Peripheral vascular injury is a severe although infrequent complication of acute trauma (1). Its incidence has increased due to the rise in workplace accidents, traffic incidents and firearm assaults (2). Regardless of its etiology, the vessels in the lower limbs are usually the most affected (3), particularly the femoral artery and vein (4). Although the mortality rate for these injuries does not exceed 10% (5), the potential functional repercussions can be incapacitating (6), both due to neurological sequelae and in cases of limb loss through amputation (7). Although historically, the latter has been the most effective treatment for the survival of patients (8), since the late 20th century, the therapeutic approach of ‘damage control’ has been adopted, aiming to preserve both life and limb functionality (9). Prolonged ischemia is the main predictor for amputation (10), this approach is indicated in up to 85% of cases where ischemia lasts longer than six hours (11). Therefore, ensuring rapid reperfusion is an imperative goal in the treatment of vascular injury (12). This can be achieved through the placement of stents, bypasses (13) or venous grafts during the intraoperative period (14). However, on some occasions, the severity of the injury requires multidisciplinary management causing delays in revascularization (15). Providing temporary relief from ischemia through shunts helps maintain tissue perfusion until the patient stabilizes (16), at which point definitive treatment can proceed (17). This approach improves the overall prognosis of critically ill patients or those with complex vascular trauma (18), reducing mortality while preserving the limb (19,20). The present study describes the case of a patient with severe vascular injury, who despite an unstable hemodynamic state, was successfully treated using this damage control strategy.

A 28-year-old male with no significant medical history, was admitted to the Emergency Department of Hospital Regional Universitario (Colima, Mexico) due to a hemorrhagic injury in the right lower limb secondary to a firearm wound, with a progression time of 1 h and 20 min. In the initial assessment, the patient was found to be hemodynamically unstable, presenting with grade IV hypovolemic shock, with an entry wound on the anteromedial side of the right leg and an exit wound on the lateral side. A pulsatile and expanding hematoma was observed in the area, along with a gaping wound with musculoskeletal tissue loss secondary to short blunt trauma. Absent pulses were noted in the dorsalis pedis, posterior tibial and anterior tibial arteries; the affected limb was pale and poikilothermic, with a capillary refill time of 6 sec. Sensitivity and muscle strength were preserved and the revised trauma score (RTS) was calculated at 7.8408. Management was initiated with oxygen therapy, hyperhydration, the transfusion of blood products, as well as antibiotics (cclindamycin: 600 mg, i.v. administration, every 8 h; and cefixime: 2 g i.v. administration, every 12 h) and analgesia (buprenorphine: 0.3 mg i.v. administration, every 8 h, combined with the continuous intravenous infusion of paracetamol at a dose of 1 g). Following the aforementioned, the decision was made to take the patient urgently to the operating room for vascular exploration.

The present study described the case of a young male patient with a firearm-induced vascular injury in the lower limb. The complication resulted in grade IV hypovolemic shock and metabolic acidosis, necessitating urgent intervention for hemostatic control. However, due to the complexity of the injuries and the presence of ischemia, a damage control strategy was implemented, leading to limb preservation and a favorable postoperative recovery following the definitive intervention.

The case described herein highlights the complexity of limb salvage decisions in acute vascular injuries, where the option between amputation and preservation depends on multiple factors, including the severity of ischemia and the patient's overall condition (21). The patient had no significant medical history, and no fractures were identified. Despite this, the development of grade IV hypovolemic shock and metabolic acidosis posed challenges in patient management, as these conditions require immediate surgical intervention in such injuries (22).

Although simple indices, such as the mangled extremity score (MES) or the mangled extremity severity index (MESI), can help determine the most appropriate treatment for acute vascular injuries (23), functional and individual patient factors should also be considered. While survival rates following amputation can reach 100%, depending on the technique used and the condition of the patient (24), the long-term consequences are critical. Studies have reported substantial psycho-emotional distress, increased mobility-related costs and disruptions in interpersonal relationships, particularly when amputation results from traumatic events (25), as in the case described herein. Additionally, phantom limb pain, somatosensory alterations (26) and weight gain (27) are commonly reported following amputation. These negative effects can be mitigated through early rehabilitation, physiotherapy, and prosthesis adaptation (28). However, previous research has indicated that while cerebral cortex reorganization occurs following upper limb amputations, it is less effective in lower limb amputations. Consequently, symptoms such as phantom limb pain, reduced dexterity and impaired balance tend to be more persistent (14).

