Vascular Diagnosis
Proximity Injuries: Correlation with Results of Extremity Arteriography! Stephen H. Smyth, MD Gerald D. Pond, MD Phillip L. Johnson, MD 2 Robert F. Rauch, MD Kenneth E. Mcintyre, MD
Index terms: Arteries, injuries, 91.41, 92.41 • Extremities, angiography, 91.122, 92.122 • Extremities, injuries, 91.41, 92.41 • Trauma, 91.41, 92.41
JVIR 1991; 2:451-456
The results of 170 emergency arteriography procedures in 142 patients who had sustained extremity injuries near major arteries were correlated with the findings from a physical examination conducted prior to arteriography. Radiographically demonstrable significant arterial injuries, which usually required surgical repair, were present at 42 of the 170 injury sites (25%). Major physical findings suggestive of arterial injury were noted at 105 of 170 sites (62%). Arteriography demonstrated a significant injury in 40 (38%) of these 105 injury sites, representing 95% of all major arterial injuries. Among the 65 injury sites without any suggestive major physical finding, only two were associated with a significant vascular injury at arteriography (3%) (5% of all 42 arterial injuries). At each ofthese 65 injury sites, the decision to perform emergency arteriography was based solely on the proximity of the wound to a major artery. In spite of this very low yield in the subgroup of 51 patients without major physical findings, emergency arteriography is still routinely requested for extremity injuries at the authors' institutions. The validity of this policy, a possible reason for its development, and its effect on patient disposition are examined.
~TERIOGRAPHY is a reliable and ac-
1 From the Departments of Radiology, Section of Vascular and Interventional Radiology (S.H.S., G.D.P., P.L.J.), and Surgery, Section of Vascular Surgery (K.E.M.), University of Arizona Health Sciences Center, 1501 N Campbell Ave, Tucson, AZ 85724, and the Department of Radiology, Tucson Medical Center, Tucson (R.F.R.). Received January 2, 1991; revision requested March 11; revision received July 16; accepted July 25. Address reprint requests to G.D.P. 2 Current address: Baptist Medical Center, Oklahoma City.
©
SCVIR, 1991
curate means of evaluating vascular injury in the extremities (1-11). However, its utilization in injuries unassociated with major physical findings (on the basis of proximity to major arteries only) has become increasingly controversial. Although a number of studies document the low yield of arteriography when proximity to major arteries is the only indication (2,6,12-20), this finding still remains a commonly used indication. The tendency to perform emergency arteriography of all extremity injuries regardless of physical findings may be a holdover from surgical procedures established in wartime, when the majority of wounds were of the extremely severe variety associated with high-velocity missiles. The nature of extremity injury in the civilian setting differs substantially from that in war. These injuries are most commonly inflicted by low-velocity missiles (handguns) but also include
lacerations (knife or glass) and fractures or dislocations. Notwithstanding, many surgeons still advocate emergency arteriography or surgical exploration of all injuries regardless of mechanism (21-28). This study is a retrospective correlation of the findings at arteriography and physical examination in patients who had sustained wounds to the extremities in the civilian setting at two level I trauma centers. Also noted was the disposition of each patient, regardless of whether the arteriographic findings were positive or negative.
