CTA Imaging of Peripheral Arterial Injuries

Traumatic vascular injuries consist of direct or indirect damage to arteries and/or veins and account for 3% of all traumatic injuries. Typical consequences are hemorrhage and ischemia. Vascular injuries of the extremities can occur isolated or in association with major trauma and other organ injuries. They account for 1-2% of patients admitted to emergency departments and for approximately 50% of all arterial injuries. Lower extremities are more frequently injured than upper ones in the adult population. The outcome of vascular injuries is strictly correlated to the environment and the time background. Treatment can be challenging, notably in polytrauma because of the dilemma of which injury should be prioritized, and treatment delay can cause disability or even death, especially for limb vascular injury. Our purposes are to discuss the role of computed tomography angiography (CTA) in the diagnosis of vascular trauma and its optimized protocol to achieve a definitive diagnosis and to assess the radiological signs of vascular injuries and the possible pitfalls.

Cinematic rendering in the evaluation of complex vascular injury of the lower extremities: how we do it

Lower extremity trauma is one of the most common injury patterns seen in emergency medical and surgical practice. Vascular injuries occur in less than one percent of all civilian fractures. However, if not treated promptly, such injuries can lead to ischemia and death. Computed tomography angiography (CTA) is the non-invasive imaging gold standard and plays a crucial part in the decision-making process for treating lower extremity trauma. A novel, FDA-approved 3D reconstruction technique known as cinematic rendering (CR) yields photorealistic reconstructions of lower extremity vascular injuries depicting clinically important aspects of those injuries, aiding in patient workup and surgical planning, and thus improving patient outcomes. In this article, we provide clinical examples of the use of CR in evaluating lower extremity vascular injuries, including the relationship of these injuries to adjacent osseous structures and overlying soft tissues, and its role in management of lower extremity trauma.

Low-velocity, civilian firearm extremity injuries-review and update for radiologists

Firearm injuries are a preventable epidemic in the USA. Extremities are commonly affected in gunshot injuries. Such injuries may be complex with concomitant osseous, soft tissue, and neurovascular components. The maximum wounding potential of a projectile is determined by its kinetic energy and the proportion of the kinetic energy that is transmitted to the target. Accurate assessment of ballistic injuries is dependent on utilizing the principles of wound ballistics, accurate bullet count, and ballistic trajectory analysis. The goals of this article are to review wound ballistics and the imaging evaluation of extremity civilian firearm injuries in the adult population, with emphasis on ballistic trajectory analysis, specific ballistic fracture patterns, and diffuse, secondary soft tissue ballistic injuries.

Imaging in extremity vascular trauma: can MDCT angiography predict the nature of injury?

OBJECTIVE

This study aims to evaluate the utility of computed tomography angiography (CTA) signs of vascular injury in the differentiation of vessel transection from pure thrombosis with intact vessel wall.

METHODS

Retrospective analysis was done on 146 consecutive patients who had undergone CTA and surgical exploration from January 2015 to September 2019. Twelve imaging parameters were assessed. Chi-square was used to test the difference between groups. In addition, a scoring system was devised where one point each was added for the presence of 5 signs and absence of 3 signs. ROC analysis was done for the variables which had shown significant difference between groups and for the composite score.

RESULTS

On surgical exploration, 87 patients had transection of vessel, while 59 had thrombosis. Significant difference was found among the two groups in non-opacification, pseudoaneurysm, extravasation (p = 0.04 each), thrombosed cord (p < 0.001), collaterals (p = 0.001) and hematoma (p = 0.002), while other signs did not show significant difference. The AUC value for each of these variables was < 0.650, while for the score, AUC was .843(.773-.913). A cut-off value of ≥ 1.5 gave 83.1% sensitivity and 70% specificity for diagnosing transection.

CONCLUSION

CTA is a useful tool to classify the nature of vascular injury. It is advisable to use a composite score for maximum diagnostic value.

Roles of Trauma CT and CTA in Salvaging the Threatened or Mangled Extremity

Extremity arterial injuries account for up to 50% of all arterial traumas. The speed, accuracy, reproducibility, and close proximity of modern CT scanners to the trauma bay have led to the liberal use of CT angiography (CTA) when a limb is in ischemic jeopardy or is a potential source of life-threatening hemorrhage. The radiologist plays a critical role in the rapid communication of findings related to vessel transection and occlusion. Another role of CT that is often overlooked involves adding value to surgical planning. The following are some of the key questions addressed in this review: How does CTA help determine whether a limb is salvageable? How do concurrent multisystem injuries affect decision making? Which arterial injuries can be safely managed with observation alone? What damage control techniques are used to address compartment syndrome and hemorrhage? What options are available for definitive revascularization? Ideally, the radiologist should be familiar with the widely used Gustilo-Anderson open-fracture classification system, which was developed to prognosticate the likelihood of a functional limb salvage on the basis of soft-tissue and bone loss. When functional salvage is feasible or urgent hemorrhage control is required, communication with trauma surgeon colleagues is augmented by an understanding of the unique surgical, endovascular, and hybrid approaches available for each anatomic region of the upper and lower extremities. The radiologist should also be familiar with the common postoperative appearances of staged vascular, orthopedic, and plastic reconstructions for efficient clinically relevant reporting of potential down-range complications. Online supplemental material is available for this article. ^©RSNA, 2022.

