persistence of flow through collateral branches of the tibioperoneal trunk, a second operative stage was planned to prevent aneurysmal growth.

Stage 2 (January 31, 2025): Targeted Superselective Embolization

Superselective microcoil embolization of the major collateral feeding vessels of the aneurysm was performed to reduce cavity filling (Fig. 5).

 

Fig. 5. Embolization stage of afferent vessels: a, Identification of a large collateral afferent vessel to the aneurysm (arrow). b, Result of embolization of the afferent vessel with microcoils (arrow).

 

Antithrombotic and Anticoagulant Management

The first stage involved implantation of a metallic stent-graft into a small-caliber artery (tibioperoneal trunk), which carried a high risk of subacute thrombosis. Accordingly, dual antiplatelet therapy (aspirin 100 mg/day plus clopidogrel 75 mg/day) was initiated. The duration of dual antiplatelet therapy was 6 months. In addition, during the early postoperative period (first 3 days), enoxaparin sodium 4,000 anti-Xa IU was administered subcutaneously twice daily for prophylaxis against thrombosis at the embolization and stenting sites. Enoxaparin was selected due to its predictable bioavailability and the ability to rapidly discontinue it in the event of a puncture-site hematoma (which did not occur). Following discharge, the patient continued dual antiplatelet therapy. At 6 months (December 2024), dual antiplatelet therapy was transitioned to clopidogrel monotherapy 75 mg/day, as the risk of in-stent thrombosis remained persistent, and aspirin carried a risk of exacerbating the patient’s erosive gastritis (confirmed by esophagogastroduodenoscopy).

Following the second stage (microcoil aneurysm embolization), enoxaparin 4,000 anti-Xa IU subcutaneously once daily for 3 days was added to the clopidogrel 75 mg/day regimen. Coil embolization does not require prolonged antithrombotic therapy, as the objective of the intervention is to initiate cavitary thrombosis; however, the risk of stent-graft thrombosis and distal embolization from thrombus fragments persisted. After discharge, clopidogrel monotherapy 75 mg/day was continued.

At the time of the most recent follow-up visit (August 2025), the patient remained on clopidogrel; therapy is planned to continue for a minimum of 12 months following the second stage, after which conversion to aspirin or complete discontinuation will be considered.

At initial evaluation, the patient tested positive for HBsAg (hepatitis B virus); however, repeat testing yielded negative results, and the initial finding was regarded as a false positive. No chronic active hepatitis was identified; nonetheless, transaminase levels and coagulation parameters were monitored and remained within normal limits throughout follow-up. Erosive gastritis was also diagnosed, which precluded long-term aspirin use. For this reason, after 6 months of dual antiplatelet therapy, the regimen was transitioned to clopidogrel monotherapy, which carries a lower ulcerogenic potential. The risk of gastrointestinal bleeding from erosions was assessed as moderate; no exacerbations were observed during concomitant proton pump inhibitor therapy (rabeprazole 20 mg/day). In summary, the antithrombotic strategy employed was aggressive during the early post-stenting and post-embolization period (dual antiplatelet therapy plus a short course of low-molecular-weight heparin) and less intensive during the long-term follow-up period (clopidogrel monotherapy), in accordance with the patient’s comorbid gastropathy. We believe that this tailored approach contributed to preservation of stent-graft patency and prevention of aneurysm recurrence.

FOLLOW-UP AND OUTCOMES

Following completion of the second stage, the patient was followed up at his place of residence. He reported no complaints, edema resolved completely, and walking distance was unrestricted. One year later, the patient was re-evaluated at the Vascular Surgery Department of FNKTS FMBA Russia. DUS and contrast-enhanced CT confirmed patency of the popliteal artery endograft, markedly reduced perfusion of the aneurysmal cavity, and a decrease in aneurysm dimensions to 9×11 mm (Fig. 6, 7). The clinical outcome was rated as good. In the absence of clinical manifestations (edema and pain), with restoration of the patient’s functional capacity and pronounced scarring at the aneurysm site as a sequela of mine-blast injury, further intervention, whether endovascular or open, was deferred. Dynamic surveillance at 6-month intervals was recommended.