PATIENTS AND METHODS Patients who had undergone emergency arteriography for suspected vascular injury to an extremity were identified by reviewing the angiography logbooks and trauma registries from a 5-year period (1985-1989) at two level I trauma centers. In all in-
451
452 • Journal of Vascular and Interventional Radiology November 1991
stances, the decision to request arteriography was made by a group of trauma surgeons on the basis of the mechanism of injury and physical findings, as well as the proximity of the injury to a major artery. Although noninvasive studies, including conventional and color Doppler ultrasonography, may often provide valuable data, the surgeons at our institutions prefer arteriography as the procedure of choice in the emergency setting. No attempt was made to evaluate these lesions with noninvasive studies or compare noninvasive studies with angiographic findings. Arteriography was performed by radiologists experienced in angiography with either conventional or digital technique. Each patient's medical record was reviewed to obtain historical data and the physical findings reported by the trauma team prior to angiography. The arteriograms were independently interpreted by two senior vascular radiologists. A third radiologist was available for any disagreements for a consensus diagnosis, but no discrepancies regarding significant arterial injuries were encountered. Upper extremity injuries were those at or distal to the axilla, and lower extremity injuries were those at or distal to the inguinalligament. Arteriographic findings considered to be evidence of significant vascular injury included contrast material extravasation, occlusion, transection, thrombosis, intimal flap, pseudoaneurysm, or arteriovenous fistula. On physical examination, major findings considered suggestive of a serious arterial injury included hypotension (unexplained by another bleeding source), diminished or absent pulse, a large or expanding hematoma, active bleeding from the wound, bruit, or evidence of distal ischemia (pallor or cyanosis). The injuries were grouped by mechanism into gunshot wounds, lacerations, and fracture or dislocations. The positive and negative predictive values of physical findings for radiographically demonstrable significant vascular
injury were then determined. Also determined was the disposition of each patient, regardless of whether the arteriogram was positive or negative.
RESULTS The patients were predominantly male (122 of 142 [86%]). Ages ranged from 6 to 81 years (mean, 30 years). There were 170 individual, noncontiguous injury sites in 142 patients. Of these sites, 83 were due to gunshot wounds (49%), 62 were due to fractures and/or dislocations (36%), and 25 were due to lacerations produced by a knife or other foreign object (15%). Two patients with significant soft-tissue (crush) injuries were also included in the last category, although there was no cutaneous puncture wound. Among the gunshot wounds, the injury was known to be due to a low-velocity (less than 1,800 ftlsec [550 m/sec]) missile at 59 of83 sites (71%). For 23 ofthe 83 gunshot wounds, the type of weapon used was either unknown or unspecified in the record (28%). However, the soft-tissue injuries in these 23 patients were not of the type expected from highvelocity rounds, which produce catastrophic soft-tissue (cavitation) injury. There were only three shotgun wounds in this series, representing 2% of all injuries, and only 4% of all gunshot wounds. Shotgun wounds are low velocity, but are caused by multiple and usually small individual missiles. There was only one injury documented to be due to a high-velocity missile, that from a .30 caliber rifle (1%). Among the 170 injury sites, 105 were associated with a major physical finding suggesting vascular injury (62%). At arteriography, significant injury was documented in 40 (38%) of these 105 sites. Among the 65 of 170 (38%) injury sites unassociated with any major physical finding, only two patients had a significant vascular injury at arteriography (3%). Of these two patients, only one underwent surgical repair of the injured
Table 1 Mechanism of Injury Mechanism No. of Injuries Gunshot wound 83 (49) 62 (36) Fracture/dislocation Laceration 25 (15) Total 170 (100) Note.-Numbers in parentheses are percentages.
vessel. The other patient was observed, and arterial repair was not performed (occluded posterior tibial artery following crush injury). Tables 1 and 2 summarize the mechanism of injury, the number of cases with or without major physical findings, and the number of cases in which significant vascular injury was identified. When the data from the three mechanisms of injury are combined, the positive predictive value of at least one major physical finding was 0.38, whereas the negative predictive value of absence of a major finding, that is, proximity-only cases was 0.97. The extremely low prevalence of significant vascular injury in the absence of major physical findings is statistically significant by means of X2 analysis at P < .05 level, whether the expected value versus the observed value chosen for analysis was chance, the prevalence of vascular injury for all patients, or the prevalence of injury among those with major physical findings. Of all 142 patients, 140 were admitted for a period of 12 hours or more (99%). Only two patients were discharged after the arteriogram was found to be normal (1%).
DISCUSSION The current controversy regarding the need to perform arteriography for possible vascular injury of an extremity in the absence of major physical findings reflects the continuing evolution of a long-standing controversy regarding the diagnosis and management of these injuries.
