In a detailed case report, Patel et al. examine the management of a traumatic arteriovenous fistula (AVF) in the popliteal segment of a 35-year-old male. This patient presented with a painful swelling at the back of his left knee following arthroscopic cruciate ligament repair after a knee injury. The authors conducted thorough diagnostic investigations, identifying a post-traumatic AVF, and subsequently performed endovascular treatment using two balloon-expandable stent grafts.

A review of the literature on traumatic AVF treatments reveals only about 20 publications addressing a handful of cases, and notably, no long-term follow-up data. This highlights the limited scientific foundation for treating post-traumatic AVFs.

Broader investigations into popliteal injuries, including treatment of popliteal injuries in general, yield more information. Studies by Potter et al. [1] and Abdou et al. [2] analyzed outcomes from the American National Trauma Data Bank (NTDB), examining 2,873 and 3,698 patients, respectively, although only a small fraction underwent endovascular treatment (5.7% and 5.3%). Recent reviews by Vaidya et al. [3] and Qi et al. [4] in 2024 include meta-analyses comparing open and endovascular treatments for popliteal injuries. However, the quality of data in these studies is limited due to the studies included. Qi et al.’s meta-analysis primarily relies on NTDB data, which only tracks in-hospital outcomes, failing to provide insights into long-term vascular reconstruction performance. Vaidya et al.’s review involves 864 patients, but 3 out of 8 studies on endovascular treatment lacked follow-up, and the other studies (56 patients) had a mean follow-up of just 33 months.

Overall, these studies indicate minimal differences between open and endovascular techniques for popliteal injuries in the short perspective. However, the significant issue of long-term patency with endovascular methods remains largely unaddressed. It is therefore concerning that many authors still describe the endovascular approach as “promising.”

A notable study by Jiang et al. in 2020 [5] evaluated 46 patients with popliteal injuries treated with 41 stent grafts, reporting a primary patency rate of 75.3% at 12 months, 61.9% at 24 months, and 55.7% at 48 months, with an assisted patency rate of 85.2% at 48 months. These long-term results are strikingly similar to those for other popliteal stent graft treatments. In line with Jiang et al.’s result, Saxon et al. [6] reported a primary patency of only 55% after four years for stent grafts used in popliteal artery aneurysm treatments, while Cervin et al. [7] found a 44% occlusion rate after stent grafting compared to 17.6% for open bypass surgery at three years.

Given these findings, I express concerns about using a stent graft in a young, healthy patient. In cases of popliteal AVF presenting electively, my concerns intensify. If endovascular treatment is considered, a self-expanding stent graft—exclusively used in the studies cited—should be the choice.

Open surgical repair of a traumatic AVF in the popliteal segment is typically straightforward, raising the question of why a young patient should face the risks of stent graft occlusion. Reporting only in-hospital or six-month results seems inadequate, especially for a 35-year-old man whose long-term function is at stake.

I strongly believe that stent grafts in highly mobile arteries, such as the popliteal artery, should be reserved for young patients facing immediate life-threatening conditions or, rather, used temporarily, with plans for open reconstruction. Additionally, I urge the authors to ensure that their patient undergoes long-term ultrasound monitoring to facilitate timely management of the stent graft occlusion.