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Balakrishnan S. CT angiography of non-aortic thoracic arterial trauma. Emerg Radiol 2023; 30:667-681. [PMID: 37704920 DOI: 10.1007/s10140-023-02170-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 08/28/2023] [Indexed: 09/15/2023]
Abstract
While aortic injury is the most commonly cited thoracic arterial injury, non-aortic arterial injuries represent an uncommon but significant source of morbidity and mortality in blunt and penetrating thoracic trauma patients. Knowledge of the spectrum of vascular injury and anatomic considerations that dictate patterns of associated thoracic hemorrhage will assist the radiologist in the accurate and efficient diagnosis of these injuries. This article provides a review of anatomy, pertinent clinical exam and CT angiography findings, as well as therapeutic options for non-aortic thoracic arterial trauma.
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Affiliation(s)
- Sudheer Balakrishnan
- Department of Radiology, Division of Emergency and Trauma Imaging, Emory University School of Medicine, Atlanta, GA, USA.
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2
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Gopireddy DR, Kee-Sampson JW, Vulasala SSR, Stein R, Kumar S, Virarkar M. Imaging of penetrating vascular trauma of the body and extremities secondary to ballistic and stab wounds. J Clin Imaging Sci 2023; 13:1. [PMID: 36751564 PMCID: PMC9899476 DOI: 10.25259/jcis_99_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 12/20/2022] [Indexed: 01/04/2023] Open
Abstract
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.
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Affiliation(s)
- Dheeraj Reddy Gopireddy
- Department of Radiology, UF College of Medicine-Jacksonville, Jacksonville, Florida, United States
| | - Joanna W. Kee-Sampson
- Department of Radiology, UF College of Medicine-Jacksonville, Jacksonville, Florida, United States
| | - Sai Swarupa Reddy Vulasala
- Department of Internal Medicine, East Carolina University Health Medical Center, Greenville, North Carolina, United States.,Corresponding author: Sai Swarupa Reddy Vulasala, Department of Internal Medicine, East Carolina University Health Medical Center, Greenville, United States.
| | - Rachel Stein
- Department of Radiology, UF College of Medicine-Jacksonville, Jacksonville, Florida, United States
| | - Sindhu Kumar
- Department of Radiology, UF College of Medicine-Jacksonville, Jacksonville, Florida, United States
| | - Mayur Virarkar
- Department of Radiology, UF College of Medicine-Jacksonville, Jacksonville, Florida, United States
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3
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Kee-Sampson JW, Gopireddy DR, Vulasala SSR, Stein R, Kumar S, Virarkar M. Role of imaging in penetrating vascular injuries of the craniocervical region. J Clin Imaging Sci 2022; 12:63. [PMID: 36601604 PMCID: PMC9805603 DOI: 10.25259/jcis_98_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 11/16/2022] [Indexed: 12/04/2022] Open
Abstract
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.
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Affiliation(s)
- Joanna W. Kee-Sampson
- Department of Radiology, UF College of Medicine-Jacksonville, Jacksonville, Florida, United States
| | - Dheeraj Reddy Gopireddy
- Department of Radiology, UF College of Medicine-Jacksonville, Jacksonville, Florida, United States
| | - Sai Swarupa Reddy Vulasala
- Department of Internal Medicine, East Carolina University Health Medical Center, Greenville, United States.,Corresponding author: Sai Swarupa Reddy Vulasala, Department of Internal Medicine, East Carolina University Health Medical Center, Greenville, United States.
| | - Rachel Stein
- Department of Radiology, UF College of Medicine-Jacksonville, Jacksonville, Florida, United States
| | - Sindhu Kumar
- Department of Radiology, UF College of Medicine-Jacksonville, Jacksonville, Florida, United States
| | - Mayur Virarkar
- Department of Radiology, UF College of Medicine-Jacksonville, Jacksonville, Florida, United States
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4
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Chen Zhou ZH, Martínez Chamorro E, Ibánez Sanz L, Sanz De Lucas R, Chico Fernández M, Borruel Nacenta S. Traumatic arterial injuries in upper and lower limbs: what every radiologist should know. Emerg Radiol 2022; 29:781-790. [PMID: 35513546 DOI: 10.1007/s10140-022-02053-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 04/25/2022] [Indexed: 11/26/2022]
Abstract
Traumatic arterial injuries of the extremities are a rare but potentially fatal event. Computed tomography (CT) angiography of the extremities has become the technique of choice and can provide rapid accurate detection and characterization of vascular lesions. Vascular injuries can be classified in active hemorrhage, vasospasm, occlusion, post-traumatic arteriovenous fistula, pseudoaneurysm, and patterns of intimal injuries. The learning objectives of this pictorial essay are to review the normal arterial anatomy of the upper and lower limbs, describe the technique of CT angiography in vascular trauma of the extremities, describe and illustrate the CT-angiography findings of traumatic arterial injuries, and know the potential pitfalls when interpreting a CT-angiography of the extremities.