Smyth et al • 453 Volume 2 Number 4
Table 2 Relationship between Major Physical Findings and Significant Vascular Injury With Significant Without Significant Vascular Injury Vascular Injury No. ofInjury Sites 105 with at least one major physical finding 40 65 65 without any major physical finding 63 2
During World War II, the majority of extremity arterial injuries were treated by means of ligation of the vessel, with few attempts (5%) at vascular repair (29). From the Vietnam experience, a review of 1,000 extremity vascular injuries revealed that ligation was performed in only 1.5%, while primary vascular repair was attempted in 92.3% of all cases (30). These wartime experiences led to a heightened recognition of the catastrophic soft-tissue effects of highvelocity missiles (muzzle velocity > 1,800 ft/sec [550 m/sec]), specifically cavitation injury, which requires prompt and extensive surgical debridement (31). These principles of surgical exploration were initially extended to the civilian arena, with some surgeons advocating mandatory surgical exploration of all extremity injuries regardless of mechanism (21,23-28). However, since the late 1970s, the reliability of arteriography has resulted in its increased use for evaluating acute extremity vascular injury (1,4-6,8,11,22,32-34). Arteriography has, in great part, eliminated the need for surgical exploration in many patients. Now, surgeons tend to be advocates not of surgical exploration of every extremity injury, but of angiographic evaluation of all cases, regardless of the findings at physical examination. Recently, a number of studies have questioned the need for routine emergency angiography of injured extremities without signs of major vascular injury on physical examination (7,8,1215). In our study, we found a 3% prevalence of major vascular injury in patients without a major physical finding. This is at the low end of the
range reported in studies from the late 1970s and early 1980s (3.6%21%) (1,2,5,6,14,16,31). However, the 3% yield falls within the range (0%9%) reported in the most recent literature (12,16-20,35,36). While no good explanation for the changes in the prevalence of these injuries has been set forth, factors could include differences in study design (retrospective vs prospective), varying skills in the performance of physical examination, and different methods of injury. Concerns about failure to diagnose significant vascular injuries in patients lacking a major physical finding continue to drive surgeons to advocate arteriography. While the low prevalence of major vascular injury does not by itselfjustify elimination of arteriography, some authors maintain that such injuries are uncommon and the natural history of clinically silent arterial injuries is benign (36-38). This assertion will need additional validation before it is generally accepted. At the very least, however, the available data support the need to reassess the current standard of universal emergency arteriography. Shotgun wounds, which were uncommon in this series, may require a different approach than wounds inflicted by a single low-velocity projectile, such as a pistol, due to the sheer number of penetrating injuries and the greater likelihood of vascular insult. This is suggested in one study (38) in which arterial injuries from shotgun wounds (three of 17,17.6%) were almost twice as frequent as those from handgun wounds (24 of 247, 9.7%) or stab wounds (five of 54, 9.3%). This possibility will also re-
quire further study. The argument often presented to justify emergency arteriography is that a negative arteriogram will allow immediate discharge, as opposed to admission to the hospital. The findings of this study contradict that argument. Among the 51 patients with proximity injuries alone, 49 (96%) were admitted for observation for a minimum of 12 hours. Patients undergoing arteriography are typically observed for a period of several hours after the procedure, often for longer periods due to other injuries. On the basis of findings from this study, it is our position that the best approach for the majority of patients with extremity injuries without major physical findings is observation and/or elective arteriography. References 1. Snyder WH III, Thal ER, Bridges RA, et al. The validity of normal arteriography in penetrating trauma. Arch Surg 1978; 113:424428. 2. Geuder JW, Hobson RW II, Padberg FT, et al. The role of contrast arteriography in suspected arterial injuries of the extremities. Am Surg 1985; 51:89-93. 3. Ben-Menachem Y. Vascular injuries of the extremities: hazards of unnecessary delays in diagnosis. Orthopedics 1986; 9:333-335. 4. Redman HC. Thoracic, abdominal, and peripheral trauma: evaluation with angiography. JAMA 1977; 237: 2415-2418. 5. Keeley SB, Snyder WH III, Weigelt JA. Arterial injuries below the knee: fifty-one patients with 82 injuries. J Trauma 1983; 23:285-292. 6. O'Gorman RB, Feliciano DV, Bitondo CG, et al. Emergency center arteriography in the evaluation of suspected peripheral vascular injuries. Arch Surg 1984; 119:568-573. 7. McDonald EJ Jr, Goodman PC, Winestock DP. The clinical indications for arteriography in trauma to the extremity: a review of 114 cases. Radiology 1975; 116:45-47. 8. Rees R, BonnevaI M, Batson R, et aI. Angiography in extremity trauma: a prospective study. Am Surg 1978; 44:661-663. 9. Sirinek KR, Gaskill HV III, Dittman WI, Levine AL. Exclusion angiog-
454 • Journal of Vascular and Interventional Radiology November 1991
10.
