Multi-slice CT angiography for arterial evaluation in the injured lower extremity

Use of Computed Tomography Angiography to Predict Complications in Tibia Fractures: A Multicenter Retrospective Analysis

OBJECTIVES

To assess the ability of computed tomography angiography identified infrapopliteal vascular injury to predict complications in tibia fractures that do not require vascular surgical intervention.

DESIGN

Multicenter retrospective review.

SETTING

Six Level I trauma centers.

PATIENTS AND INTERVENTION

Two hundred seventy-four patients with tibia fractures (OTA/AO 42 or 43) who underwent computed tomography angiography maintained a clinically perfused foot not requiring vascular surgical intervention and were treated with an intramedullary nail. Patients were grouped by the number of vessels below the trifurcation that were injured.

MAIN OUTCOME MEASUREMENTS

Rates of superficial and deep infection, amputation, unplanned reoperation to promote bone healing (nonunion), and any unplanned reoperation.

RESULTS

There were 142 fractures in the control (no-injury) group, 87 in the one-vessel injury group, and 45 in the two-vessel injury group. Average follow-up was 2 years. Significantly higher rates of nerve injury and flap coverage after wound breakdown were observed in the two-vessel injury group. The two-vessel injury group had higher rates of deep infection (35.6% vs. 16.9%, P = 0.030) and unplanned reoperation to promote bone healing (44.4% vs. 23.9%, P = 0.019) compared with controls, as well as increased rates of any unplanned reoperation compared with control and one-vessel injury groups (71.1% vs. 39.4% and 51.7%, P < 0.001), respectively. There were no significant differences in rates of superficial infection or amputation.

CONCLUSIONS

Tibia fractures with two-vessel injuries were associated with higher rates of deep infection and unplanned reoperation to promote bone healing compared with those without vascular injury, as well as increased rates of any unplanned reoperation compared with controls and fractures with one-vessel injury.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Rethinking protocolized completion angiography following extremity vascular trauma: A prospective observational multicenter trial

BACKGROUND

Completion angiography (CA) is commonly used following repair of extremity vascular injury and is recommended by the Eastern Association for the Surgery of Trauma practice management guidelines for extremity trauma. However, it remains unclear which patients benefit from CA because only level 3 evidence exists.

METHODS

This prospective observational multicenter (18LI, 2LII) analysis included patients 15 years or older with extremity vascular injuries requiring operative management. Clinical variables and outcomes were analyzed with respect to with our primary study endpoint, which is need for secondary vascular intervention.

RESULTS

Of 438 patients, 296 patients required arterial repair, and 90 patients (30.4%) underwent CA following arterial repair. Institutional protocol (70.9%) was cited as the most common reason to perform CA compared with concern for inadequate repair (29.1%). No patients required a redo extremity vascular surgery if a CA was performed per institutional protocol; however, 26.7% required redo vascular surgery if the CA was performed because of a concern for inadequate repair. No differences were observed in hospital mortality, length of stay, extremity ischemia, or need for amputation between those who did and did not undergo CA.

CONCLUSION

Completion angiogram following major extremity injury should be considered in a case-by-case basis. Limiting completion angiograms to those patients with concern for an inadequate vascular repair may limit unnecessary surgery and morbidity.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level III.

Team Approach: Treatment of Traumatic Dislocations of the Knee

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Traumatic knee dislocations are complex injuries that can be associated with compromise of the neurovascular structures about the knee.

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Various classification systems for knee dislocations exist in the literature but should be used with caution as a prognostic tool because many knee dislocations fit into more than 1 category.

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Special populations of knee dislocations, such as obese patients and high-velocity mechanism injuries, require additional caution during the initial evaluation for possible vascular injuries.

Imaging of penetrating vascular trauma of the body and extremities secondary to ballistic and stab wounds

In the United States, gunshot wounds (GSWs) have become a critical public health concern with substantial annual morbidity, disability, and mortality. Vascular injuries associated with GSW may pose a clinical challenge to the physicians in the emergency department. Patients demonstrating hard signs require immediate intervention, whereas patients with soft signs can undergo further diagnostic testing for better injury delineation. Although digital subtraction angiography is the gold standard modality to assess vascular injuries, non-invasive techniques such as Doppler ultrasound, computed tomography angiography, and magnetic resonance angiography have evolved as appropriate alternatives. This article discusses penetrating bodily vascular injuries, specifically ballistic and stab wounds, and the corresponding radiological presentations.

Role of imaging in penetrating vascular injuries of the craniocervical region

Penetrating vascular injury has become the topic of interest with increased gun violence in the United States. The radiologist plays a crucial role in establishing and systemizing the signs of vascular injury such as intimal flap, dissection, pseudoaneurysm, rupture, and arteriovenous fistula. Various imaging techniques such as ultrasound Doppler, computed tomographic angiography (CTA), magnetic resonance angiography, and conventional angiography are being employed based on clinical recommendations. Of all the techniques, CTA has been shown to embrace a promising role in identifying vascular injuries with superior sensitivity, specificity, and accuracy. An acquaintance of the imaging features has been shown to improve the approach to trauma patients in clinical settings. This article details the imaging modalities and the features of the head-and-neck penetrating vascular injury.

