Successful open repair of a civilian low-energy ballistic suprarenal abdominal aortic injury: Case report and literature review

Abstract

Background

Civilian suprarenal abdominal aortic injuries are exceptionally rare and highly lethal, with mortality rates exceeding 80% in high-energy firearm mechanisms. Most patients die before hospital arrival or within the first 24 h. In contrast, low-energy handgun injuries may occasionally be survivable when prompt recognition, damage-control resuscitation, and immediate operative intervention are achieved.

Case presentation

A 45-year-old man sustained a low-energy ballistic wound from a civilian handgun, with entry in the lower right basithoracic region and exit in the posterior left lumbar area. On arrival, he was haemodynamically unstable, intubated, and managed with massive transfusion under damage-control principles. Computed tomography angiography revealed a posterolateral suprarenal aortic laceration with active extravasation, peri-aortic haematoma, and hepatic dome laceration; the projectile was lodged in the left lumbar subcutaneous tissue. Emergency thoraco-phreno-lumbotomy provided direct retroperitoneal supraceliac control (cross-clamp time: 5 min), followed by primary repair with polypropylene suture. A complementary midline laparotomy allowed diaphragmatic closure and hepatic haemostasis.

Results

The patient was discharged from the intensive care unit on postoperative day 3 with restored intestinal transit. The postoperative course was uneventful, and at one-month follow-up he remained clinically stable.

Conclusion

In unstable patients with complex anatomy, immediate supraceliac control via a dual surgical approach can be life-saving when endovascular options are not feasible.

Highlights

• •Single-stage operative management of combined vascular and visceral injury
• •Early, targeted resuscitation facilitated rapid haemodynamic stabilisation
• •Swift supraceliac aortic control minimised ischaemia and blood loss
• •Open surgical repair remains the gold standard for suprarenal abdominal aortic trauma
• •International guidelines endorse thorough exploration with definitive repair

Introduction

Penetrating suprarenal abdominal aortic injuries from civilian firearms are exceptionally rare. Contemporary evidence from systematic reviews and trauma registries confirms that they remain among the most lethal vascular injuries, with mortality rates exceeding 85–90% in high-energy rifle wounds, most deaths occurring before hospital arrival or within the first 24 h [1]. In contrast, low-energy handgun injuries, though uncommon, may occasionally be survivable when bleeding is contained and rapid operative control is achieved. Their proximity to major visceral branches and the risk of rapid exsanguination leave only minutes for effective intervention, making prompt diagnosis and decisive haemorrhage control essential [2].

While endovascular repair has transformed the management of many aortic pathologies, its role in unstable patients with unfavourable anatomy or concomitant intra-abdominal injuries remains limited. A recent systematic review highlights the importance of immediate supraceliac aortic control, minimisation of cross-clamp time, and complete abdominal exploration in unstable patients, while reserving endovascular strategies for haemodynamically stable cases with suitable anatomy [3].

Historical data, such as the series by Demetriades et al. (1996), reported mortality rates above 80% for penetrating aortic injuries (87.5% for gunshot wounds, 64.7% for knife injuries). Contemporary registry analyses confirm that lethality remains extremely high, frequently approaching 85–100% in suprarenal injuries and high-energy firearm mechanisms, although incremental improvements are observed in patients who survive to hospital admission and undergo timely surgical or endovascular intervention [4], [5], [6].

We report a rare case of survivable suprarenal abdominal aortic injury caused by a low-energy ballistic wound from a civilian handgun, managed through a dual open surgical approach enabling simultaneous vascular and visceral repair. This case illustrates a reproducible, evidence-aligned pathway for a presentation that is otherwise frequently fatal and underscores the continuing relevance of open techniques in anatomically complex, unstable trauma.

Case presentation

A 45-year-old man with a history of treated psychosis sustained a ballistic injury from a low-energy handgun. On arrival to the intensive care unit (ICU) he was haemodynamically unstable (blood pressure 80/50 mmHg; heart rate 128 bpm), intubated for agitation and mechanically ventilated. Peripheral pulses were palpable. Abdominal examination revealed a soft, non-distended abdomen with an entry wound in the lower right anterior thoraco-basal region and an exit wound in the posterior left lumbar region.