11.
12.
13.
14.
15.
16.
17.
18.
raphy for patients with possible vascular injuries of the extremities. Surgery 1983; 94:598-603. Howard CA, Thal ER, Redman HC, Gibson P. Intra-arterial digital subtraction angiography in the evaluation of peripheral vascular trauma. Ann Surg 1989; 210:108111. Sclafani SJA, Cooper R, Shaftan GW, et al. Arterial trauma: diagnostic and therapeutic angiography. Radiology 1986; 161:165-172. Hartling RP, McGaham JP, Blaisdell FW, Lindfors KK. Stab wounds to the extremities: indications for angiography. Radiology 1987; 162: 465-467. McCorkell SJ, Harley JD, Morishima MS, Cummings DK. Indications for angiography in extremity trauma. AJR 1985; 145:1245-1247. Reid JDS, Weigelt JA, Thal ER, Francis H III. Assessment of proximity of a wound to major vascular structures as an indication for arteriography. Arch Surg 1988; 123: 942-946. Gomez GA, Kreis DJ, Ratner L, et al. Suspected vascular trauma of the extremities: the role of arteriography in proximity injuries. J Trauma 1986; 26:1005-1008. Rose SC, Moore EE. Trauma angiography: the use of clinical findings to improve patient selection and case preparation. J Trauma 1988; 28:240-245. Lipchik EO, Kaebnick HW, Beres JJ, Towne JB. The role of arteriography in acute penetrating trauma to the extremities. Cardiovasc Intervent Radio11987; 10:202-204. Reid JDS, Redman HC, Weigelt JA,
19.
20.
21. 22.
23.
24.
25. 26. 27. 28. 29.
et al. Wounds of the extremities in proximity to major arteries: value of angiography in the detection of arterial injury. AJR 1988; 151:10351039. Hartling RP, McGahan JP, Lindfors KK, Blaisdell FW. Stab wounds to the neck: role of angiography. Radiology 1989; 172:79-82. Smith PL, Lim WN, Ferris EJ, Casali RE. Emergencyarteriography in extremity trauma: assessment of indications. AJR 1981; 137: 803-807. Bole PV, Purdy RT, Munda RT, et al. Civilian arterial injuries. Ann Surg 1976; 183:13-23. Turcotte JK, Towne JB, Bernhard VM. Is arteriography necessary in the management of vascular trauma of the extremities? Surgery 1978; 84:557-562. Kurzweg FT. Vascular injuries associated with penetrating wounds of the groin. J Trauma 1980; 20:214217. Lee RE, Obeid FN, Horst HM, Bivins BA. Acute penetrating arterial injuries of the forearm: ligation or repair? Am Surg 1985; 51:318324. Gill SS, Eggleston FC, Singh CM, et al. Arterial injuries of the extremities. J Trauma 1976; 16:766-772. Kelly GL, Eiseman B. Civilian vascular injuries. J Trauma 1975; 15: 507-514. Lord RSA, Irani CN. Assessment of arterial injury in limb trauma. J Trauma 1974; 14:1042-1053. Perry MO, ThaI EF, Shires GT. Management of arterial injuries. Ann Surg 1971; 173:403-408. DeBakey ME, Simeone FA. Battle
30.