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Affiliation(s)
- Zhao Hui Chen Zhou
- Department of Radiology, Hospital Universitario Doce de Octubre, Avenida de Córdoba s/n, 28041, Madrid, Spain.
| | - Elena Martínez Chamorro
- Department of Radiology, Hospital Universitario Doce de Octubre, Avenida de Córdoba s/n, 28041, Madrid, Spain
| | - Laín Ibánez Sanz
- Department of Radiology, Hospital Universitario Doce de Octubre, Avenida de Córdoba s/n, 28041, Madrid, Spain
| | - Raquel Sanz De Lucas
- Department of Radiology, Hospital Universitario Doce de Octubre, Avenida de Córdoba s/n, 28041, Madrid, Spain
| | - Mario Chico Fernández
- Intensive Care Unit, Hospital Universitario Doce de Octubre, Avenida de Córdoba s/n, 28041, Madrid, Spain
| | - Susana Borruel Nacenta
- Department of Radiology, Hospital Universitario Doce de Octubre, Avenida de Córdoba s/n, 28041, Madrid, Spain
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5
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Stefanou N, Arnaoutoglou C, Papageorgiou F, Matsagkas M, Varitimidis SE, Dailiana ZH. Update in combined musculoskeletal and vascular injuries of the extremities. World J Orthop 2022; 13:411-426. [PMID: 35633747 PMCID: PMC9125001 DOI: 10.5312/wjo.v13.i5.411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 10/31/2021] [Accepted: 04/24/2022] [Indexed: 02/06/2023] Open
Abstract
Combined musculoskeletal and vascular injuries of the extremities are conditions in which a multidisciplinary approach is a sine qua non to ensure life initially and limb viability secondarily. Vascular injuries as part of musculoskeletal trauma are usually the result of the release of a high energy load in the wound site so that the prognosis is determined by the degree of soft-tissue damage, duration of limb ischemia, patient’s medical status and presence of associated injuries. The management of these injuries is challenging and requires a specific algorithm of action, because they are usually characterized by increased morbidity, amputation rate, infection, neurological and functional deficits, and they could be life threatening. Although vascular injuries are rare and occur either isolated or in the context of major combined musculoskeletal trauma, the high index of suspicion, imaging control, and timely referral of the patient to organized trauma centers ensure the best functional outcome of the extremity in such challenging cases. Even after a successful initial treatment of a combined trauma pattern, long-term follow-up is crucial to prevent and detect early possible complications. The purpose of this manuscript is to provide an update on diagnosis and treatment of combined musculoskeletal and vascular injuries of the extremities, from an orthopedic point of view.
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Affiliation(s)
- Nikolaos Stefanou
- Department of Orthopaedic Surgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa 41500, Greece
| | - Christina Arnaoutoglou
- Department of Orthopaedic Surgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa 41500, Greece
| | - Fotios Papageorgiou
- Department of Orthopaedic Surgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa 41500, Greece
| | - Miltiadis Matsagkas
- Department of Vascular Surgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa 41500, Greece
| | - Sokratis E Varitimidis
- Department of Orthopaedic Surgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa 41500, Greece
| | - Zoe H Dailiana
- Department of Orthopaedic Surgery, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa 41500, Greece
- Department of Hand, Upper Extremity and Microsurgery, IASO Thessalias, Larissa 41500, Greece
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6
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Bhalla D, Kumar A, Gamanagatti S, Sagar S, Kumar S, Gupta A. Imaging in extremity vascular trauma: can MDCT angiography predict the nature of injury? Emerg Radiol 2022; 29:683-690. [PMID: 35467224 DOI: 10.1007/s10140-022-02050-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 04/14/2022] [Indexed: 10/18/2022]
Abstract
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.
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Affiliation(s)
- Deeksha Bhalla
- Department of Radiodiagnosis, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Atin Kumar
- Department of Radiodiagnosis, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India.
| | - Shivanand Gamanagatti
- Department of Radiodiagnosis, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Sushma Sagar
- Department of Surgical Disciplines, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Subodh Kumar
- Department of Surgical Disciplines, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Amit Gupta
- Department of Surgical Disciplines, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
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Dreizin D, Smith EB, Champ K, Morrison JJ. Roles of Trauma CT and CTA in Salvaging the Threatened or Mangled Extremity. Radiographics 2022; 42:E50-E67. [PMID: 35230918 PMCID: PMC8906352 DOI: 10.1148/rg.210092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
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.
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Affiliation(s)
- David Dreizin
- From the Division of Trauma and Emergency Radiology (D.D., E.B.S.), Department of Diagnostic Radiology and Nuclear Medicine (D.D., E.B.S., K.C.), and Department of Vascular Surgery (J.J.M.), University of Maryland and R Adams Cowley Shock Trauma Center, 655 W Baltimore St, Baltimore, MD 21201
| | - Elana B. Smith
- From the Division of Trauma and Emergency Radiology (D.D., E.B.S.), Department of Diagnostic Radiology and Nuclear Medicine (D.D., E.B.S., K.C.), and Department of Vascular Surgery (J.J.M.), University of Maryland and R Adams Cowley Shock Trauma Center, 655 W Baltimore St, Baltimore, MD 21201
| | - Kathryn Champ
- From the Division of Trauma and Emergency Radiology (D.D., E.B.S.), Department of Diagnostic Radiology and Nuclear Medicine (D.D., E.B.S., K.C.), and Department of Vascular Surgery (J.J.M.), University of Maryland and R Adams Cowley Shock Trauma Center, 655 W Baltimore St, Baltimore, MD 21201
| | - Jonathan J. Morrison
- From the Division of Trauma and Emergency Radiology (D.D., E.B.S.), Department of Diagnostic Radiology and Nuclear Medicine (D.D., E.B.S., K.C.), and Department of Vascular Surgery (J.J.M.), University of Maryland and R Adams Cowley Shock Trauma Center, 655 W Baltimore St, Baltimore, MD 21201
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8
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Weaver JJ, Chick JFB, Monroe EJ, Johnson GE. Life and Limb: Current Concepts in Endovascular Treatment of Extremity Trauma. Semin Intervent Radiol 2021; 38:64-74. [PMID: 33883803 DOI: 10.1055/s-0041-1724011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Traumatic injury is the leading cause of death worldwide in younger patient populations and extremity trauma with associated vascular injury accounts for many trauma-related deaths. Iatrogenic injury is also a common cause of extremity vascular trauma and the incidence of iatrogenic injury will likely increase as endovascular techniques continue to become more ubiquitous. For many vascular injuries involving the extremities, surgical repair is viewed as the standard of care. Historically, endovascular techniques did not play a role in the treatment of these vascular injuries, rather they were utilized only as part of the diagnostic assessment; however, there is an increasing trend toward endovascular management of extremity vascular trauma. No validated, widely implemented algorithm to select patients for endovascular intervention exists. Transcatheter techniques, however, play an important role in the management of these patients. For arterial injuries, embolization can be used to rapidly achieve hemostasis if the vessel can be sacrificed. More advanced endovascular techniques such as stent-graft placement may be best employed in the context of isolated, proximal extremity injuries, although there is increasing literature supporting the use of advanced techniques for more distal arterial injuries. The management of peripheral venous trauma remains controversial; however, there is growing data describing successful endovascular management of some peripheral venous injuries. The purpose of this article is to review extremity vascular trauma, concepts of injury triage, endovascular techniques, and intraprocedural considerations.