Management of Complex Upper Extremity Trauma with Associated Vascular Injury

Introduction Combined soft tissue and vascular injuries of the upper extremity pose several challenges at once to the plastic surgeon. Many decisions have to be taken urgently that will influence the salvage or amputation of the affected extremity. The aim of this article was to provide an evidence-based outline for the management of such injuries. Learning objectives of this article are as follows: (1) approach to a patient with upper extremity composite tissue and vascular injury presenting to the emergency, (2) decision-making as to when to salvage and when to go for amputation of the traumatized upper extremity, (3) role of imaging in emergency situation, (4) role of fasciotomy, (5) intraoperative sequencing of steps, and (6) options for vascular reconstruction and the flaps used for coverage. After reading this article, the reader should have a clear understanding of the management of vascular injury in a patient with composite defects of upper extremity.

Utility of computed tomography angiography in traumatic lower limb injury: Review of clinical impact in level 1 trauma centre

INTRODUCTION

CT angiography (CTA) is efficient and accurate in detecting lower limb vascular injury in the setting of trauma (1-6). Less clear is the in-practice correlation between appropriate indications for these examinations and subsequent clinical impacts.

MATERIALS AND METHODS

All CT leg angiography acquired from January 2016 through April 2019 were reviewed via retrospective search. Studies not acquired for trauma were excluded. Imaging and reports were reviewed to assess for vascular injury. Electronic medical records were reviewed to assess the presence or absence of classical 'hard' or 'soft' signs of vascular injury and whether vascular intervention was undertaken.

RESULTS

A total of 347 lower limb injuries were identified in 273 men and 74 women. Mean age was 41.5 years ranging from 15-95 years. 268 cases were fractures with 177 open injuries. 301 of injuries were secondary to blunt trauma, 31 penetrating injury occurred and 15 cases were ascribed to blast/gunshot injury. 74 (21.3%) studies were deemed to have a positive finding of vascular injury, 249 (71.8%) were reported as negative and 24 (6.9%) were indeterminate. Of the cases with positive findings, 26 underwent intervention (7.4% of all patients undergoing CTA). No patients with negative CTA required intervention, while three (3, 0.8% of total) with indeterminate findings required intervention. Where there were no clinical signs (absence of any hard or soft signs) 249 CTA's were performed and none required any form of intervention.

CONCLUSION

In the absence of clinical signs of vessel injury, CT angiography is unlikely to demonstrate vascular injury requiring intervention in the setting of lower limb trauma.

Lower extremity CT angiograms and their effect on kidney function in orthopedic trauma patients

OBJECTIVES

To evaluate the frequency of unindicated CT Angiograms (CTAs) obtained at our institution and the association between contrast-induced nephropathy (CIN) and decreased glomerular filtration rate (GFR).

DESIGN

Retrospective case series SETTING: Academic Level 1 trauma center PATIENTS/PARTICIPANTS: Patients aged 18 years and older with CTAs following lower-extremity (LE) trauma between 2010-2018.

INTERVENTION

CTAs performed in 257 LEs and corresponding pre- and post-contrast renal function labs in these LE trauma patients.

MAIN OUTCOME MEASUREMENTS

The primary outcome was vascular injury requiring intervention. Secondary outcomes were CIN and the association of CIN with decreased GFR and injury severity score (ISS).

RESULTS

There was no indication (no hard signs of vascular injury, ABI>0.9) for CTA in 121 patients (61%) of the total 199 patients. Of the 78 patients with signs of vascular injury or ABI<0.9, 35 (45%) had positive CTAs and 15 (19.2%) required vascular intervention. Of the 121 unindicated patients, 26 (21%) had positive CTAs and 1 (0.008%), a knee dislocation, required vascular intervention. In 155 patients with renal function labs, initial GFR<60ml/min was a risk factor for CIN as compared to GFR>60ml/min (p=0.001). Rate of CIN did not correlate with Injury Severity Score (ISS).

CONCLUSIONS

CTAs are obtained more often than indicated and initial GFR<60ml/min is a risk factor for developing CIN, irrespective of the trauma burden. CTAs should be reserved for when hard signs of vascular injury or ABI<0.9, especially in those patients with decreased renal function.

LEVEL OF EVIDENCE

Level IV.

Yield of CT angiography in penetrating lower extremity trauma

PURPOSE

CT angiography (CTA) has become a valuable tool in the assessment of suspected arterial injury in patients with penetrating lower extremity trauma. However, expensive imaging such as CTA should be judiciously utilized to ensure value-based care. We therefore assessed the yield of CTA in this setting at a level-1 trauma unit and correlated it with the clinical history provided.

