Embolization of a profunda femoris artery injury following battlefield tourniquet application: A case report

Abstract

Background

Vascular trauma of the lower extremity remains a major cause of preventable deaths in combat environments. Among these, injury to the profunda femoris artery is rare due to its deep location in the thigh. Blast injuries in military settings can cause extensive soft tissue and vascular disruption, making both diagnosis and hemorrhage control challenging. In such circumstances, early bleeding control and revascularization are crucial to optimize outcomes. Initial hemorrhage control can begin on the battlefield through appropriate tourniquet application. Definitive management may involve either open surgical or endovascular techniques, with embolization serving a vital role when suitable equipment and hospital resources are available.

Case report

A 37-year-old soldier sustained a blast injury to the right thigh during the Thailand–Cambodia border conflict and self-applied a tourniquet in the field. On arrival, he was hypotensive with diminished distal pulses. Emergency surgical exploration with intraoperative angiography revealed active bleeding from a profunda femoris artery branch. Coil embolization was performed, supplemented with Gelfoam to reinforce thrombosis and ensure complete vessel occlusion. Fasciotomy was performed for compartment decompression. A vacuum-assisted closure dressing was applied for 2 weeks, followed by split-thickness skin graft coverage. At two months, the wound was fully healed, and the patient was able to ambulate independently.

Conclusion

This case highlights the importance of prehospital tourniquet application and a pragmatic, resource-based approach to vascular trauma management in wartime conditions, utilizing available resources to achieve the best possible outcome.

Introduction

Extremity vascular injuries are a leading cause of morbidity and mortality in both civilian and military trauma. Military-related vascular trauma often results from explosive devices or high-velocity firearm injuries, leading to complex tissue and vascular damage that challenges both diagnosis and management [1], [2]. Rapid hemorrhage control is critical in such settings, where prolonged transport time, limited resources, and hemodynamic instability create significant challenges. Prehospital tourniquet application, as one of the essential roles in bleeding control, has been shown to improve limb salvage and reduce mortality in combat casualties [3]. In wartime conditions, open surgical repair remains the mainstay of treatment for extremity vascular injuries. At the same time, endovascular techniques have emerged as effective complementary modalities that enhance treatment outcomes [4].

The Thailand–Cambodia border conflict arose on 24 July 2025, causing casualties among both military personnel and civilians. Injured victims with minor trauma were initially treated at nearby community hospitals, while those with significant injuries were referred to our center, where the mass casualty protocol was activated. We share one case of our patient who sustained a blast injury to the right thigh and applied a tourniquet himself in the field. Sequential evaluation revealed a profunda femoris artery injury (PFA), which was successfully managed with groin exploration and coil embolization. This case illustrates patient management in wartime within a resource-limited setting, utilizing a combination of open surgical and endovascular approaches to achieve the best possible patient outcome.

Case report

The Thailand–Cambodia border conflict erupted on the morning of 24 July 2025, with reports of mass shootings and bomb explosions along the frontier. Our hospital was immediately alerted as casualties with moderate to severe injuries were being transferred to our center. Through the Emergency Medical Service (EMS) onboard CCTV system, our team received real-time updates on patients' clinical status, vital signs, and treatments administered by paramedics. The ambulance locations were also projected onto the emergency department control center screen, allowing us to estimate arrival time.

A 37-year-old soldier sustained penetrating injuries to the right thigh and knee from grenade fragments during combat. He immediately applied a tourniquet to his upper right thigh after observing profuse bleeding from the wound. Continuous gunfire prevented immediate medical assistance from reaching him. During this period, the patient intermittently loosened and retightened the tourniquet every hour. Approximately 90 min after the injury, he was evacuated to a nearby community hospital, which was itself in evacuation mode due to a BM-21 rocket strike hitting in front of the emergency department. Despite this chaotic situation, the healthcare providers were able to deliver initial resuscitative treatment, administering one unit of packed red blood cells and 2000 mL of warmed normal saline. The tourniquet was carefully removed and replaced with a compression bandage to maintain hemostasis. The patient was intubated and transferred to our center for definitive management.