 

Fig. 6. Follow-up contrast-enhanced computed tomography (CT) of the lower limb vessels 1 year after surgery (the aneurysm cavity and endoprosthesis are indicated by arrows).

 

Fig. 7. Follow-up duplex ultrasound scan of the lower limb vessels 1 year after surgery (the aneurysm cavity is indicated by an arrow).

 

DISCUSSION

A distinctive feature of contemporary combat trauma is the predominance of mine-blast injuries to the lower extremities, frequently involving occult tangential vascular injuries from small shell fragments or bone fragments in comminuted fractures—injuries that are not accompanied by active hemorrhage and are diagnostically challenging. Indirect arterial and venous injury from the shock wave, with subsequent development of an arteriovenous fistula, is also possible. In prior military conflicts, arteriovenous fistula formation was reported in 2.3–3.9% of cases. The advent of new weapons systems has apparently led to an increase in this incidence; in one report, 59 of 500 wounded patients (11.8%) evaluated at a central military hospital were diagnosed with major vascular injury complicated by arteriovenous fistula formation [9].

Advances in high-technology methods have expanded the diagnostic and therapeutic options for post-traumatic arteriovenous fistulas, however, owing to their relative rarity, the published evidence base remains limited. The development of an optimal diagnostic and therapeutic strategy represents a clinically important challenge in light of the increasing number of such patients.

The present case illustrates contemporary principles for managing complex combined vascular pathology and allows several key aspects to be highlighted.

Critical importance of dynamic postoperative surveillance. As demonstrated by this case, meticulous DUS-based monitoring following each procedural stage is an indispensable component of successful treatment. The identification of persistent aneurysmal flow after the first stage was not a failure, but rather a rational indication for a subsequent intervention. This underscores the need to plan treatment not as a single isolated operation, but as a therapeutic strategy with built-in capacity for adjustment.

The value of precise diagnostic imaging. The initial DUS finding of a popliteal artery arteriovenous fistula proved to be inaccurate. CTA, serving as the definitive diagnostic modality, revealed the true pathological anatomy: avulsion of the ATA ostium from the popliteal artery, formation of a pseudoaneurysm with a fistula to the popliteal vein [4, 10]. This fundamentally altered the operative strategy, directing efforts toward selective ATA embolization and popliteal artery endografting rather than open popliteal artery reconstruction. This case confirms that surgical planning for complex vascular lesions, despite the high informative value of DUS as a screening tool, requires a “gold standard” approach in the form of CTA or MR angiography, corroborated by superselective angiography.

Pathophysiological rationale and efficacy of the staged approach. The selected strategy— implementing the principle of “diagnosis → reconstruction → definitive embolization”—proved fully justified. The first stage (tibioperoneal trunk endografting and ATA embolization) addressed the restoration of main-trunk blood flow and elimination of the primary fistulous shunting source. It was anticipated that occlusion of the ATA proximal to the fistula would lead to thrombosis of both the fistula and the aneurysmal cavity. However, as demonstrated by the present and other reported cases, embolization of the feeding artery does not invariably guarantee thrombosis of the aneurysmal sac in the setting of a well-developed collateral network [7]. Intraoperatively and on follow-up DUS, the aneurysm was found to continue filling through collateral branches—most likely from the posterior tibial or peroneal artery system via perforating branches—despite successful ATA embolization. This is a typical finding in chronic post-traumatic aneurysms: over time, numerous collateral pathways develop that sustain blood flow within the aneurysmal sac. Embolizing all such branches during the first stage would have been technically demanding, requiring superselective catheterization of multiple small vessels, with attendant risks of perforation and prolonged procedural time. Moreover, the first stage typically targets only the major perforating branches that play a dominant role in pseudoaneurysm perfusion. The persistent aneurysm was intentionally placed under watchful observation with antiplatelet therapy, and follow-up DUS was scheduled at 3–4 months. As spontaneous thrombosis did not occur and high-velocity intracavitary flow persisted, the decision was made to proceed with direct aneurysm embolization. The 7-month interval between the second and third stages (June 2024 to January 2025) was determined by several factors: the need for complete stabilization following the second intervention, the requirement to await DUS follow-up results, and the elective nature of the hospitalization (the patient did not require emergency care, allowing selection of an optimal timing).