Initial resuscitation followed damage-control resuscitation principles with a limited crystalloid bolus, early activation of the massive transfusion protocol, and balanced transfusion of packed red blood cells and fresh frozen plasma. Initial haemoglobin was 6.1 g/dL. After a transient haemodynamic response to resuscitation, a focused contrast-enhanced computed tomography angiography (CTA) was obtained to localise the injury and plan the operative approach.

CTA demonstrated a left posterolateral defect of the suprarenal abdominal aorta with active arterial extravasation and a peri-aortic haematoma extending toward the iliac bifurcation (Fig. 1). Additional findings included a low-volume retroperitoneal haematoma, a right anterior abdominal wall defect with adjacent soft-tissue infiltration along the bullet tract, and a subcapsular hypodense lesion of the hepatic dome (segments I and VIII) measuring 65 × 37 mm with small intralesional air bubbles and mass effect on the suprahepatic veins, consistent with a hepatic laceration. The hepatic arteries were patent. Low-volume haematomas were present in the perihepatic, peri-splenic, and bilateral paracolic gutter regions without pneumoperitoneum. The projectile was lodged in the subcutaneous tissue of the left lumbar region without further migration (Fig. 2).

Fig. 1.

Contrast-enhanced computed tomography angiography in axial (A), coronal (B), and sagittal (C, D) planes demonstrating a posterolateral wall laceration of the suprarenal abdominal aorta (arrow), with active contrast extravasation.

Fig. 2.

Axial contrast-enhanced computed tomography angiography showing left retroperitoneal haematoma (yellow arrow) and subcutaneous bullet (blue arrow) in the left lumbar area.

The interval from hospital admission to skin incision was 2 h, which included initial stabilisation, activation of the massive transfusion protocol, preparation for theatre and the focused CTA. Emergency surgery was performed under general anaesthesia by the vascular team. A left thoraco-phreno-lumbotomy centred on the 11th rib provided direct retroperitoneal access to the posterior suprarenal aorta. Wide left retrocolic and retro-renal dissection exposed the aorta; division of the left diaphragmatic crus permitted supraceliac control by gentle retraction of the left pleura.

On evacuation of a large peri-aortic haematoma, active arterial bleeding from a 2-cm posterolateral aortic laceration above the renal arteries was identified (Fig. 3). After administration of half-dose systemic heparin, proximal control was obtained by clamping the descending thoracic aorta and the infrarenal aorta. The aortic defect was then repaired with continuous 4–0 polypropylene suture while the aorta remained clamped; supraceliac cross-clamp time was limited to 5 min. The clamps were released, and meticulous haemostasis was achieved on declamping.

Fig. 3.

Intraoperative view of the suprarenal abdominal aorta (1) and right renal artery (2), demonstrating the site of aortic laceration (arrow) prior to definitive repair.

A complementary supra- and infraumbilical midline laparotomy was then performed to complete intraperitoneal exploration and manage associated injuries. The round ligament was ligated to facilitate hepatic retraction; a haematoma within the pars flaccida was incised and drained. No gastric injury was identified after division of the gastrocolic ligament and entry into the lesser sac. A diaphragmatic defect was closed with interrupted 1-silk sutures. Hepatic bleeding was controlled by targeted electrocoagulation of focal parenchymal bleeding, direct compression and selective capsule suturing; no Pringle manoeuvre was required (Fig. 4). Total operative time was 6 h.

Fig. 4.

Intraoperative view illustrating the trajectory of the bullet through the hepatic parenchyma (arrow).

Postoperative management included placement of a left thoracic drain and two abdominal drains in the paracolic gutter and inter-hepato-diaphragmatic space. Incisions were closed in layers. Drains were removed after 48 h. The patient left the intensive care unit on postoperative day 3 with restored intestinal transit. The immediate postoperative course was uneventful; at one-month clinical follow-up the patient remained clinically stable (no postoperative imaging available).

Discussion

Civilian suprarenal abdominal aortic injuries are uncommon and carry a high risk of early mortality. Their deep retroperitoneal location and proximity to major visceral branches complicate diagnosis and surgical exposure, so survival depends on rapid recognition, aggressive resuscitation and decisive operative control [2]. In large civilian series, abdominal aortic injuries represent approximately 5% of penetrating abdominal vascular trauma, most often accompanied by visceral damage to the bowel, liver, spleen or kidney, which significantly increases the risk of sepsis, multi-organ failure and death [5].