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Affiliation(s)
- John J Weaver
- Division of Interventional Radiology, Department of Radiology, University of Washington, Seattle, Washington
| | - Jeffrey F B Chick
- Division of Interventional Radiology, Department of Radiology, University of Washington, Seattle, Washington
| | - Eric J Monroe
- Division of Interventional Radiology, Department of Radiology, University of Washington, Seattle, Washington.,Division of Interventional Radiology, Department of Radiology, Seattle Children's Hospital, Seattle, Washington
| | - Guy E Johnson
- Division of Interventional Radiology, Department of Radiology, University of Washington, Seattle, Washington
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9
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le Roux A, Du Plessis AM, Pitcher R. Yield of CT angiography in penetrating lower extremity trauma. Emerg Radiol 2021; 28:743-749. [PMID: 33619684 DOI: 10.1007/s10140-021-01902-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Accepted: 01/18/2021] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Alwyn le Roux
- Division of Radiodiagnosis, Department of Medical Imaging and Clinical Oncology, Faculty of Medicine and Health Sciences, Stellenbosch University, PO Box 241, Cape Town, 8000, South Africa.
| | - Anne-Marie Du Plessis
- Division of Radiodiagnosis, Department of Medical Imaging and Clinical Oncology, Faculty of Medicine and Health Sciences, Stellenbosch University, PO Box 241, Cape Town, 8000, South Africa
| | - Richard Pitcher
- Division of Radiodiagnosis, Department of Medical Imaging and Clinical Oncology, Faculty of Medicine and Health Sciences, Stellenbosch University, PO Box 241, Cape Town, 8000, South Africa
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10
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Gulmeden C. Reconstruction of mutilating injuries of the lower extremity – Surgical decision-making for the plastic surgeon. TURKISH JOURNAL OF PLASTIC SURGERY 2021. [DOI: 10.4103/tjps.tjps_36_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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11
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Morandi EM, Rieger M, Baur EM, Piza-Katzer H. Three-dimensional CT angiography for surgical planning in congenital hand malformations: a case series presentation. J Hand Surg Eur Vol 2020; 45:1017-1022. [PMID: 32941101 DOI: 10.1177/1753193420954357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Between January 2000 and December 2019, three-dimensional computer tomographic (CT) angiography was used in a total of 140 hands (116 patients, mean age 6.8 years) with congenital hand malformation to assess the vascular and bony structures. Analysis showed overall satisfactory three-dimensional CT images for operative planning, including detailed abnormal vascular patterns and bony malformations. Among the 116 patients, six patients with typical findings of a few malformations are reported in detail. Pitfalls in interpretation of the images and the use of three-dimensional CT angiography in surgical planning are discussed. We conclude that three-dimensional CT angiography is useful for preoperative planning of complex congenital hand malformations.Level of evidence: IV.
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Affiliation(s)
- Evi M Morandi
- Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University Innsbruck, Innsbruck, Austria
| | - Michael Rieger
- Department of Radiology, Community Hospital Hall in Tirol, Innsbruck, Austria
- Department of Radiology, Medical University Innsbruck, Innsbruck, Austria
| | - Eva-Maria Baur
- Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University Innsbruck, Innsbruck, Austria
| | - Hildegunde Piza-Katzer
- Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University Innsbruck, Innsbruck, Austria
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12
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Taljanovic MS, Chang EY, Ha AS, Bartolotta RJ, Bucknor M, Chen KC, Gorbachova T, Khurana B, Klitzke AK, Lee KS, Mooar PA, Nguyen JC, Ross AB, Shih RD, Singer AD, Smith SE, Thomas JM, Yost WJ, Kransdorf MJ. ACR Appropriateness Criteria® Acute Trauma to the Knee. J Am Coll Radiol 2020; 17:S12-S25. [PMID: 32370956 DOI: 10.1016/j.jacr.2020.01.041] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 01/27/2020] [Indexed: 11/20/2022]
Abstract
Acute trauma to the knee is a common presentation seen in the emergency department. After a routine clinical examination, imaging is frequently performed to facilitate the diagnosis and almost always starts with radiographs. If clinically indicated, advanced cross-sectional imaging may then be performed for further evaluation. CT is often performed for preoperative planning of the complex tibial plateau and distal femur fractures. Currently, MRI is the study of choice for evaluation of bone marrow, internal derangements, and other soft-tissue injuries about the knee joint. In patients with knee dislocations, MR angiography may be performed simultaneously with MRI for evaluation of internal derangements and vascular injuries with less morbidity compared to conventional angiography. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
| | - Eric Y Chang
- Panel Chair, VA San Diego Healthcare System, San Diego, California
| | - Alice S Ha
- Panel Vice-Chair, University of Washington, Seattle, Washington
| | | | - Matthew Bucknor
- University of California San Francisco, San Francisco, California
| | - Karen C Chen
- VA San Diego Healthcare System, San Diego, California
| | | | | | - Alan K Klitzke
- Roswell Park Comprehensive Cancer Center, Buffalo, New York
| | - Kenneth S Lee
- University of Wisconsin Hospital & Clinics, Madison, Wisconsin
| | - Pekka A Mooar
- Temple University Hospital, Philadelphia, Pennsylvania; American Academy of Orthopaedic Surgeons
| | - Jie C Nguyen
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Andrew B Ross
- University of Wisconsin School of Medicine & Public Health, Madison, Wisconsin
| | - Richard D Shih
- Schmidt College of Medicine, Florida Atlantic University, Boca Raton, Florida; American College of Emergency Physicians
| | - Adam D Singer
- Emory University School of Medicine, Atlanta, Georgia
| | - Stacy E Smith
- Brigham & Women's Hospital & Harvard Medical School, Boston, Massachusetts
| | - Jonelle M Thomas
- Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - William J Yost
- UnityPoint Health, Des Moines, Iowa; American College of Physicians
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13
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CT angiography of lower extremities from anatomy to traumatic and nontraumatic lesions: a pictorial review. Emerg Radiol 2020; 27:441-450. [PMID: 32221718 DOI: 10.1007/s10140-020-01770-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 03/02/2020] [Indexed: 12/14/2022]
Abstract
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.