31.
32.
33.
34. 35.
36.
37.
38.
injuries of the arteries in World War II. Ann Surg 1946; 123:534-579. Rich NM, Baugh JH, Hughes CWo Acute arterial injuries in Vietnam: 1,000 cases. J Trauma 1970; 10: 359-369. Burnett HF, Parnell CL, Williams GD, Campbell GS. Peripheral arterial injuries: a reassessment. Ann Surg 1976; 183:701-709. Snyder WH III, Watkins WL, Whiddon LL, Bone GE. Civilian popliteal artery trauma: an 11 year experience with 83 injuries. Surgery 1979; 85:101-108. Sirinek KR, Levine BA, Gaskill HV III, Root HD. Reassessment of the role of routine operative exploration in vascular trauma. J Trauma 1981; 21:339-344. Saletta JD, Freeark RJ. The partially severed artery. Arch Surg 1968; 97:198-205. Rose SC, Moore EE. Trauma angiography of the extremity: the impact of injury mechanism on triage decisions. Cardiovasc Intervent Radio11988; 11:136-139. Frykberg EF, Vines FS, Alexander RH. The natural history of clinically occult arterial injuries: a prospective evaluation. J Trauma 1989; 29:577-583. Frykberg ER, Crump JM, Vines FS, et al. A reassessment of the role of arteriography in penetrating proximity extremity trauma: a prospective study. J Trauma 1989; 29:10411052. Dennis JW, Frykberg ER, Crump JM, et al. New perspectives on the management of penetrating trauma in proximity to major limb arteries. J Vasc Surg 1990; 11:84-93.
Comment From: Salvatore J.A. Sclafani, MD Department of Radiology, Kings County Hospital Center The article by Smyth et al is one of several recent reviews that have assessed the need for and timing of diagnostic arteriography in patients
who have sustained trauma resulting in wounds near vascular structures in the extremities. Smyth et al have reviewed the clinical records and ar-
teriograms of 142 patients with wounds at 170 sites in the extremities. One-half of the patients sustained penetrating trauma from gun-
Proximity Injuries: Correlation with Results of Extremity Arteriography! Stephen H. Smyth, MD Gerald D. Pond, MD Phillip L. Johnson, MD 2 Robert F. Rauch, MD Kenneth E. Mcintyre, MD
Index terms: Arteries, injuries, 91.41, 92.41 • Extremities, angiography, 91.122, 92.122 • Extremities, injuries, 91.41, 92.41 • Trauma, 91.41, 92.41
JVIR 1991; 2:451-456
The results of 170 emergency arteriography procedures in 142 patients who had sustained extremity injuries near major arteries were correlated with the findings from a physical examination conducted prior to arteriography. Radiographically demonstrable significant arterial injuries, which usually required surgical repair, were present at 42 of the 170 injury sites (25%). Major physical findings suggestive of arterial injury were noted at 105 of 170 sites (62%). Arteriography demonstrated a significant injury in 40 (38%) of these 105 injury sites, representing 95% of all major arterial injuries. Among the 65 injury sites without any suggestive major physical finding, only two were associated with a significant vascular injury at arteriography (3%) (5% of all 42 arterial injuries). At each ofthese 65 injury sites, the decision to perform emergency arteriography was based solely on the proximity of the wound to a major artery. In spite of this very low yield in the subgroup of 51 patients without major physical findings, emergency arteriography is still routinely requested for extremity injuries at the authors' institutions. The validity of this policy, a possible reason for its development, and its effect on patient disposition are examined.
