Non-standard surgical treatment of a shrapnel wound of the thigh with damage of the vascular bundle and embolism of the arteries of the leg

This clinical case report describes the surgical management of a shrapnel wound to the thigh with associated vascular damage. A 55-year-old male soldier sustained a shrapnel injury to his left thigh during a combat mission. A tourniquet was applied immediately at the point of injury to control life-threatening bleeding. Upon evacuation to the nearest military field hospital (MFH), ultrasound examination revealed a rupture of the superficial femoral artery (SFA) and superficial femoral vein (SFV), along with an embolism of the posterior tibial artery and anterior tibial artery. Acute ischemia of the left lower limb, classified as grade 2b according to the Fontaine-Pokrovsky classification, was diagnosed. The case was complicated by a multi-level vascular injury, combining a proximal rupture of major vessels and distal embolism, which posed a significant threat of irreversible ischemia. Given the imminent risk of limb loss and the impossibility of evacuation to a higher-level multi-specialty military hospital, a decision was made to perform emergency surgery at the MFH. The surgical strategy involved a comprehensive set of reconstructive procedures on both the arteries and the vein. The intervention included resection of the SFA with an end-to-end anastomosis, repair of the SFV wall defect, removal of a thromboembolus from the popliteal artery bifurcation, and popliteal-to-distal posterior tibial artery bypass grafting using a reversed great saphenous vein. The postoperative course was uneventful, with complete resolution of acute ischemic symptoms and primary healing of the surgical wounds. The successful outcome demonstrates the feasibility of performing complex revascularization procedures in a military field hospital setting, even without on-site angiographic support. The surgical care provided at the MFH stage ultimately prevented limb amputation and subsequent disability.

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