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14
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Kuwahara JT, Kord A, Ray CE. Penetrating Extremity Trauma Endovascular versus Open Repair? Semin Intervent Radiol 2020; 37:55-61. [PMID: 32139971 DOI: 10.1055/s-0039-3401840] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
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.
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Affiliation(s)
- Jeffery T Kuwahara
- Division of Interventional Radiology, Department of Radiology, University of Illinois at Chicago, Chicago, Illinois
| | - Ali Kord
- Division of Interventional Radiology, Department of Radiology, University of Illinois at Chicago, Chicago, Illinois
| | - Charles E Ray
- Division of Interventional Radiology, Department of Radiology, University of Illinois at Chicago, Chicago, Illinois
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Adler C, Hangge PT, Albadawi H, Knuttinen MG, Alzubaidi SJ, Naidu SG, Oklu R. Multi-Detector Computed Tomography Imaging Techniques in Arterial Injuries. J Clin Med 2018; 7:jcm7050088. [PMID: 29695034 PMCID: PMC5977127 DOI: 10.3390/jcm7050088] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2018] [Revised: 04/17/2018] [Accepted: 04/18/2018] [Indexed: 12/22/2022] Open
Abstract
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.
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Affiliation(s)
- Cameron Adler
- Department of Vascular and Interventional Radiology, Minimally Invasive Therapeutics Laboratory, Mayo Clinic, Phoenix, AZ 85054, USA.
| | - Patrick T Hangge
- Department of Vascular and Interventional Radiology, Minimally Invasive Therapeutics Laboratory, Mayo Clinic, Phoenix, AZ 85054, USA.
- Department of General Surgery, Mayo Clinic, Phoenix, AZ 85054, USA.
| | - Hassan Albadawi
- Department of Vascular and Interventional Radiology, Minimally Invasive Therapeutics Laboratory, Mayo Clinic, Phoenix, AZ 85054, USA.
| | - M-Grace Knuttinen
- Department of Vascular and Interventional Radiology, Minimally Invasive Therapeutics Laboratory, Mayo Clinic, Phoenix, AZ 85054, USA.
| | - Sadeer J Alzubaidi
- Department of Vascular and Interventional Radiology, Minimally Invasive Therapeutics Laboratory, Mayo Clinic, Phoenix, AZ 85054, USA.
| | - Sailendra G Naidu
- Department of Vascular and Interventional Radiology, Minimally Invasive Therapeutics Laboratory, Mayo Clinic, Phoenix, AZ 85054, USA.
| | - Rahmi Oklu
- Department of Vascular and Interventional Radiology, Minimally Invasive Therapeutics Laboratory, Mayo Clinic, Phoenix, AZ 85054, USA.
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Frostbite, Injury, and Trauma in the Extremities. CURRENT TRAUMA REPORTS 2017. [DOI: 10.1007/s40719-017-0098-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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17
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Madhuripan N, Mehta P, Smolinski SE, Njuguna N. Computed Tomography Angiography of the Extremities in Emergencies. Semin Ultrasound CT MR 2017; 38:357-369. [DOI: 10.1053/j.sult.2017.03.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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Stacy MR, Dearth CL. Multimodality Imaging Approaches for Evaluating Traumatic Extremity Injuries: Implications for Military Medicine. Adv Wound Care (New Rochelle) 2017; 6:241-251. [PMID: 28736684 DOI: 10.1089/wound.2016.0716] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Accepted: 12/22/2016] [Indexed: 01/08/2023] Open
Abstract
Significance: Military service members are susceptible to traumatic extremity injuries that often result in limb loss. Tremendous efforts have been made to improve medical treatment that supports residual limb function and health. Despite recent improvements in treatment and novel prosthetic devices, many patients experience a wide range of clinical problems within residual limbs that can negatively impact the progress of rehabilitation programs while also impairing functional capacity and overall quality of life. Recent Advances: In addition to existing standard imaging modalities that are used for clinical evaluation of patients suffering from traumatic extremity injury, novel noninvasive imaging techniques are in development that may facilitate rapid and sensitive assessment of various aspects of traumatic extremity injuries and residual limb health. Critical Issues: Despite recent advances, there remains a clinical need for noninvasive quantitative imaging techniques that are capable of providing rapid objective assessments of residual limb health at the time of initial presentation as well as after various forms of medical treatment. Future Directions: Ongoing development of imaging techniques that allow for assessment of anatomical and physiological characteristics of extremities exposed to traumatic injury should greatly enhance the quality of patient care and assist in optimizing clinical outcomes.