On arrival, approximately 3 h after the injury, the patient was unconscious, with a blood pressure of 60/40 mmHg. Primary survey revealed no immediate life-threatening conditions. Physical examination identified two penetrating wounds: one on the right lateral mid-thigh and another on the right lateral knee. After removal of the compression bandage, slow blood oozing was observed from the mid-thigh wound, while the knee wound showed no active bleeding. The right thigh was markedly tense and swollen. The right femoral and popliteal pulses were palpable, whereas the dorsalis pedis and posterior tibial pulses were diminished but detectable by Doppler. Initial hematocrit was 15%. Given his hemodynamic instability and compromised distal perfusion, the patient was taken directly for emergency surgical exploration with intraoperative angiography.

Through a right groin incision, the common femoral artery (CFA), superficial femoral artery (SFA), and profunda femoris artery (PFA) were exposed and encircled with vascular loops. The CFA was punctured directly with an 18 G needle, and a 0.035-inch hydrophilic guidewire was advanced, followed by placement of a 6-Fr introducer sheath. Initial diagnostic angiography demonstrated normal vascular contours from CFA to the plantar arch without contrast extravasation (Fig. 1a). Based on these findings, both wounds were explored, and hematoma evacuation was performed. Upon extension of the right thigh wound, active bleeding was encountered. Vascular clamps were promptly applied to the encircled CFA, SFA, and PFA; however, bleeding persisted. This suggested an injury to PFA branches, which, due to their extensive collaterals, may continue to bleed despite proximal inflow control.

Fig. 1.

(a) Initial angiogram showed no contrast extravasation from the superficial femoral artery (arrow A) or profunda femoris artery (arrow B).

(b) Selective angiogram after profunda femoris artery cannulation demonstrated contrast extravasation from a profunda femoris artery branch (arrow).

(c) Post–coil embolization image.

(d) Minimal contrast leakage remained after coil embolization (arrow).

(e) Post–gel foam embolization angiogram showed complete occlusion of the injured site.

The sheath was reinserted, and selective catheterization of the PFA was achieved using a 0.035-inch hydrophilic wire and a 5-Fr Bern catheter. Angiography revealed active contrast extravasation from a mid-PFA branch that had not been visible on the initial angiogram (Fig. 1b). Coil embolization was planned; however, only three detachable coils (4 mm × 8 cm, Concerto nylon helical, Metronic) were available on the shelf. Using a 2.7-Fr microcatheter, the coils were deployed sequentially into the outflow tract, aneurysmal sac, and inflow tract of the lesion (Fig. 1c). Post-embolization angiography showed residual slow contrast leakage, suggesting incomplete thrombosis (Fig. 1d). Consequently, Gelfoam was injected over the coils, resulting in complete occlusion of the injured branch while preserving the main PFA trunk (Fig. 1e).

The right thigh remained tense intraoperatively, raising concern for compartment syndrome. The mid-thigh incision was extended to perform a fasciotomy for compartment decompression. The patient was adequately resuscitated intraoperatively with 5000 mL of crystalloid fluids and 7 units of packed red blood cells. He was transferred to the intensive care unit with stable vital signs, without the need for continuous inotropic support. The right limb remained viable, and no further bleeding was observed from the fasciotomy wound.

During the first two postoperative days, serum creatine phosphokinase (CPK) levels progressively increased, consistent with rhabdomyolysis. Adequate crystalloid resuscitation was provided, and fluid balance was closely monitored. On postoperative day 3, after CPK levels declined and the patient's vital signs stabilized, a planned second-look operation was performed to further evacuate the clot. Hemostasis was confirmed, and no additional bleeding source was identified. Vacuum-assisted closure (VAC) therapy was applied and subsequently changed every other day.

Over the following two weeks, the fasciotomy wound demonstrated progressive granulation tissue formation. Afterward, the patient was returned to the operating room for split-thickness skin grafting harvested from the contralateral thigh. The graft successfully covered the fasciotomy site. The patient completed a comprehensive rehabilitation program designed to restore ambulation. At the two-month follow-up, the wound was fully healed, and he was able to ambulate independently without assistance.

