Multimodal Imaging of a Post-Traumatic Cervical Arteriovenous Fistula with Concomitant Pseudoaneurysm After a Gunshot Wound Treated with a Covered Stent-Graft

Background: Arteriovenous fistula is an abnormal connection between an artery and a vein. Post-traumatic fistulas are uncommon and usually occur after penetrating injuries, including gunshot wounds. Cervical arteriovenous fistulas are particularly rare and may coexist with a pseudoaneurysm, creating diagnostic and therapeutic challenges because of the proximity of major vascular, neurological, and aerodigestive structures. In hemodynamically stable patients, the limited external appearance of the wound may underestimate the extent of internal vascular injury; therefore, imaging is central to diagnosis and treatment planning. Case Presentation: We report the case of a 49-year-old man who presented to the emergency department with a gunshot wound to the left side of the neck. Computed tomography angiography (CTA) demonstrated a vascular injury adjacent to the left common carotid artery (LCCA), and further evaluation revealed an arteriovenous fistula (AVF) between the LCCA and the left internal jugular vein (LIJV), coexisting with a pseudoaneurysm of the LCCA. Doppler ultrasonography (DUS) identified an arterial wall defect and extrinsic compression of the LCCA by the hematoma. Selective digital subtraction angiography (DSA) confirmed an AVF between the LCCA and the LIJV, coexisting with an LCCA pseudoaneurysm. A covered stent-graft was implanted and completion angiography confirmed exclusion of both lesions with preserved patency of the LCCA. Discussion: This case demonstrates the complementary value of CTA, DUS and DSA in penetrating neck trauma. CTA provided rapid cross-sectional assessment of the injury trajectory and associated lesions, DUS added information on the arterial wall and local hemodynamic consequences, and DSA confirmed arteriovenous shunting while enabling immediate endovascular treatment. Conclusions: In hemodynamically stable patients with penetrating neck trauma, CTA should be considered when the wound trajectory approaches major vessels, even in the absence of active external bleeding. DUS and DSA may provide complementary information for lesion characterization and procedural planning. Covered stent-graft implantation may be a feasible reconstructive option in carefully selected patients.