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Affiliation(s)
- Mitchel R. Stacy
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Christopher L. Dearth
- DOD-VA Extremity Trauma and Amputation Center of Excellence, Walter Reed National Military Medical Center, Bethesda, Maryland
- Research and Development Section, Department of Rehabilitation, Walter Reed National Military Medical Center, Bethesda, Maryland
- Regenerative Biosciences Laboratory, Department of Rehabilitation Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland
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Role of lower extremity run-off CT angiography in the evaluation of acute vascular disease. Abdom Radiol (NY) 2017; 42:1028-1045. [PMID: 27730328 DOI: 10.1007/s00261-016-0907-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
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.
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Masi Z, Gussman K, Hazelton JP, Gefen R. 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? Emerg Radiol 2017; 24:335-340. [PMID: 28150047 DOI: 10.1007/s10140-017-1480-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2016] [Accepted: 01/16/2017] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- Zachary Masi
- Department of Radiology, Cooper University Hospital, Cooper Medical School of Rowan University, One Cooper Plaza, Camden, NJ, 08103, USA
| | - Kathryn Gussman
- Cooper Medical School of Rowan University, One Cooper Plaza, Camden, NJ, 08103, USA
| | - Joshua P Hazelton
- Department of Surgery, Cooper University Hospital, Cooper Medical School of Rowan University, One Cooper Plaza, Camden, NJ, 08103, USA
| | - Ron Gefen
- Department of Radiology, Cooper University Hospital, Cooper Medical School of Rowan University, One Cooper Plaza, Camden, NJ, 08103, USA.
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21
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When are CT angiograms indicated for patients with lower extremity fractures? A review of 275 extremities. J Trauma Acute Care Surg 2017; 82:133-137. [DOI: 10.1097/ta.0000000000001258] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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22
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Colip CG, Gorantla V, LeBedis CA, Soto JA, Anderson SW. Extremity CTA for penetrating trauma: 10-year experience using a 64-detector row CT scanner. Emerg Radiol 2016; 24:223-232. [DOI: 10.1007/s10140-016-1469-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Accepted: 11/15/2016] [Indexed: 11/30/2022]
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23
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Clinical indications for CT angiography in lower extremity trauma. CURRENT ORTHOPAEDIC PRACTICE 2016. [DOI: 10.1097/bco.0000000000000397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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24
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Contemporary outcomes of lower extremity vascular repairs extending below the knee. J Trauma Acute Care Surg 2016; 81:63-70. [DOI: 10.1097/ta.0000000000000996] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Mavrogenis AF, Panagopoulos GN, Kokkalis ZT, Koulouvaris P, Megaloikonomos PD, Igoumenou V, Mantas G, Moulakakis KG, Sfyroeras GS, Lazaris A, Soucacos PN. Vascular Injury in Orthopedic Trauma. Orthopedics 2016; 39:249-59. [PMID: 27322172 DOI: 10.3928/01477447-20160610-06] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Accepted: 11/30/2015] [Indexed: 02/03/2023]
Abstract
Vascular injury in orthopedic trauma is challenging. The risk to life and limb can be high, and clinical signs initially can be subtle. Recognition and management should be a critical skill for every orthopedic surgeon. There are 5 types of vascular injury: intimal injury (flaps, disruptions, or subintimal/intramural hematomas), complete wall defects with pseudoaneurysms or hemorrhage, complete transections with hemorrhage or occlusion, arteriovenous fistulas, and spasm. Intimal defects and subintimal hematomas with possible secondary occlusion are most commonly associated with blunt trauma, whereas wall defects, complete transections, and arteriovenous fistulas usually occur with penetrating trauma. Spasm can occur after either blunt or penetrating trauma to an extremity and is more common in young patients. Clinical presentation of vascular injury may not be straightforward. Physical examination can be misleading or initially unimpressive; a normal pulse examination may be present in 5% to 15% of patients with vascular injury. Detection and treatment of vascular injuries should take place within the context of the overall resuscitation of the patient according to the established principles of the Advanced Trauma Life Support (ATLS) protocols. Advances in the field, made mostly during times of war, have made limb salvage the rule rather than the exception. Teamwork, familiarity with the often subtle signs of vascular injuries, a high index of suspicion, effective communication, appropriate use of imaging modalities, sound knowledge of relevant technique, and sequence of surgical repairs are among the essential factors that will lead to a successful outcome. This article provides a comprehensive literature review on a subject that generates significant controversy and confusion among clinicians involved in the care of trauma patients. [Orthopedics. 2016; 39(4):249-259.].