American Association for the Surgery of Trauma-World Society of Emergency Surgery guidelines on diagnosis and management of peripheral vascular injuries

The peripheral arteries and veins of the extremities are among the most commonly injured vessels in both civilian and military vascular trauma. Blunt causes are more frequent than penetrating except during military conflicts and in certain geographic areas. Physical examination and simple bedside investigations of pulse pressures are key in early identification of these injuries. In stable patients with equivocal physical examinations, computed tomography angiograms have become the mainstay of screening and diagnosis. Immediate open surgical repair remains the first-line therapy in most patients. However, advances in endovascular therapies and more widespread availability of this technology have resulted in an increase in the range of injuries and frequency of utilization of minimally invasive treatments for vascular injuries in stable patients. Prevention of and early detection and treatment of compartment syndrome remain essential in the recovery of patients with significant peripheral vascular injuries. The decision to perform amputation in patients with mangled extremities remains difficult with few clear indicators. The American Association for the Surgery of Trauma in conjunction with the World Society of Emergency Surgery seeks to summarize the literature to date and provide guidelines on the presentation, diagnosis, and treatment of peripheral vascular injuries. LEVEL OF EVIDENCE: Review study, level IV.

CT angiography and MRI of hand vascular lesions: technical considerations and spectrum of imaging findings

Vascular lesions of the hand are common and are distinct from vascular lesions elsewhere because of the terminal vascular network in this region, the frequent hand exposure to trauma and microtrauma, and the superficial location of the lesions. Vascular lesions in the hand may be secondary to local pathology, a proximal source of emboli, or systemic diseases with vascular compromise. In most cases, ischaemic conditions are investigated with Doppler ultrasonography. However, computed tomography angiography (CTA) or dynamic contrast-enhanced magnetic resonance angiography (MRA) is often necessary for treatment planning. MR imaging is frequently performed with MRA to distinguish between vascular malformations, vascular tumours, and perivascular tumours. Some vascular tumours preferentially affect the hand, such as pyogenic granulomas or spindle cell haemangiomas associated with Maffucci syndrome. Glomus tumours are the most frequent perivascular tumours of the hand. The purpose of this article is to describe the state-of-the-art acquisition protocols and illustrate the different patterns of vascular lesions and perivascular tumours of the hand.

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.

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.

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.

Upper Extremity Runoff: Pearls and Pitfalls in Computed Tomography Angiography and Magnetic Resonance Angiography

Upper extremity vasculature can be affected by various traumatic and nontraumatic pathologies; however, the evaluation of these arteries can be challenging for the radiologists as well as for the clinicians. After an accurate history and clinical examination, imaging plays a vital role in the diagnosis and treatment planning of these patients. Depending on the urgency and the indication, upper extremity arteries may be evaluated by ultrasonography with color Doppler, computed tomography (CT), magnetic resonance imaging (MRI), or digital subtraction angiography. This review article discusses relevant imaging anatomy of the upper extremity arteries, presents CT and MRI protocols, briefly describes the state-of-the-art CT and MRI of various pathologies affecting the upper extremity arteries, and summarizes the important pearls needed for busy practicing radiologist.

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.

Emergency radiology: Peripheral vascular injuries

There has been a growing role for both diagnostic and interventional radiology (IR) in all types of trauma affecting different areas of the body, with imaging becoming an integral part of the multidisciplinary approach to modern trauma care. This article is intended to assess the role of radiology in peripheral trauma and highlight some of the indications, contraindications and treatment options available. It will also touch upon other associated problems encountered by the trauma patient in particular the increased risk of thromboembolic disease. We review some of the common peripheral vascular injuries in our experience in a large trauma hospital.

Damage control radiology in the severely injured patient: what the anaesthetist needs to know

In the treatment of severely injured patients, the term 'damage control radiology' has been used to parallel the modern concept of damage control surgery and the allied development of continuous damage control resuscitation from patient retrieval, through all transfers, to appropriate primary treatment. The aims of damage control radiology are (i) rapid identification of life-threatening injuries including bleeding sites, (ii) identification or exclusion of head or spinal injury, and (iii) prompt and accurate triage of patients to the operating theatre for thoracic, abdominal, or both surgeries or the angiography suite for endovascular haemorrhage control. If we are to achieve these aims, patients must have immediate access to modern multidetector computed tomography (MDCT) which is without doubt the most potent weapon in the diagnostic armamentarium. The most severely injured patients are those who have the most to benefit from early diagnosis and life-saving therapies. The traditional teaching that these patients should go immediately to surgery is challenged by technological developments in MDCT and recent clinical evidence.

CT angiography of the upper extremity arterial system: Part 1-Anatomy, technique, and use in trauma patients

OBJECTIVE

In this article, we focus on the arterial anatomy of the upper extremities, the technical aspects of upper extremity CT angiography (CTA), and CTA use in trauma patients.