METHODS

A retrospective descriptive study from 1 July 2013 to 31 June 2018 at a 1386-bed, tertiary-level, public-sector teaching hospital in Cape Town, South Africa.. All patients undergoing CTA for suspected arterial injury following penetrating lower extremity trauma were included. The imaging yield of clinically significant arterial injury and the predictive value of specific clinical signs were determined.

RESULTS

A total of 983 patients (median age 27 years, 91% male) were included; 90% (886/983) had gunshots, 9% (89/983) stabs, and 1% (8/983) other injuries. Despite an average 13% year-on-year increase in CTA performed, there was no change in the proportion demonstrating arterial injury. Thirty-four percent (23/68) of patients with strong (hard) signs of arterial injury (active pulsatile bleeding, rapidly expanding hematoma, absent pulse, palpable thrill, or audible bruit), 11% (49/459) with moderate (soft) signs (history of an arterial bleed, excessive non-pulsatile bleeding, large non-expanding hematoma, major neurological deficit, diminished but appreciable pulse, and arterial proximity), and 5% (24/456) with no indication for imaging had clinically significant arterial injuries. Significant positive correlations were rapidly expanding hematoma (p = 0.009), an absent pulse (p < 0.001), and a diminished pulse (p < 0.001). Significant negative correlations were proximity to a major artery (p = 0.005) and no clinical indication provided (p < 0.001).

CONCLUSION

There is poor correlation between clinical details provided and the presence of arterial injury at our institution. In this context, CTA serves a pivotal role in the definitive identification of arterial injury.

Multidetector CT in Vascular Injuries Resulting from Pelvic Fractures: A Primer for Diagnostic Radiologists

Pelvic vascular injuries are typically caused by high-energy trauma. The majority of these injuries are caused by motor vehicle collisions, and the rest are caused by falls and industrial or crush injuries. Pelvic vascular injuries are frequently associated with pelvic ring disruption and have a high mortality rate due to shock as a result of pelvic bleeding. Morbidity and mortality resulting from pelvic vascular injury are due to pelvic hemorrhage and resultant exsanguination, which is potentially treatable and reversible if it is diagnosed early with multidetector CT and treated promptly. The pelvic bleeding source can be arterial, venous, or osseous, and differentiating an arterial (high-pressure) bleed from a venous-osseous (low-pressure) bleed is of paramount importance in stratification for treatment. Low-pressure venous and osseous bleeds are initially treated with a pelvic binder or external fixation, while high-pressure arterial bleeds require angioembolization or surgical pelvic packing. Definitive treatment of the pelvic ring disruption includes open or closed reduction and internal fixation. Multidetector CT is important in the trauma setting to assess and characterize pelvic vascular injuries with multiphasic acquisition in the arterial and venous phases, which allows differentiation of the common vascular injury patterns. This article reviews the anatomy of the pelvic vessels and the pelvic vascular territory; discusses the multidetector CT protocols used in diagnosis and characterization of pelvic vascular injury; and describes the spectrum of pelvic vascular injuries, the differentiation of common injury patterns, mimics, and imaging pitfalls. Online supplemental material is available for this article. ^©RSNA, 2019 See discussion on this article by Dreizin.

Imaging primer for CT angiography in peripheral vascular trauma

The use of computed tomography angiography (CTA) for the evaluation of peripheral vascular trauma has become increasingly prevalent in the past decade with the development of multidetector CT (MDCT) and multiple studies subsequently demonstrating high sensitivity, specificity, and diagnostic accuracy when compared with conventional angiography. Additional benefits of MDCT include the ability to rapidly acquire the images, perform multiplanar and 3D reconstructions, and assess the adjacent soft tissues and bones. Rapid intravenous injection of iodinated contrast material is required for optimal arterial enhancement. CTA manifestations of an arterial injury may be direct, and include active contrast extravasation, pseudoaneurysm, arteriovenous fistula (AVF), intimal injury, dissection, or occlusion. There are also indirect signs which have a high association with vascular injury, and should raise suspicion, when present. Pitfalls related to image acquisition or patient factors can be mitigated with appropriate planning and post-processing techniques.

CT angiography of lower extremities from anatomy to traumatic and nontraumatic lesions: a pictorial review

After the introduction and the quick improvement of multidetector computed tomography technology, computed tomographic angiography (CTA) has become the imaging examination of choice for the first assessment of patients affected by lower extremities acute disorders. The widespread availability of CT equipment, the high temporal and spatial resolution with post-processing reformation possibilities represent the main advantages of this technique, which can reliably identify different findings related to arterial vessel pathology, such as occlusion, dissection, active bleeding, and pseudoaneurysm. Radiologists should know the anatomy, the acquisition protocols, and the CTA appearances of the different vascular lesions. The right interpretation of CTA findings is essential to establish the best treatment management of each patient.

Penetrating Extremity Trauma Endovascular versus Open Repair?