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Tuite MJ, Kransdorf MJ, Beaman FD, Adler RS, Amini B, Appel M, Bernard SA, Dempsey ME, Fries IB, Greenspan BS, Khurana B, Mosher TJ, Walker EA, Ward RJ, Wessell DE, Weissman BN. ACR Appropriateness Criteria Acute Trauma to the Knee. J Am Coll Radiol 2015; 12:1164-72. [DOI: 10.1016/j.jacr.2015.08.014] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Accepted: 08/16/2015] [Indexed: 01/03/2023]
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27
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Branco BC, Linnebur M, Boutrous ML, Leake SS, Inaba K, Charlton-Ouw KM, Azizzadeh A, Fortuna G, DuBose JJ. The predictive value of multidetector CTA on outcomes in patients with below-the-knee vascular injury. Injury 2015; 46:1520-6. [PMID: 26105130 DOI: 10.1016/j.injury.2015.06.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2015] [Revised: 05/25/2015] [Accepted: 06/01/2015] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
| | - Megan Linnebur
- Division of Trauma and Surgical Critical Care, University of Southern California, Los Angeles, CA, USA
| | - Mina L Boutrous
- Department of Cardiothoracic and Vascular Surgery, University of Texas Medical School at Houston, Herman Memorial Hospital, 6400 Fannin St, Suite 2850, Houston, TX 77030, USA
| | - Samuel S Leake
- Department of Cardiothoracic and Vascular Surgery, University of Texas Medical School at Houston, Herman Memorial Hospital, 6400 Fannin St, Suite 2850, Houston, TX 77030, USA
| | - Kenji Inaba
- Division of Trauma and Surgical Critical Care, University of Southern California, Los Angeles, CA, USA
| | - Kristofer M Charlton-Ouw
- Department of Cardiothoracic and Vascular Surgery, University of Texas Medical School at Houston, Herman Memorial Hospital, 6400 Fannin St, Suite 2850, Houston, TX 77030, USA
| | - Ali Azizzadeh
- Department of Cardiothoracic and Vascular Surgery, University of Texas Medical School at Houston, Herman Memorial Hospital, 6400 Fannin St, Suite 2850, Houston, TX 77030, USA
| | - Gerald Fortuna
- Department of Cardiothoracic and Vascular Surgery, University of Texas Medical School at Houston, Herman Memorial Hospital, 6400 Fannin St, Suite 2850, Houston, TX 77030, USA
| | - Joseph J DuBose
- Department of Cardiothoracic and Vascular Surgery, University of Texas Medical School at Houston, Herman Memorial Hospital, 6400 Fannin St, Suite 2850, Houston, TX 77030, USA.
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Baker JC, Hillen TJ, Demertzis JL. The role of imaging in musculoskeletal emergencies. Semin Roentgenol 2014; 49:169-85. [PMID: 24836492 DOI: 10.1053/j.ro.2014.01.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Affiliation(s)
- Jonathan C Baker
- Musculoskeletal Section, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO.
| | - Travis J Hillen
- Musculoskeletal Section, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO
| | - Jennifer L Demertzis
- Musculoskeletal Section, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO
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Management of major limb injuries. ScientificWorldJournal 2014; 2014:640430. [PMID: 24511296 PMCID: PMC3913364 DOI: 10.1155/2014/640430] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2013] [Accepted: 10/02/2013] [Indexed: 12/16/2022] Open
Abstract
Management of major limb injuries is a daunting challenge, especially as many of these patients have severe associated injuries. In trying to save life, often the limb is sacrificed. The existing guidelines on managing such trauma are often confusing. There is scope to lay down such protocols along with the need for urgent transfer of such patients to a multispecialty center equipped to salvage life and limb for maximizing outcome. This review article comprehensively deals with the issue of managing such major injuries.
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Jens S, Kerstens M, Legemate D, Reekers J, Bipat S, Koelemay M. Diagnostic Performance of Computed Tomography Angiography in Peripheral Arterial Injury due to Trauma: A Systematic Review and Meta-analysis. Eur J Vasc Endovasc Surg 2013; 46:329-37. [DOI: 10.1016/j.ejvs.2013.04.034] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2013] [Accepted: 04/26/2013] [Indexed: 11/30/2022]
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Zaiton F, Ahmed AF, Samir AM. Value of multislice computed tomography angiography (MCTA) in neglected post traumatic vascular injuries of the extremities. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2013. [DOI: 10.1016/j.ejrnm.2013.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
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Chien LJ, Su YJ, Chen CC, Tsai W. Sonographic detection of pseudoaneurysm in vascular injury in emergency department. Sultan Qaboos Univ Med J 2013; 13:E350-2. [PMID: 23862052 DOI: pmid/23862052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2012] [Revised: 10/14/2012] [Accepted: 11/26/2012] [Indexed: 02/07/2023] Open
Abstract
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.
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Affiliation(s)
- Li-Jen Chien
- Department of Emergency Medicine, Mackay Memorial Hospital, Taipei, Taiwan
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Suárez Poveda T, Morales Uribe CH, Cruz Vásquez R, Montoya Arango MDP, Ochoa Escudero M. [Efficacy of multidetector computed angiotomography in the diagnosis of limb arterial injuries]. Cir Esp 2012; 91:257-62. [PMID: 23063204 DOI: 10.1016/j.ciresp.2012.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2012] [Revised: 06/22/2012] [Accepted: 07/11/2012] [Indexed: 11/24/2022]
Abstract
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.
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Crist BD, Ferguson T, Murtha YM, Lee MA. Surgical timing of treating injured extremities. J Bone Joint Surg Am 2012; 94:1514-24. [PMID: 22992821 DOI: 10.2106/jbjs.l.00414] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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35
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Tuite MJ, Daffner RH, Weissman BN, Bancroft L, Bennett DL, Blebea JS, Bruno MA, Fries IB, Hayes CW, Kransdorf MJ, Luchs JS, Morrison WB, Roberts CC, Scharf SC, Stoller DW, Taljanovic MS, Ward RJ, Wise JN, Zoga AC. ACR appropriateness criteria(®) acute trauma to the knee. J Am Coll Radiol 2012; 9:96-103. [PMID: 22305695 DOI: 10.1016/j.jacr.2011.10.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2011] [Accepted: 10/24/2011] [Indexed: 01/03/2023]
Abstract
There are more than 1 million visits to the ER annually in the United States for acute knee trauma. Many of these are twisting injuries in young patients who can walk and bear weight, and emergent radiography is not required. Several clinical decision rules have been devised that can considerably reduce the number of radiographic studies ordered without missing a clinically significant fracture. Although fractures are seen on only 5% of emergency department knee radiographs, 86% of knee fractures result from blunt trauma. In patients with falls or twisting injuries who have focal tenderness, effusion, or inability to bear weight, radiography should be the first imaging study performed. If radiography shows no fracture, MRI is best for evaluating for a suspected meniscal or ligament tear or patellar dislocation. Patients with knee dislocation should undergo radiography and MRI, as well as fluoroscopic angiography, CT angiography, or MR angiography. The ACR Appropriateness Criteria(®) are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.
