An exsanguinating arterial-vesical injury after a gunshot wound to the lower extremity: a case report

Arterial-vesical injuries are rare entities, often presenting with bladder distension, bright red hematuria, and clot retention. The few cases reported in the literature typically occur following traumatic injuries to the groin or pelvis. We present a case of an arterial and vesical injury with decompression through the bladder. Our patient was a 21-year-old man who presented to a level I trauma center as a high-level activation trauma case following a single gunshot wound to the left lateral thigh. Upon arrival, the patient's systolic blood pressure was 80/50 mmHg. A pelvic x-ray revealed ballistic fragments in the pelvis. Physical examination showed a 1+ palpable left dorsalis pedis pulse. He underwent a formal trauma laparotomy, which did not identify any acute injuries. Concurrently, his Foley catheter exhibited bloody output with bladder distension. Following continuous bladder irrigation, he had profuse sanguineous output. Angiography revealed a complete disruption of the profunda femoris artery. An open exploration of the femoral canal was performed to achieve proximal control of the common femoral artery. We identified a 3-cm longitudinal injury to the profunda femoris artery and an obliterated femoral vein, both of which were ligated, resulting in decreased bladder exsanguination and hemodynamic stabilization. Consistent with the limited published cases of arterial-vesical fistula, our patient presented after a traumatic groin injury. Maintaining a high index of suspicion for communication between the thigh and extraperitoneal space due to projectile trajectory remains crucial to successfully managing these challenging injuries.