Penetrating extremity trauma (PET) accounts for an estimated 5-15% of trauma with vascular injury and these injuries are accountable for a significant percentage of trauma-related deaths. Historically, vascular injuries were best treated by open repair. While a defined selection criteria and a comprehensive algorithm have not been validated, the advancement of endovascular techniques, embolotherapy, and stent grafting have become viable options for the treatment of penetrating arterial extremity trauma in select patients. Advantages endovascular repair offers include decreasing mortality and morbidity associated with open repair, decreasing blood loss, decreasing iatrogenic injury such as nerve injury, and lower rate of wound infection. Patients stability, type of vascular injury, and lesion location are main factors help deciding between endovascular and open repair. Patient selection between endovascular and open repair should be determined by on a case-by-case situation, individual hospital guidelines, a multidisciplinary approach, and technical expertise.

Evaluation and Management of Knee Dislocation in the Emergency Department

BACKGROUND

Knee dislocations are a potentially limb-threatening injury, and it is essential that emergency medicine clinicians are aware of them.

OBJECTIVE

This article provides a review of the diagnosis and management of knee dislocation for the emergency provider.

DISCUSSION

Knee dislocations are uncommon injuries with the potential for significant morbidity. A thorough history and examination are important, because 50% of dislocations may have reduced before arrival to the emergency department. Knee dislocations should be quickly reduced in the emergency department setting. The presence of equal pulses does not exclude vascular injury, and all patients should undergo serial vascular examinations and evaluation with ankle-brachial indices. Those with abnormal ankle-brachial indices should receive computed tomographic angiography. Radiographs are important to identify any fractures, while magnetic resonance imaging may be deferred until after admission.

CONCLUSION

Knee dislocation is a potentially dangerous medical condition requiring rapid diagnosis and management. It is essential for emergency clinicians to know how to diagnose and treat this disorder.

Long-Term Outcomes of Endovascular Stenting for Blunt Renal Artery Injuries with Stenosis: A Report of Five Consecutive Cases

BACKGROUND

Renal artery stenting is performed for renal artery injuries to preserve renal function and prevent renovascular hypertension. However, its indications are controversial and its long-term prognosis remains unknown. Here, we evaluate the characteristics and long-term outcomes of renal artery stenting for blunt renal artery injuries at our institution.

METHODS

We retrospectively reviewed patients with blunt renal artery injuries who had been treated with stenting over a 12-year period at our institution. Five patients (three men and two women) were included.

RESULTS

Trauma resulted from falls in three patients and motor vehicle accidents in two. All patients had experienced multiple injuries (median injury severity score, 24 [range, 16-48]; median revised trauma score, 5.9672 [4.0936-7.8408]; and median probability of survival, 0.689 [0.533-0.980]). All renal artery injuries involved stenosis because of traumatic arterial dissection or intimal tear; no cases of total occlusion were observed. No complications due to the intervention itself were observed. Although two patients developed reversible acute renal failure, none required long-term hemodialysis. One patient with renovascular hypertension was treated with antihypertensive agents for a month and subsequently became normotensive without further medication. All patients underwent postoperative computed tomography, which revealed no stent occlusion or renal atrophy. Renal scintigraphy for three patients demonstrated preserved differential renal function. All five patients survived.

CONCLUSIONS

Renal artery stenting for hemodynamically stable blunt renal artery injuries with stenosis is suggested to be safe and helps in avoiding long-term hemodialysis and renovascular hypertension.

Over-utilization of computed tomography angiography in extremity trauma

Objectives:

Widespread availability of computed tomography angiography (CTA) for diagnosing arterial injury in injured extremities has created the possibility of overuse. The objective of this study was to evaluate CTA utilization, indications, ordering personnel, and rate of significant findings for blunt or penetrating extremity trauma at a level I trauma center.

Methods:

We performed a retrospective chart review of 1440 consecutive CTAs of upper and lower extremities from 2010 to 2012 at a large level I trauma center, and included only those done for acute trauma. Data were collected with regard to injury, initial exam, reason given for ordering a CTA, specialty of physician ordering CTA, results, and vascular interventions needed. CTAs were categorized as appropriately ordered based on if there was a documented abnormal distal pulse or ankle-brachial index (ABI). Study indication was classified as inconclusive if no vascular exam was documented or physical exam varied.

Results:

A total of 481 CTAs were performed after blunt or penetrating trauma in the emergency room with 31.0% appropriately indicated, 48.0% without indication, and 21.8% inconclusive. Mechanism of injury was most commonly a gunshot wound (40.3%), followed by motor vehicle accidents (39.5%). Overall, 61.5% of the studies had normal arterial flow and only 15.8% of CTAs required vascular operative intervention. Of the studies appropriately indicated, 76.5% had positive findings, with 43% needing operative intervention compared to the inappropriately indicated studies only 11.6% had positive findings, with 0.4% needing operative intervention (P < .0001).