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The role of preoperative radiological assessment of vascular injury on surgical decision making in mutilating injuries of the upper extremity. Ann Plast Surg 2012; 70:289-95. [PMID: 22214801 DOI: 10.1097/sap.0b013e318233fdaf] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Preoperative assessment of the extent of vascular injury is important in patients with mutilating injuries of the upper extremity. The aim of this report was to discuss the influence of computed tomography angiography (CTA) and digital subtraction angiography (DSA) on the operating room decision-making in mutilating injuries and limb-salvage procedures of the traumatic upper extremity. Four DSA and 3 CTA were performed in 7 patients with a mean age of 28.3 (range, 4-48) years. The results of the DSA and CTA altered the preoperative planning. In 5 patients, the reconstructive decision of the type of flap was altered, whereas in all 7 patients, either the level or type of anastomosis was changed after radiologic investigations. The mean follow-up period was 37.8 months. During the follow-up period, all patients underwent subsequent procedures such as sensory restoration, tendon reconstruction, or capsulotomy. The effects of radiologic results in which flap selection, target donor vessel, and level and type of anastomosis have changed are discussed in correlation with intraoperative findings.
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Patterson BO, Holt PJ, Cleanthis M, Tai N, Carrell T, Loosemore TM. Imaging vascular trauma. Br J Surg 2011; 99:494-505. [DOI: 10.1002/bjs.7763] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/16/2011] [Indexed: 01/06/2023]
Abstract
Abstract
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.
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Affiliation(s)
- B O Patterson
- St George's Vascular Institute, St George's University of London, London, UK
| | - P J Holt
- St George's Vascular Institute, St George's University of London, London, UK
| | - M Cleanthis
- Imperial College Regional Vascular Unit, Imperial College Healthcare NHS Trust, London, UK
| | - N Tai
- Trauma Clinical Academic Unit, Barts and the London NHS Trust, London, UK
| | - T Carrell
- National Institute for Health Research Comprehensive Biomedical Research Centre of Guy's and St Thomas' NHS Foundation Trust and Department of Vascular Surgery, King's College London, London, UK
| | - T M Loosemore
- St George's Vascular Institute, St George's University of London, London, UK
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Foster BR, Anderson SW, Uyeda JW, Brooks JG, Soto JA. Integration of 64-Detector Lower Extremity CT Angiography into Whole-Body Trauma Imaging: Feasibility and Early Experience. Radiology 2011; 261:787-95. [DOI: 10.1148/radiol.11100604] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Evaluation and management of peripheral vascular injury. Part 1. Western Trauma Association/critical decisions in trauma. ACTA ACUST UNITED AC 2011; 70:1551-6. [PMID: 21817992 DOI: 10.1097/ta.0b013e31821b5bdd] [Citation(s) in RCA: 80] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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Mazzini FN, Vu T, Prichayudh S, Sciarretta JD, Chandler J, Lieberman H, Marini C, Asensio JA. Operative exposure and management of axillary vessel injuries. Eur J Trauma Emerg Surg 2011; 37:451. [PMID: 26815415 DOI: 10.1007/s00068-011-0134-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2011] [Accepted: 06/19/2011] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Axillary vessel injuries are uncommon and challenging injuries encountered by trauma surgeons. Proximity of this vessel to other adjacent veins including the axillary vein, brachial plexus and the osseous structures of the shoulder and upper arm account for a large number of associated injuries. MATERIALS AND METHODS Systematic review of the literature, with emphasis on the diagnosis, treatment and outcomes of these injuries, incorporating the authors' experience. CONCLUSIONS Although uncommon, axillary arterial injuries can result in significant morbidity, limb loss and mortality. Early diagnosis and timely repair of the artery leads to good outcomes.
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Affiliation(s)
- F N Mazzini
- Division of Trauma Surgery and Surgical Critical Care, Dewitt-Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Ryder Trauma Center, 1800 NW 10 Avenue Suite T-247, Miami, FL, 33136-1018, USA
| | - T Vu
- Division of Trauma Surgery and Surgical Critical Care, Dewitt-Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Ryder Trauma Center, 1800 NW 10 Avenue Suite T-247, Miami, FL, 33136-1018, USA
| | - S Prichayudh
- Division of Trauma Surgery and Surgical Critical Care, Dewitt-Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Ryder Trauma Center, 1800 NW 10 Avenue Suite T-247, Miami, FL, 33136-1018, USA
| | - J D Sciarretta
- Division of Trauma Surgery and Surgical Critical Care, Dewitt-Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Ryder Trauma Center, 1800 NW 10 Avenue Suite T-247, Miami, FL, 33136-1018, USA
| | - J Chandler
- Division of Trauma Surgery and Surgical Critical Care, Dewitt-Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Ryder Trauma Center, 1800 NW 10 Avenue Suite T-247, Miami, FL, 33136-1018, USA
| | - H Lieberman
- Division of Trauma Surgery and Surgical Critical Care, Dewitt-Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Ryder Trauma Center, 1800 NW 10 Avenue Suite T-247, Miami, FL, 33136-1018, USA
| | - C Marini
- Division of Trauma Surgery and Surgical Critical Care, Dewitt-Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Ryder Trauma Center, 1800 NW 10 Avenue Suite T-247, Miami, FL, 33136-1018, USA
| | - J A Asensio
- Division of Trauma Surgery and Surgical Critical Care, Dewitt-Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Ryder Trauma Center, 1800 NW 10 Avenue Suite T-247, Miami, FL, 33136-1018, USA.
