Endovascular treatment of complex traumatic lesions of the infrapopliteal segment

The occurrence of vascular trauma due to a range of causes has increased considerably. In this setting, endovascular repair has arisen as a new and less invasive approach. We report the case of three patients with lesions of below-knee vessels that were treated by endovascular procedures.


Introduction
Many factors can interfere with therapeutic success on the treatment of traumatic lesions in infrapopliteal arteries, such as inaccessibility of the vascular lesion, anatomical distortions due to excessive bleeding, and venous hypertension.
The incidence of popliteal artery lesions corresponds to 5-19% of all traumatic arterial lesions.These lesions are related to a high rate of limb amputation, mainly when a concomitant distal artery pattern is observed, resulting in a mortality rate of over 5%.
Experience concerning the endovascular treatment of peripheral vascular disease is still very limited and longterm results are yet to be evaluated.However, this modality of treatment has proven to be feasible and safe in special cases.

Case study
We report the cases of three patients with bulletwounds of below-knee vessels caused by common handgun.
Case 1.A 45-year-old man presented with pain, hematoma and bleeding after right leg penetrating trauma and reduced posterior tibial pulse.Angiography revealed an arteriovenous fistula (Figure 1).

Case 2.
A 20-year-old man presented with bleeding after right leg penetrating trauma and normal distal pulses.Angiography revealed an arteriovenous fistula (Figure 2).Case 3. A 27-year-old man presented with pain and edema 24 hours after left leg penetrating trauma, reduced posterior tibial pulse and fibula fracture.Angiography revealed a pseudoaneurysm of the tibiofibular trunk (Figure 3).
After diagnostic arteriography, wounds were classified as surgically complex and difficult-to-reach lesions.Endovascular treatment was immediately performed using anterograde puncture.
Angiographic control confirmed treatment adequacy with complete exclusion of the fistula and the pseudoaneurysm, as shown in Figures 1B (case 1), 2B (case 2) and 3B (case 3).In all patients distal pulses were observed immediately after the end of treatment.

Discussion
The severity of the ischemia is associated with the extension of the lesion in the affected artery of leg-injured patients.Surgical treatment depends on the patient's general condition and the degree of limb ischemia.Nonconcomitant lesions increase treatment success rates. 1,2successful treatment can be achieved through artery reconstruction, which should be performed up to 6-8 hours after lesion occurrence.[5] Most endovascular experience with arterial trauma results from the treatment of arterial and arteriovenous fistula pseudoaneurysms. 6Potential advantages of endovascular treatment are based on the fact that surgical procedures generally demand longer hospital stay and are associated with higher morbidity rates. 7,8eoperative angiography can accurately estimate the diameter and extension of the injured arterial segments, as well as the nature of the lesion. 9tervention should be performed immediately after diagnosis, reducing complications due to prolonged ischemia time, and in the same room where arteriography was performed. 10,11chnological development in stent diameter and composition has increased the success rate of coronary interventions on endovascular treatment of infrapopliteal diseases.The use of coated stents for definitive repair of traumatic lesions has been associated with less anesthetic use, lower blood loss and reduced exposure. 11,12 our opinion, endovascular repair resulted in shorter duration of surgery and presented lower risk for these patients.