Conclusion:

CTA for blunt or penetrating trauma at a level I trauma center may be over-utilized. Often, this advanced imaging is ordered prior to orthopaedic evaluation or limb reduction, without exam-based indication, and most do not affect patients’ treatment. From our study, CTA utilization based on more stringent exam findings at our hospital could eliminate 48% of all CTA studies for trauma.

Decreased National Rate of below the Knee Amputation in Patients with Popliteal Artery Injury

BACKGROUND

Popliteal arterial injury (PAI) is the second most common infrainguinal arterial injury after femoral artery injury with an incidence < 0.2%. A 2003 analysis of the National Trauma Data Bank (NTDB) reported a below the knee amputation (BKA) rate of 7.1% in patients with PAI as well as higher risk in those with an associated fracture or nerve injury. Given advances in vascular surgical techniques, improved multidisciplinary care, and expeditious diagnosis with computed tomography angiography, we hypothesized that the national rate of BKA in patients with PAI has decreased and sought to identify risk factors for BKA in patients with PAI.

METHODS

A retrospective analysis of the NTDB was performed from 2007 to 2015. Patients ≥15 years of age with PAI were included and grouped by mechanism of injury (blunt versus penetrating). Interfacility transfers were excluded. The primary outcome of interest was BKA. Univariable and multivariable analyses were performed to identify predictors of BKA in patients with PAI.

RESULTS

From 4,385,698 patients, 5,143 were identified with PAI (<0.2%) with most involved in a blunt mechanism (56.8%). The overall limb loss rate was 5.1% (decreased from 7.1% in 2003, P = 0.0037). After adjusting for covariates, a blunt mechanism (odds ratio [OR] = 3.53, confidence intervals [CI] = 2.49-5.01, P < 0.001) and open proximal tibia/fibula fracture or dislocation (OR = 2.71, CI = 2.08-3.54, P < 0.001) were independent risk factors for BKA in patients with PAI. A combined popliteal vein injury (PVI) did not increase the risk for BKA (P = 0.64).

CONCLUSIONS

The national rate of limb loss in trauma patients with PAI has decreased from 7.1 to 5.1%. A blunt mechanism of injury as well as proximal open tibia/fibula fracture or dislocation continue to be the independent risk factors for BKA. Confirming a previous report, we found a combined PVI not to be associated with higher risk for BKA. Future prospective research to determine other possible contributing factors such as intraoperative hemodynamics and utilization of vascular shunt and fasciotomy appears warranted.

Multi-Detector Computed Tomography Imaging Techniques in Arterial Injuries

Cross-sectional imaging has become a critical aspect in the evaluation of arterial injuries. In particular, angiography using computed tomography (CT) is the imaging of choice. A variety of techniques and options are available when evaluating for arterial injuries. Techniques involve contrast bolus, various phases of contrast enhancement, multiplanar reconstruction, volume rendering, and maximum intensity projection. After the images are rendered, a variety of features may be seen that diagnose the injury. This article provides a general overview of the techniques, important findings, and pitfalls in cross sectional imaging of arterial imaging, particularly in relation to computed tomography. In addition, the future directions of computed tomography, including a few techniques in the process of development, is also discussed.

Evaluation of Experience with Lower Extremity Arterial Injuries at an Urban Trauma Center

Lower extremity arterial injuries (LEAIs) can be complicated injuries resulting in limb loss and death. Patients with LEAI often have multiple injuries increasing the risk for morbidity and mortality. We sought to evaluate the incidence and management of LEAI and to define associations between injuries and outcomes. We performed a retrospective review of LEAI at an urban level-1 trauma center from April 2005 to April 2015. Chi-square tests were used to compare independent groups with respect to mortality and amputation. Means were compared between independent groups using two-sample t -tests. From April 2005 to April 2015, 208 arterial injuries occurred in 163 patients. The majority (80.4%) suffered concomitant lower extremity injuries with 35.6% suffering systemic injuries. Surgical intervention was required for 72.1% of injuries. Amputation rate was 14.7%. Mortality rate was 8.0%. Data from 2010 to 2015 were more specifically analyzed. Injury severity score (ISS) was higher with fatalities (37 ± 13.16 vs. 11.8 ± 8.51, p  < 0.0001) and in patients requiring an amputation (25.4 ± 15.32 compared with 11.6 ± 9.05, p  = 0.0015). Popliteal artery injury was most likely to require an amputation (odds ratio [OR] = 2.9, p  = 0.04). Mortality was more likely when systemic injuries were present (OR = 18.1, p  = 0.0005). The majority of patients with arterial injuries require surgical management, most often with open surgical techniques. Arterial injuries associated with systemic injuries, blunt injury mechanisms, and higher ISS are at a significantly increased risk of mortality.