Conversely, limb salvage reduces the risk of long-term complications, such as cardiovascular diseases and arterial disease (29). Although not always possible, the use of tools such as vascular shunts can extend the time window for intervention (30). Additionally, the use of grafts as in the case in the present study, both anatomical and extra-anatomical, can improve the condition of the patient until the definitive intervention (31), preserving the affected limb and resulting in lower rates of future reinterventions (32).

In the patient in the present study, factors such as a young age and the absence of comorbidities supported the decision to manage the vascular injury with a damage control approach. This choice was based on the greater capacity of the patient for recovery and tissue regeneration. The literature emphasizes that damage control techniques can be particularly beneficial in such cases, as they allow for the restoration of distal perfusion through temporary vascular shunts prior to definitive revascularization. This is particularly relevant when the duration of ischemia is <6 h (2,33), as observed in the patient in the present study. Indeed, reports of similar cases have described favorable outcomes with the use of damage control strategies in young patients. In a previously documented case, a young male patient sustained severe vascular trauma following a shark attack, resulting in multiple fractures of his right pelvic limb and hemorrhage leading to hypovolemic shock (34). Following initial management, a damage control approach was selected, with intervention on the popliteal artery and vein. Following reconstruction, limb functionality was preserved without neurological or vascular deficits (34). Similarly, another study described the case of a young female patient who sustained a tibia and fibula fracture in her left leg after being struck by a vehicle; in that case, limb preservation was achieved through direct vascular repair of the popliteal vessels (35). Likewise, in another study, a 33-year-old male presented with a Gustilo-Anderson type IIIA fracture of the distal tibia and fibula, accompanied by a closed calcaneus fracture and tibial nerve transection (36). Although amputation was considered, the decision was made to preserve the limb using a nerve allograft. At 29 months of post-operative follow-up, the patient demonstrated satisfactory functional recovery without the need for major revision, grafting, arthrodesis or amputation (36).

Furthermore, in support of the damage control approach, a recent meta-analysis found that patients who underwent limb salvage demonstrated improved psychological well-being compared to those who underwent amputations, despite the possibility of reinterventions and a prolonged recovery period (37). Additionally, the Lower Extremity Assessment Project (LEAP) study revealed that although long-term functional outcomes may be similar between both strategies, limb reconstruction is generally preferred by patients due to the negative psychosocial effects of amputation, which include depressive disorders and anxiety (38).

Moreover, while immediate amputation reduces the risk of developing late complications, such as infections and multiple reinterventions, recent research has highlighted that the use of temporary vascular shunts and delayed revascularization can significantly improve the success rate of limb salvage without compromising patient safety (33). There is evidence to suggest that careful selection of candidates for the damage control strategy can optimize outcomes, avoiding the adverse consequences associated with amputation, such as phantom limb pain and difficulty adapting to prostheses (23).

However, it is important to acknowledge the inherent risks associated with this approach, many of which arise during the procedure itself. Among the most frequent complications are vascular thrombosis, infections and the development of anastomotic stenosis, all of which can jeopardize limb viability (39). Fortunately, in the case described herein, the use of heparin and the close monitoring of the progress of the patient reduced the risk of thrombosis during the intraoperative period until the definitive surgical approach could be implemented. Moreover, the risk of anastomotic stenosis can be mitigated through surgical techniques, such as balloon angioplasty, stent placement, or the use of temporary shunts in selected cases. These shunts help prolong vascular patency (40), which is why these were implemented in the patient in the present study, facilitating stabilization and enabling a subsequent definitive intervention.

In conclusion, based on the evidence presented, the damage control strategy emerges as a highly favorable approach in cases of acute vascular injury, balancing the risks and benefits associated with limb salvage. Finally, it is noteworthy that the patient exhibited satisfactory progress 3 months following the intervention, at which point full limb functionality was restored with no apparent clinical deficits. Despite this positive outcome, future studies should consider longer follow-up periods and imaging evaluations to assess the long-term efficacy of the damage control strategy.