Discussion

We presented a case of PFA injury successfully treated with endovascular embolization in a military combat setting. The successful outcome of this case was a result of several critical factors: the effective use of a prehospital self-applied tourniquet, accurate and timely diagnosis of the injury site using intraoperative angiography, and the team's ability to prepare for endovascular intervention despite some equipment limitations.

Prehospital tourniquet application

Tourniquet use has long been established as a cornerstone of hemorrhage control in military combat and can be life-saving in case of massive hemorrhage. The evidence suggests that prehospital tourniquet application in the military reduces mortality, blood transfusion use, and increases limb salvage rates [3], [5]. However, the outcomes are related to tourniquet time, as tourniquet times exceeding 4 h demonstrated significantly lower limb salvage rates and higher mortality compared to those less than 2 h [6]. Longer tourniquet time leads to compartment syndrome, vascular thrombosis, rhabdomyolysis, and irreversible myonecrosis resulting in major tissue loss [7]. Another factor to prevent unnecessary damage from its use is the accuracy of tourniquet application, as the user should be well-trained. The tourniquet should be applied just proximal to the bleeding point and should be loosened every hour to evaluate for ongoing bleeding [7], [8]. Consequently, with this factor, the outcomes of tourniquet application vary among different war settings across regions worldwide, being mainly affected by evacuation time to surgical care and the number of well-trained medics [7], [8], [9].

Our patient unit is a well-trained army for first aid care and is well-equipped with an IFAK (Individual first aid kit) with 1 set of tourniquets included. He was able to accurately apply the tourniquet proximal to the penetrating wound and loosen it himself while waiting for the rescue team. The tourniquet time is reduced as short as possible when it is removed by the primary care team at the first community hospital and replaced with a compression bandage. This emphasizes the importance of both training and the widespread distribution of personal tourniquet devices in combat zones, along with a robust patient transfer system and proper medical staff support.

Role of endovascular modalities in trauma: from civilian to military settings

Vascular injury is a major cause of trauma-related mortality in both civilian and military settings, with extremity trauma accounting for more than half of all vascular injuries. The incidence of vascular injury in combat can reach up to 4–20% of trauma cases, with extremity involvement in about half of these patients [1], [10], [11], [12], [13]. The Western Trauma Association recommends that patients with signs of active bleeding or ischemic penetrating injury undergo urgent operative exploration, while those with equivocal physical findings should receive immediate computed tomography angiography (CTA). Intraoperative angiography is an alternative in cases where CTA is not feasible or in unstable patients [14]. These recommendations, however, are based largely on civilian trauma experience.

In military environments, open surgical repair has traditionally been the mainstay of treatment due to resource limitations and high casualty volumes [1], [2], [10]. CTA is not always available in combat zones, whereas intraoperative angiography has been increasingly adopted since the early 2000s during the Afghanistan–Iraq conflicts, following successful results from civilian settings. In 2004, Fox et al. reported the use of catheter-based angiography in 63% of soldiers after aeromedical evacuation, identifying occult vascular injuries in nearly half (46%) of them [10]. Later, in 2008, Rasmussen et al. documented the first large-scale implementation of endovascular capabilities in a war theater, with 150 catheter-based procedures performed on 139 patients for diagnostic, embolization, and stenting purposes [4]. In the modern era, endovascular management has evolved into an essential component of both diagnosis and treatment of trauma. It plays an important complementary role in detecting missed or occult injuries, especially in cases involving multiple fragmentations from blast injuries [15].

According to the Society of Interventional Radiology, the primary endovascular options for extremity trauma are covered stents and embolization. While the long-term patency of covered stents remains uncertain compared to open repair, their use is particularly advantageous in anatomical regions where surgical exposure is technically challenging and associated with greater morbidity, such as the subclavian, axillary, common iliac, and external iliac arteries. Conversely, embolization is a well-accepted and effective endovascular treatment for hemorrhage arising from the branches or tributaries of extremity vessels [16].