The second, definitive stage (embolization of the aneurysmal feeding vessels) enabled precise targeted treatment of the persistent cavity. This staged approach allowed distribution of operative risks, objective assessment of the efficacy of each step, and ultimately the achievement of a durable outcome while avoiding excessive invasiveness.

Advantages of the endovascular approach in a post-traumatic field. Performing open reconstruction in the setting of pronounced fibroadhesive changes following prior surgical interventions and fracture is associated with increased risk of intraoperative hemorrhage, iatrogenic nerve and venous injury, and significant technical difficulties in dissecting vascular structures [5]. The endovascular approach minimized these risks, enabling highly targeted treatment of the pathological focus without the need for extensive tissue dissection [6, 7].

Not all authors subscribe to a fully endovascular approach. Petrov et al. [11] reported experience with 32 patients with post-traumatic arteriovenous fistulas and pseudoaneurysms; endovascular (38%), open (53%), and hybrid (9%) techniques were utilized, with stent-graft implantation performed in only one case. The rationale for this selective approach included: evidence of pronounced morphological changes in the arterial wall with loss of structural integrity in the zone of the arteriovenous fistula after high-energy munition injuries, and concerns that stent-graft implantation in such areas carries a poor prognosis; the undesirability of stent placement in kinetically mobile zones due to an elevated risk of thrombosis; and the necessity for long-term antiplatelet therapy in young male patients. To mitigate potential adverse events, these authors proposed an original technique involving stent implantation with an autologous vein sleeve secured by a Goose Neck loop (applied in individual patients).

Experience with 66 open reconstructive procedures and 17 endovascular interventions with stent-graft implantation in patients with lower-extremity arteriovenous fistulas following mine-blast injuries has also been reported [12]. No complications were observed in the open surgery group. In the stent-graft cohort, 3 (17.6%) complications were documented during follow-up: 2 cases of stent-graft thrombosis (in the popliteal and posterior tibial arteries) without limb ischemia and not requiring additional intervention, and 1 case of distal migration of a previously placed popliteal artery stent-graft into the tibioperoneal trunk and posterior tibial artery requiring open re-grafting.

In our opinion, in the present case, the risks of endovascular stent-graft implantation were substantially lower than those of open surgical intervention. The pseudoaneurysm and arteriovenous fistula involved the proximal ATA, in immediate proximity to the tibioperoneal trunk and popliteal vein, and within the zone of a previously sustained leg fracture. Open exploration of this region would have been associated with extraordinary technical challenges attributable to pronounced fibroadhesive changes, distorted anatomical relationships, and high risk of injury to the popliteal vein and common peroneal nerve. Moreover, access to the ATA in this zone requires either an extended popliteal approach or resection of the fibular head, both of which increase procedural morbidity.

The risks described by our colleagues—intimal dissection, stent migration, distal embolization [11, 12]—were minimized through the use of superselective angiography, balloon-expandable stent-grafts with high radial force, and intraoperative angiographic verification following each stage. Admittedly, no technique is free of limitations; however, in this specific anatomical and clinical context, the endovascular approach was considered less hazardous than open surgery in the popliteal–tibioperoneal segment, which is regarded as technically demanding for successful revascularization.

We therefore do not view endovascular and open strategies as mutually exclusive, but rather as complementary modalities. The indications for endovascular treatment in our case were defined by: the location of the injury in a region poorly accessible to open exploration; the absence of active infection or tissue suppuration; the patient’s young age; and the desire to avoid prolonged immobilization. A hybrid approach (e.g., open access to the popliteal artery for proximal control combined with endovascular embolization) could have been considered as an alternative; however, it would not have eliminated the need for dissection in scar-laden tissue, which was precisely what we sought to avoid.

