Avoiding Pandora's Box: Endovascular Management of Penetrating Iliac Vascular Injury with Concomitant Bowel Injury, A Case Report

Abstract

Background: Penetrating iliac vascular injuries are rare but highly lethal, particularly when associated with concomitant venous injury and intra-abdominal organ damage. The coexistence of bowel injury has traditionally favored open or hybrid repair owing to concerns regarding contamination, infected hematoma, graft infection, and sepsis. However, accumulating evidence supports an expanding role for endovascular techniques in the management of traumatic iliac vascular lesions. We report a case of penetrating internal iliac arteriovenous fistula associated with bowel injury that was successfully managed using a staged endovascular approach while avoiding formal exploration of a stable retroperitoneal hematoma.

Case Presentation: A 20-year-old man sustained a gunshot wound to the right flank and presented with transient hemorrhagic shock. Initial computed tomography demonstrated a retroperitoneal hematoma associated with suspected right internal iliac venous injury, hepatic injury, bowel injury, and a retained pelvic bullet. Following transfer to a Level I trauma center, exploratory laparotomy revealed ileal and sigmoid injuries requiring resection and primary anastomosis. A stable retroperitoneal hematoma with a palpable thrill was identified. To preserve retroperitoneal tamponade and avoid extensive pelvic dissection in a contaminated field, the hematoma was not explored; limited irrigation through the bullet tract and closure of the peritoneal defect were performed instead. Subsequent multiphasic computed tomography confirmed a right internal iliac arteriovenous fistula, which was treated by endovascular occlusion using a vascular plug. The postoperative course was uneventful apart from transient paralytic ileus, and the patient was discharged without hemorrhagic or infectious complications.

Conclusion: This case demonstrates that concomitant bowel injury should not be regarded as an absolute contraindication to endovascular management of penetrating iliac vascular injury. In selected patients, a strategy prioritizing hemorrhage control, preservation of retroperitoneal tamponade, and selective management of infectious risk may provide an effective and less invasive alternative to extensive open vascular reconstruction.