Our patient presented with a diminished peripheral pulse, which may have been obscured by concurrent hypotensive shock, making the physical examination findings equivocal. Since the patient was unstable, immediate exploration was indicated, with intraoperative angiography providing the best possible vascular mapping. The situation represented a mixed civilian–military setting, as the number of cases transferred to our center was not overwhelming. However, the flow of management in the emergency department (ED) was implemented in a wartime setting, reducing door-to-OR time as much as possible to provide more ED space for incoming patients. Fortunately, the setting was well-equipped to provide both open and endovascular treatment.

Profunda femoris artery injury: an uncommon entity with variable treatment options

PFA injury is rare because the vessel lies deep beneath the vastus medialis muscle, protected by surrounding thigh musculature [17]. In civilian settings, most reported cases involve iatrogenic injury during orthopedic procedures or proximal femoral fractures [18]. In military trauma, PFA injury is uncommon and more often associated with gunshot wounds than blast injuries [1], [19]. Diagnosis can be challenging, as bleeding signs may not be apparent compared to injuries of the main axial vessels. Delayed diagnosis is common and often manifests as unexplained anemia, large thigh hematomas, or even traumatic arteriovenous fistulas [20]. Our patient's clinical presentation was similar to many previously reported cases, being equivocal and easily overlooked, which nearly led us to miss the diagnosis on the initial angiogram. Guided by clinical suspicion and intraoperative findings, selective catheterization of the profunda femoris branch was required to reveal the exact site of injury.

Treatment options for PFA injury range from conservative management, open surgical repair, endovascular interventions, to ligation in severe cases. Many published reports of transcatheter embolization for PFA injury are from civilian cases with delayed presentations of pseudoaneurysm or persistent bleeding [20], [21], [22]. In contrast, most military reports describe ligation as the preferred approach. Jonathan et al. reported 18 cases of isolated PFA injury during the Beirut civil war, all treated by ligation, with 10 deaths and 8 amputations [23]. Data from the UK Joint Theatre Trauma Registry and the U.S. Global War on Terror Vascular Injuries Initiative documented 26 cases of PFA injury, all managed with open surgery [1].

In our case, although the patient was injured in a combat setting, there was sufficient time and facility capability to perform embolization, which offered the best possible outcome. The PFA has extensive muscular collaterals, making complete embolization challenging. The “sandwich technique”, which involves occluding both inflow and outflow vessels, is recommended to prevent distal recanalization through collateral channels and delayed bleeding [24]. In this case, coil embolization was performed, with coils deployed precisely at the distal outflow, within the pseudoaneurysm, and at the inflow branch. Since only three coils were available in our setting, incomplete embolization occurred. Consequently, additional Gelfoam was used to reinforce the thrombosis and ensure complete vessel occlusion [25]. This combination enabled us to achieve effective embolization despite the limited availability of coil resources.

Conclusion

This case highlights the evolving role of endovascular therapy in managing vascular trauma in combat environments. Despite the resource limitations typical of military field hospitals, proper prehospital care, an efficient transfer system, and intraoperative endovascular capability can together achieve excellent outcomes.

Profunda femoris artery injury is uncommon in trauma. Treatment options vary, including open surgical repair, endovascular interventions (such as embolization or stenting), or ligation in severe cases. While PFA embolization is rarely reported in combat-related trauma, combining open and endovascular strategies using available resources can provide a practical and effective solution for limb and life-saving management.

CRediT authorship contribution statement

Sineetorn Boonyatikarn: Writing – original draft, Project administration, Investigation, Data curation, Conceptualization. Krit Wangkeeratikarn: Investigation, Formal analysis. Nawin Kuntaraksa: Supervision, Project administration, Investigation. Chawamai Suebnukarn: Supervision, Resources. Pakarat Sangkla: Supervision, Resources. Chanrit Lawthaweesawat: Visualization, Validation, Conceptualization.

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.