Current ESVS (2025) and AAST–WSES guidelines recommend immediate proximal control, minimisation of cross-clamp time, and complete exploration in unstable patients, while reserving endovascular repair for stable patients with favourable anatomy and no associated injuries requiring laparotomy [3], [7]. These principles are consistent with the AAST/ACS protocol for damage-control resuscitation, which further highlights the need for rapid haemorrhage control and physiological optimisation before definitive repair [8].

In this case the aortic breach was posterior and the projectile followed a retroperitoneal trajectory, so we elected a left thoraco-phreno-lumbotomy to obtain direct retroperitoneal access to the posterior suprarenal abdominal aorta and permit supraceliac clamp placement without immediate entry into the peritoneal cavity. This targeted exposure allowed prompt proximal control of the bleeding source while reducing the risk of contaminating a distended or blood-filled peritoneal cavity.

Minimising supraceliac cross-clamp time is essential to limit visceral ischaemia and reperfusion injury. In our patient the clamp time was 5 min, shorter than the 8 min reported in a comparable open suprarenal repair series, and this brief interval together with meticulous haemostasis and optimisation of haemodynamics likely contributed to preserved visceral perfusion and an uncomplicated early postoperative course [9]. Perioperative measures to mitigate ischaemia–reperfusion, including rapid clamp release when feasible, careful temperature and haemodynamic management and staged restoration of flow, remain important adjuncts.

Endovascular tools, including resuscitative balloon occlusion and stent grafting, have expanded options for junctional and thoracic vascular injuries. Their utility in suprarenal aortic disruption is limited by the proximity of visceral branches, the frequent absence of suitable landing zones and the common need for concurrent laparotomy to address associated intra-abdominal injuries. Hybrid strategies may be appropriate in selected stable patients with favourable anatomy, but in unstable, multi-injured patients a prompt open approach that secures proximal control remains the most reliable life-saving option [10], [11], [12].

The staged strategy used here, consisting of rapid retroperitoneal supraceliac control via thoraco-phreno-lumbotomy followed by a midline laparotomy for intraperitoneal exploration and visceral repair, exchanges the morbidity of a second incision for faster targeted vascular access and reduced intraperitoneal contamination. Advantages include direct access to posterior aortic lesions, shortened time to proximal control in selected anatomies and the ability to prioritise haemorrhage control before definitive visceral repairs. Limitations include the need for specific surgical expertise in retroperitoneal exposure, potential logistical complexity of two operative fields and the added morbidity of two incisions; these trade-offs should be weighed against patient physiology and local resources. The patient's uneventful postoperative course, with drain removal and ICU discharge by day 3, underscores the benefit of expeditious intervention and meticulous haemostatic technique. Although no follow-up imaging was performed, sustained clinical improvement without signs of ischaemia was consistent with durable repair and preserved collateral circulation.

Penetrating aortic trauma also carries risks of delayed complications such as projectile migration, bullet embolization [13], and late post-traumatic pseudoaneurysm formation [14]. These risks underscore the importance of thorough intraoperative exploration and structured long-term imaging surveillance when feasible.

In summary, when endovascular options are unsuitable because of anatomy or concomitant injuries, a well-planned open strategy that prioritises rapid retroperitoneal proximal control and minimises clamp time can achieve haemorrhage control, limit visceral ischaemia and produce favourable early outcomes in anatomically complex suprarenal aortic injury.

Conclusion

High-energy civilian ballistic suprarenal abdominal aortic injuries are rare but can be survivable with prompt, decisive management. In unstable patients, immediate supraceliac control with clamp times under 5 min, combined with a dual surgical approach, enables simultaneous vascular and visceral repair. When executed in accordance with current vascular trauma guidelines, this strategy offers a reproducible and effective pathway for managing an otherwise frequently fatal presentation. This case underscores the continuing relevance of open surgical repair in anatomically complex, unstable trauma, even in the era of expanding endovascular options.

CRediT authorship contribution statement

Imane Boulahroud: Writing – review & editing, Writing – original draft, Visualization, Validation, Supervision, Software, Resources, Project administration, Methodology, Investigation, Funding acquisition, Formal analysis, Data curation, Conceptualization. Imane Halaouate: Investigation, Formal analysis, Data curation. Saleh Khader: Resources, Investigation, Data curation. Tarik Bakkali: Validation, Supervision. Ayoub Bounssir: Validation, Supervision. Samir El Kheloufi: Validation, Supervision. Brahim Lekehal: Validation, Supervision.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.