Overutilization of Cross-Sectional Imaging in the Lower Extremity Trauma Setting

Objective  In an era of managed care and cost savings, we are faced with the question of whether another test is necessary to confirm our clinical suspicion. We hypothesized that a few computed tomography angiographies (CTAs) are necessary to identify lower extremity vascular injuries (LEVIs). We reviewed our trauma center's experience in the management of LEVI. Methods  A retrospective review of all trauma patients between 2012 and 2016 was performed. Four-thousand nine-hundred fourteen trauma patients were evaluated with 46 suspected LEVIs (either with cross-sectional imaging and/or operative exploration). Our primary end point was the utility of CTA in the setting of LEVI. Receiver operating characteristic curves were performed to evaluate sensitivity and specificity for hard signs and CTA identification of LEVI. Results  Out of the initial 46 patients with suspected LEVI, 41 (89%) had a CTA as part of their initial evaluation. Sixteen patients (35%) with LEVI were due to penetrating injuries. Seventeen patients (41%) had a CTA with LEVI. Fourteen of the 17 patients (82%) with injury on CTA also had hard signs of LEVI. Twenty-two patients (48%) underwent operative exploration: three had no LEVI that was previously believed to be on CTA; operative exploration identified two missed injuries not observed on CTA. Seven of forty-one (17%) CTA studies provided a false assumption of the presence/absence of LEVI. One patient (2%) underwent operative exploration and was found to have LEVI in the absence of hard signs, but with a CTA identifying LEVI. Conclusion  The recognition of hard signs through physical examination is paramount to assessing need for operative intervention with suspicion of LEVI. CTA should be reserved as an adjunct for identification of LEVI in patients with high clinical suspicion and absence of hard signs, rather than utilizing CTA as an initial screening tool for the identification of LEVI.

Reassessing the utility of CT angiograms in penetrating injuries to the extremities

BACKGROUND

Computed tomography angiography has become routine in the management of penetrating trauma to the extremity. Our objective was to evaluate the efficacy of physical examination findings compared with computed tomography angiography for detection of clinically significant vascular injuries associated with penetrating trauma to the extremity.

METHODS

This was a retrospective chart review of patients presenting to a single level 1 trauma center from January 2013-June 2016. Patients with penetrating trauma to the extremity and no hard signs of vascular injury were included. Physical examination and computed tomography angiography findings were analyzed, with particular focus given to missed injuries.

RESULTS

We identified 393 patients with penetrating trauma to the extremity without hard signs of vascular injury. Computed tomography angiography was performed in 114 patients (29%). Four patients with distal pulses documented on their initial trauma surveys were found to have vascular injuries on computed tomography angiography, although 3 of these injuries were identified on repeat physical examination. One additional patient had a delayed presentation of a pseudoaneurysm. No mortality or limb loss resulted from these injuries. Total hospital charges for computed tomography angiography amounted to over $700,000.

CONCLUSION

Patients with penetrating trauma to the extremity and no hard signs of vascular injury do not require computed tomography angiography for identification of clinically relevant vascular injuries that require emergent operative repair. Serial physical examination appears to provide accurate detection of vascular injury requiring procedural intervention.

Role of lower extremity run-off CT angiography in the evaluation of acute vascular disease

In the acute care setting, radiologists are frequently asked to assist in the evaluation of patients presenting with signs and symptoms of lower extremity peripheral vascular disease. Non-traumatic peripheral vascular emergencies are most commonly the result of thrombosis, either in a native vessel or within a bypass graft or stent. Arterial emboli, peripheral aneurysm with embolus or thrombosis, and direct arterial trauma are additional, less common causes. Traumatic peripheral vascular emergencies include vessel occlusion, transection, pseudoaneurysms, active extravasation, and arteriovenous fistulas. The high morbidity and mortality associated with acute limb ischemia makes rapid diagnosis and early initiation of therapy critical in the management of such patients. Computed tomographic angiography (CTA) offers the vascular specialist a rapid, widely available, and accurate means to diagnose and grade the extent of vascular disease in the acute care setting. In this pictorial essay, the key elements of lower extremity run-off CTA are reviewed, including relevant anatomy, imaging approach, and spectrum of imaging findings.

Knee Dislocation: A Case Report, Diagnostic Vascular Work-Up, and Literature Review

Knee dislocation is an uncommon, potentially limb-threatening, knee injury. Most often caused by high-velocity trauma, it can also result from low- or even ultra-low-velocity trauma. Rapid identification of the injury, reduction, and definitive management are necessary to minimize neurovascular damage. We present a case of rotatory anterolateral knee dislocation sustained during a twisting sports-related event. Special emphasis is placed on diagnosing vascular injuries associated with knee dislocations.

Evaluation of the diagnostic value of a venous phase in CT angiography of the extremities in the setting of trauma: is vein imaging in vain?

PURPOSE

This study examined the value of including a venous phase in addition to the initial arterial phase in the CT angiography evaluation of extremity trauma.