CONCLUSION

CTA using modern MDCT scanners has evolved into a highly accurate noninvasive diagnostic tool for the evaluation of patients with abnormalities of the upper extremity arterial system.

[Traumatic dissection of the carotid artery: challenges for diagnostics and therapy illustrated by a case example]

Traumatic dissection of the carotid artery is an easily overlooked consequence of trauma with notable morbidity and mortality which can be observed in up to 4% of cases involving multiple trauma. Certain mechanisms and patterns of injury as well as specific symptoms should serve as indicators of a dissection and should therefore result in further diagnostic measures. An early diagnosis is of major relevance. This report describes the case of a 45-year-old victim of a traffic accident who showed symptoms of a dissection which had initially not been diagnosed.

Can CT Angiography Replace Conventional Bi-Planar Angiography in the Management of Severe Scapulothoracic Dissociation Injuries?

Severe scapulothoracic dissociation (SSTD) (Type III or IV; Zelle classification) is often life-threatening and is commonly associated with other devastating injuries. Rapid evaluation, including of the vascular system, is critical to limit the time to definitive therapy. CT angiography (CTA) has evolved as a diagnostic tool, replacing angiography (angio) as it can simultaneously evaluate bony, soft tissue, and vascular injuries. We hypothesized that CTA would be useful in evaluating patients with SSTD. We retrospectively reviewed the trauma registry between June 2002 and June 2010 to identify patients over 18 years of age who sustained SSTD. Patients that were transferred or died before diagnostic imaging were excluded. Comparisons were made between the group that underwent angio before surgery compared with CTA with regards to outcome and length of hospital and intensive care unit stay. Fourteen patients were identified with Type III or IV SSTD over the study period. In the CTA group, mean Injury Severity Score was higher, but time to definitive operative intervention was significantly shorter. There was no difference in amputation rates or mortality. Replacing arteriography with CTA in the preoperative workup of patients with SSTD reduces time to surgery. Despite a greater injury severity in the group in which CTA was used as the primary imaging modality, length of stay, amputation rates, and mortality were no different. CTA can be safely used to evaluate patients with suspected SSTD.

Perioperative Management of Peripheral Vascular Trauma

Peripheral vascular trauma is not uncommon in the civilian setting, and it can be uniquely challenging because of the limited time during which intervention can salvage an ischemic extremity. Injuries can be from a blunt or penetrating mechanism, and these injuries can be isolated or can be in the setting of a complex multisystem trauma. The intent of this review is to discuss the perioperative management of peripheral vascular trauma with an emphasis of predicting, preventing, and managing common postoperative complications.

Western Trauma Association critical decisions in trauma: management of the mangled extremity

BACKGROUND

The operative management of mangled extremities after trauma remains controversial. We have sought to develop an evidence-based algorithm to help guide practitioners when faced with these relatively infrequent but very challenging clinical dilemmas.

METHODS

The Western Trauma Association Critical Decisions Committee queried the literature to identify high-quality managements that would help guide the care of mangled extremities. When good data were not available, the Committee relied on expert opinions, either from the literature or from our senior members.

RESULTS

Virtually, all the scoring systems used to guide therapy have not been proven to be valid. Hemodynamically unstable patients who failed to respond to initial resuscitation should be taken to the operating room for exploration and vascular control. Those who are stable should undergo a stepwise vascular and neurologic evaluation process. A comprehensive evaluation of factors that may help predict the appropriateness of limb salvage should be done in the operating room. Patients who are not candidates for salvage should undergo primary amputation. Those who are should undergo attempts at limb salvage.

CONCLUSIONS

Patients with mangled extremities remain a significant management challenge. This algorithm represents a guideline based on the best evidence available in the literature and expert opinion. It does not establish a standard of care. It should provide a framework for treating physicians and other healthcare professionals to guide therapy, considering individual patients' clinical status and institutional resources.

[Fractures of the extremities with severe open soft tissue damage. Initial management and reconstructive treatment strategies]

The successful management of open extremity injuries continues to represent a surgical challenge requiring a structured and multidisciplinary treatment concept. The treatment strategy depends on specific parameters, including the overall injury severity, life threatening trauma components, the degree oft soft tissue injury, the ischemia time, the contamination of the wound as well as the age and accompanying diseases of the patient. The treatment of fractures with a high-grade open soft tissue injury is guided by the severity of soft tissue damage including neurovascular damages, type of the fracture, overall state of the patient and is based on a clearly defined reconstructive algorithm sequentially employing initial wound treatment (debridement), stabilisation of the fracture and soft tissue coverage. The initial wound management includes radical and serial debridements and vessel reconstruction, followed by the gradual reconstruction of bone, tendons and nerves and a subsequent plastic soft tissue coverage.The sequential and priority-orientated implementation of these treatment steps is decisive for the long term outcome, which ideally results in an regular healing of bone and soft tissue without the presence of infection and good regain of extremity function.