We consider the approach of applying minimally invasive techniques as a first step, reserving open reconstructive surgery for cases in which endovascular methods prove insufficient, to be well founded.

The selection of the optimal therapeutic strategy in patients with arteriovenous fistula following mine-blast injury should be individualized and carried out at expert-level vascular centers.

CONCLUSION

The present case report illustrates the diagnostic and therapeutic challenges of managing complex injuries to major lower-extremity vessels in the remote period following a mine-blast wound. In such cases, CTA and superselective angiography play a defining role in topographic diagnosis and operative planning. Staged endovascular interventions demonstrate high efficacy and safety, enabling the resolution of complex, multi-level vascular problems with minimal invasiveness and maximum precision. Between stages, patients require systematic instrumental surveillance to monitor intermediate outcomes and ensure timely execution of subsequent therapeutic steps. The application of a pathophysiologically grounded endovascular strategy allowed complete clinical success—limb salvage with restoration of function—while avoiding a technically demanding and high-risk open surgical procedure in a zone of severe post-traumatic fibrosis. This approach may be recommended for application in analogous clinical situations.

Additional information

Author contributions: S.V. Deryabin, preparation of the manuscript draft, data collection and processing, patient supervision, literature analysis, preparation of illustrations, performing the surgery; V.L. Baldin, performing the surgery, general management of the patient’s treatment; A.V. Smirnov, literature analysis, participation in writing and editing the manuscript, R.I. Khabazov, A.V. Troitsky, general management, concept and design, editing the manuscript. Thereby, all authors provided approval of the version to be published and agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Acknowledgments: The authors thank to the staff of the Vascular Surgery Department of Federal Scientific and Clinical Center for Specialized Types of Medical Care and Medical Technologies.

Consent for publication: The authors obtained the patient’s written informed consent to publish personal data in a scientific journal, including its electronic version (signed April 6, 2026). The scope of the published data was agreed upon with the patient.

Funding source: This study was conducted with support from the Federal Medical and Biological Agency of Russia.

Disclosure of interests: The authors declare no explicit or potential conflicts of interest related to the publication of this article.

Statement of originality: The authors did not use previously published information (text, illustrations, or data) while conducting this research and preparing this manuscript.

Data availability statement: The editorial data sharing policy does not apply to this work; data may be published as open access.

Generative AI: Generative AI technologies were not used for this article creation.

About the authors

Sergey V. Deryabin

Federal Research and Clinical Center of Specialized Medical Care and Medical Technologies

Email: Deryabin@mail.ru
ORCID iD: 0000-0003-2754-4836
SPIN-code: 4929-0910

MD

Russian Federation, Moscow

Victor L. Baldin

Federal Research and Clinical Center of Specialized Medical Care and Medical Technologies

Email: baldinvl@gmail.com
ORCID iD: 0000-0003-3033-5605

MD, PhD

Russian Federation, Moscow

Alexander V. Smirnov

Federal Research and Clinical Center of Specialized Medical Care and Medical Technologies

Author for correspondence.
Email: smirnov.av@fnkc-fmba.ru
ORCID iD: 0000-0003-3897-8306
SPIN-code: 5619-1151

MD, PhD, Assistant Professor

Russian Federation, Moscow

Robert I. Khabazov

Federal Research and Clinical Center of Specialized Medical Care and Medical Technologies

Email: khabazov119@gmail.com
ORCID iD: 0000-0001-6801-6568
SPIN-code: 8264-7791

MD, PhD

Russian Federation, Moscow

Aleksandr V. Troitskiy

Federal Research and Clinical Center of Specialized Medical Care and Medical Technologies

Email: dr.troitskiy@gmail.com
ORCID iD: 0000-0003-2143-8696
SPIN-code: 2670-6662

MD, PhD, Professor

Russian Federation, Moscow

References

Supplementary files