METHODS

CT studies from 157 patients (average age 38 years, age range 18-89 years, male 83%, female 17%) were obtained for trauma to the upper or lower extremity with both arterial and venous phases and retrospectively reviewed. The detection rate and type of vascular injury were evaluated by using the arterial phase alone and compared to the detection rate when interpreting the arterial and venous phases together.

RESULTS

Arterial injury was identified in 35 cases (22%), and venous injury was identified in seven cases (5%). Four cases of discrepant diagnoses were identified between image interpretation of the arterial phase alone and interpretation using both phases, all of which were venous injuries that were visible only on the venous phase. None of the four cases of venous injury required a change in surgical management. Overall, no significant difference in diagnosis between the two methods of image interpretation (arterial phase alone, arterial and venous phases) was discovered (p > 0.125; CI 95%).

CONCLUSIONS

The use of a venous phase in the CT angiography evaluation of extremity trauma does not add significant arterial diagnostic or clinical management value despite its potential of increasing the diagnostic detection rate of venous injury.

CT-detected traumatic small artery extremity injuries: surgery, embolize, or watch? A 10-year experience

Advances in computed tomography (CT) angiography have increased the sensitivity and specificity of detecting small branch arterial injuries in the extremities of trauma patients. However, it is unclear whether these patients should undergo surgery, angioembolization, or conservative watchful waiting. We hypothesized that uncomplicated small arterial branch injuries can be managed successfully with watchful waiting. A 10-year retrospective review of extremity CT angiograms with search findings of arterial "active extravasation" or "pseudoaneurysm" was performed at a level 1 county trauma center. Subgroup analysis was performed on those with isolated extremity injury and those with concurrent injuries. A total of 31 patients had CT-detected active extravasation (84 %) or pseudoaneurysm (16 %), 71 % of which were isolated vascular injuries. Of the patients evaluated, 71 % (n = 22) were managed with watchful waiting, 19 % (n = 6) with angioembolization, and 10 % (n = 3) with surgery. Watchful waiting complications included progression to alternative treatment (n = 1) and blood transfusions (n = 2). Complications of surgery included the inability to find active bleeding (n = 1) and postoperative psychosis (n = 1). Complications of angioembolization were limited to a postprocedure blood transfusion (n = 1). Patients with isolated vascular injuries had an average length of stay of 2.9 days, with management averages of the following: 2.7 days with watchful waiting (n = 16), 3.3 days with angioembolization (n = 3), and 3.7 days with surgery (n = 3). CT angiography has greatly increased the reported incidence of traumatic arterial injury in the extremity. We propose that small branch arterial injuries in the extremities can be managed successfully with watchful waiting and do not often require immediate embolization.

The predictive value of multidetector CTA on outcomes in patients with below-the-knee vascular injury

BACKGROUND

Multidetector computed tomographic angiography (MDCTA) has become the gold standard for the early assessment of lower extremity vascular injury. The objective of this study was to evaluate the predictive value of MDCTA documented vessel run-off to the foot on limb salvage rates after lower extremity vascular injury.

METHODS

All trauma patients undergoing lower extremity MDCTA for suspected vascular injury assessed at 2 high-volume Level I trauma centers between January 2009 and December 2012. Demographics, clinical data and outcomes (compartment syndrome requiring fasciotomy and limb salvage) were extracted. The predictive value of MDCTA vessel run-off was tested against an aggregate gold standard of operative intervention, clinical follow-up and all imaging obtained.

RESULTS

During the 4-year study period, 398 patients sustained lower extremity trauma and were screened for inclusion into this study. Of those, 166 (41.7%) patients (72.9% at MHH and 27.1% at LAC+USC Medical Center) underwent initial evaluation with MDCTA, 86 (51.8%) had vascular injury below the knee identified by MDCTA. Among these, the average age was 38.0±15.8 years, 80.2% were men and 83.7% sustained a blunt injury mechanism. On admission, 8.1% were hypotensive and the median ISS was 10 (range 1-57). There was a direct correlation between the number of patent vessels to the foot and the need for operative intervention (86.4% with no patent vessels, 56.0% with 1 patent vessel, 33.3% with 2 and 0.0% with 3, p<0.001). When outcomes were analysed, the rates of fasciotomy for compartment syndrome decreased in a stepwise fashion as the number of patent vessels to the foot increased (63.6% with no patent vessels; 44.0% with 1; 21.2% with 2; and 0.0% with 3; p=0.003). No amputations occurred in patients with 2 or more patent vessels to the foot (68.2% for no patent vessel; 16.0% for 1; 0.0% for 2; and 0.0% for 3; p<0.001).

CONCLUSIONS

In this multicenter evaluation of patients undergoing MDCTA for suspected below-the-knee vascular injury, there was a stepwise increase in the need for operative intervention, fasciotomy and amputation as the number of patent vessels to the foot decreased.