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Abstract
Since the development of angiography and transcatheter techniques, interventional radiology has played an important role in the management of trauma patients. The ability to treat life-threatening hemorrhage with transcatheter embolization has spared countless patients the morbidity of surgery. Advances in cross-sectional imaging and increases in understanding of which patients will best benefit from embolization promise to further refine the interventional radiologist's role. As the applications of transcatheter therapy broaden to include embolization of unstable patients with solid organ injuries and endovascular repair of major arterial injuries, the interventional radiologist must be increasingly prepared to provide prompt, efficient, and high-quality service.
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Affiliation(s)
- Jennifer E Gould
- Interventional Radiology, Mallinckrodt Institute of Radiology, St. Louis, Missouri
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Wallin D, Yaghoubian A, Rosing D, Walot I, Chauvapun J, de Virgilio C. Computed Tomographic Angiography as the Primary Diagnostic Modality in Penetrating Lower Extremity Vascular Injuries: A Level I Trauma Experience. Ann Vasc Surg 2011; 25:620-3. [DOI: 10.1016/j.avsg.2011.02.022] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2010] [Revised: 02/09/2011] [Accepted: 02/10/2011] [Indexed: 11/30/2022]
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Prospective Evaluation of Multidetector Computed Tomography for Extremity Vascular Trauma. ACTA ACUST UNITED AC 2011; 70:808-15. [DOI: 10.1097/ta.0b013e3182118384] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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CT emergencies. Emerg Radiol 2009. [DOI: 10.1017/cbo9780511691935.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Cardiovascular and chest. Emerg Radiol 2009. [DOI: 10.1017/cbo9780511691935.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Free tissue transfer for lower extremity reconstruction: a study of the role of computed angiography in the planning of free tissue transfer in the posttraumatic setting. Plast Reconstr Surg 2009; 124:523-529. [PMID: 19644269 DOI: 10.1097/prs.0b013e3181addafa] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Computed tomographic angiography can be used as a means of assessing lower leg vasculature before performing free tissue transfer, but its reliability within a trauma setting has not been evaluated. The aim of this study was to examine the findings of preoperative computed tomographic angiography and correlate these findings to flap survival and limb salvage. METHODS Seventy-six consecutive lower extremity trauma patients underwent preoperative computed tomographic angiography before free flap reconstruction. Arterial inflow, venous outflow, and the incidence of traumatic occlusion were recorded. Flap survival rates, limb salvage, and postoperative complications were noted. RESULTS There were no complications associated with the computed tomographic angiography procedure. Computed tomographic angiography demonstrated normal vascular anatomy in 40 patients (52.6 percent), anatomical variants in seven patients, and atherosclerotic occlusive disease in six patients. Traumatic arterial occlusion was identified in 22 patients (28.9 percent). Flap failure was seen in five patients and the limb salvage rate was 94.7 percent. All four of the limbs amputated had at least a single artery occluded on preoperative computed tomographic angiography; preoperative arterial occlusion was found to be a significant predictor of limb loss (p < 0.05). CONCLUSIONS The incidence of single-vessel traumatic arterial occlusion within traumatized lower limbs undergoing free tissue transfer may be as high as 29 percent. Computed tomographic angiography provided excellent visualization of lower extremity vasculature, and its routine use for trauma patients is safe. Flap failure rates were low when using this technique for preoperative planning. Flap failure occurred only in patients with evidence of arterial injury. Evidence of arterial occlusion on computed tomographic angiography may be a risk factor for limb loss.
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A prospective validation of a current practice: the detection of extremity vascular injury with CT angiography. ACTA ACUST UNITED AC 2009; 67:238-43; discussion 243-4. [PMID: 19667874 DOI: 10.1097/ta.0b013e3181a51bf9] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
INTRODUCTION Arteriography is the current "gold standard" for the detection of extremity vascular injuries. Less invasive than operative exploration, conventional arteriography (CA) still has a 1% to 3% risk of morbidity and may delay definitive repair. Recent improvements in computed tomography (CT) technology has since broadened the application of CT to include the diagnosis of cervical, thoracic, and now extremity vascular injury. We hypothesized that CT angiography (CTA) provides equivalent injury detection compared with the more invasive CA, but is more rapidly completed and more cost effective. METHODS A prospective evaluation of patients, ages 18 to 50, with potential extremity vascular injuries was performed during 2006-2007. Ankle-brachial indices (ABI) of injured extremities were measured on presentation in all patients without hard signs of vascular injury. Patients whose injured extremity ABI was <0.9 were enrolled and underwent CTA followed by either CA or operative exploration if CTA findings were limb threatening. Interventionalists were blinded to CTA findings before performing and reading CAs. RESULTS Twenty-one patients (mean age, 26.1 +/- 7.1 years) had 22 extremity CTAs after gunshot (82%), stab (9%), or pedestrian struck by automobile (9%) injuries to either upper (32%) or lower (68%) extremities. Eleven of 22 (50%) extremities had associated orthopedic injuries while the mean ABI of the study population was 0.72 +/- 0.21. Twenty-one of 22 (96%) CTAs were diagnostic and all CTAs were confirmed by either CA alone (n = 18), operative exploration (n = 2), or both CA and operative exploration (n = 2). Diagnostic CTAs had 100% sensitivity and specificity for clinically relevant vascular injury detection. Unlike rapidly obtained CTA, CA required 131 +/- 61 minutes (mean +/- SD) to complete. In our center, CTA saves $12,922 in patient charges and $1,166 in hospital costs per extremity when compared with CA. CONCLUSIONS With acceptable injury detection, rapid availability, and a favorable cost profile, our results suggest that CTA may replace CA as the diagnostic study of choice for vascular injuries of the extremities.
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Pediatric Extremity Multidetector Computed Tomographic Angiography Findings. J Comput Assist Tomogr 2009; 33:770-5. [DOI: 10.1097/rct.0b013e3181949b58] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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