Management of Femoral Vessel Injuries: A 6-year Single-center Experience

Femoral vessel injuries are a familiar injury treated in busy urban trauma centers. The majority of peripheral vascular injuries to the lower extremity occur most commonly to the femoral vessels. The increasing incidence of civilian violence provides an opportunity to perform a comprehensive review and management of these injuries.

Sonographic detection of pseudoaneurysm in vascular injury in emergency department

A 31-year-old man suffered from a stab wound to the lower extremity. The patient had a hard sign of a vascular injury (a diminished distal pulse) and therefore probably should have undergone operative repair, but refused. One week later, he returned to our emergency department with a painful right thigh swelling. Bedside sonography was used to detect a pseudoaneurysm. Emergency sonography is a fast, non-invasive, and rapid decision-making approach in emergency practice.

Evaluation and management of penetrating lower extremity arterial trauma: an Eastern Association for the Surgery of Trauma practice management guideline

BACKGROUND

Extremity arterial injury after penetrating trauma is common in military conflict or urban trauma centers. Most peripheral arterial injuries occur in the femoral and popliteal vessels of the lower extremity. The Eastern Association for the Surgery of Trauma first published practice management guidelines for the evaluation and treatment of penetrating lower extremity arterial trauma in 2002. Since that time, there have been advancements in the management of penetrating lower extremity arterial trauma. As a result, the Practice Management Guidelines Committee set out to develop updated guidelines.

METHODS

A MEDLINE computer search was performed using PubMed (www.pubmed.gov). The search retrieved English language articles regarding penetrating lower extremity trauma from 1998 to 2011. References of these articles were also used to locate articles not identified through the MEDLINE search. Letters to the editor, case reports, book chapters, and review articles were excluded. The topics investigated were prehospital management, diagnostic evaluation, use of imaging technology, the role of temporary intravascular shunts, use of tourniquets, and the role of endovascular intervention.

RESULTS

Forty-three articles were identified. From this group, 20 articles were selected to construct the guidelines.

CONCLUSION

There have been changes in practice since the publication of the previous guidelines in 2002. Expedited triage of patients is possible with physical examination and/or the measurement of ankle-brachial indices. Computed tomographic angiography has become the diagnostic study of choice when imaging is required. Tourniquets and intravascular shunts have emerged as adjuncts in the treatment of penetrating lower extremity arterial trauma. The role of endovascular intervention warrants further investigation.

[Efficacy of multidetector computed angiotomography in the diagnosis of limb arterial injuries]

OBJECTIVE

To determine the diagnostic usefulness of multidetector computed angiotomography in the diagnosis limb arterial injuries in patients with suspicion of arterial injury with no indication of immediate surgery.

METHODS

Non-invasive 64-channel multidetector computed tomography (MDCT) was performed on 99 limbs suspected of having a traumatic vascular injury over a 44-month period between August 2004 and April 2008. The results were interpreted by the duty radiologist and his findings were compared with those from surgery or clinical follow-up. Inter-observer variability was evaluated by comparing the reading of the MDCT by the duty radiologists with the retrospective reading by radiology specialist in trauma.

RESULTS

MDCT as a diagnostic method of vascular injury of the limbs, interpreted by a general radiologist showed a sensitivity of 98% (95% CI: 93-100), a specificity of 88% (5% CI: 77-99), a positive predictive value of 91% (95% CI: 82-99), a negative predictive value of 97% (95% CI: 90-100), a positive likelihood radio of 8.24 (3.6-18.7), and a negative likelihood radio of 0.02 (0-0.15). The inter-observer variability by comparing the interpretation of the MDCT by the duty radiologist with that of the radiology specialist in trauma had a kappa of 0.869.

CONCLUSION

Multidetector computed angiotomography is a high precision diagnostic imaging method in arterial injury of the limbs, offering a suitable and appropriate therapeutic approach, and could be considered as new gold standard for the diagnosis of arterial injuries of the limbs.

Imaging vascular trauma

Background

Over the past 50 years the management of vascular trauma has changed from mandatory surgical exploration to selective non-operative treatment, where possible. Accurate, non-invasive, diagnostic imaging techniques are the key to this strategy. The purpose of this review was to define optimal first-line imaging in patients with suspected vascular injury in different anatomical regions.

Methods

A systematic review was performed of literature relating to radiological diagnosis of vascular trauma over the past decade (2000–2010). Studies were included if the main focus was initial diagnosis of blunt or penetrating vascular injury and more than ten patients were included.

Results

Of 1511 titles identified, 58 articles were incorporated in the systematic review. Most described the use of computed tomography angiography (CTA). The application of duplex ultrasonography, magnetic resonance imaging/angiography and transoesophageal echocardiography was described, but significant drawbacks were highlighted for each. CTA displayed acceptable sensitivity and specificity for diagnosing vascular trauma in blunt and penetrating vascular injury within the neck and extremity, as well as for blunt aortic injury.

Conclusion

Based on the evidence available, CTA should be the first-line investigation for all patients with suspected vascular trauma and no indication for immediate operative intervention.