~TERIOGRAPHY is a reliable and ac-
1 From the Departments of Radiology, Section of Vascular and Interventional Radiology (S.H.S., G.D.P., P.L.J.), and Surgery, Section of Vascular Surgery (K.E.M.), University of Arizona Health Sciences Center, 1501 N Campbell Ave, Tucson, AZ 85724, and the Department of Radiology, Tucson Medical Center, Tucson (R.F.R.). Received January 2, 1991; revision requested March 11; revision received July 16; accepted July 25. Address reprint requests to G.D.P. 2 Current address: Baptist Medical Center, Oklahoma City.
©
SCVIR, 1991
curate means of evaluating vascular injury in the extremities (1-11). However, its utilization in injuries unassociated with major physical findings (on the basis of proximity to major arteries only) has become increasingly controversial. Although a number of studies document the low yield of arteriography when proximity to major arteries is the only indication (2,6,12-20), this finding still remains a commonly used indication. The tendency to perform emergency arteriography of all extremity injuries regardless of physical findings may be a holdover from surgical procedures established in wartime, when the majority of wounds were of the extremely severe variety associated with high-velocity missiles. The nature of extremity injury in the civilian setting differs substantially from that in war. These injuries are most commonly inflicted by low-velocity missiles (handguns) but also include
lacerations (knife or glass) and fractures or dislocations. Notwithstanding, many surgeons still advocate emergency arteriography or surgical exploration of all injuries regardless of mechanism (21-28). This study is a retrospective correlation of the findings at arteriography and physical examination in patients who had sustained wounds to the extremities in the civilian setting at two level I trauma centers. Also noted was the disposition of each patient, regardless of whether the arteriographic findings were positive or negative.
PATIENTS AND METHODS Patients who had undergone emergency arteriography for suspected vascular injury to an extremity were identified by reviewing the angiography logbooks and trauma registries from a 5-year period (1985-1989) at two level I trauma centers. In all in-
451
452 • Journal of Vascular and Interventional Radiology November 1991
stances, the decision to request arteriography was made by a group of trauma surgeons on the basis of the mechanism of injury and physical findings, as well as the proximity of the injury to a major artery. Although noninvasive studies, including conventional and color Doppler ultrasonography, may often provide valuable data, the surgeons at our institutions prefer arteriography as the procedure of choice in the emergency setting. No attempt was made to evaluate these lesions with noninvasive studies or compare noninvasive studies with angiographic findings. Arteriography was performed by radiologists experienced in angiography with either conventional or digital technique. Each patient's medical record was reviewed to obtain historical data and the physical findings reported by the trauma team prior to angiography. The arteriograms were independently interpreted by two senior vascular radiologists. A third radiologist was available for any disagreements for a consensus diagnosis, but no discrepancies regarding significant arterial injuries were encountered. Upper extremity injuries were those at or distal to the axilla, and lower extremity injuries were those at or distal to the inguinalligament. Arteriographic findings considered to be evidence of significant vascular injury included contrast material extravasation, occlusion, transection, thrombosis, intimal flap, pseudoaneurysm, or arteriovenous fistula. On physical examination, major findings considered suggestive of a serious arterial injury included hypotension (unexplained by another bleeding source), diminished or absent pulse, a large or expanding hematoma, active bleeding from the wound, bruit, or evidence of distal ischemia (pallor or cyanosis). The injuries were grouped by mechanism into gunshot wounds, lacerations, and fracture or dislocations. The positive and negative predictive values of physical findings for radiographically demonstrable significant vascular
injury were then determined. Also determined was the disposition of each patient, regardless of whether the arteriogram was positive or negative.
RESULTS The patients were predominantly male (122 of 142 [86%]). Ages ranged from 6 to 81 years (mean, 30 years). There were 170 individual, noncontiguous injury sites in 142 patients. Of these sites, 83 were due to gunshot wounds (49%), 62 were due to fractures and/or dislocations (36%), and 25 were due to lacerations produced by a knife or other foreign object (15%). Two patients with significant soft-tissue (crush) injuries were also included in the last category, although there was no cutaneous puncture wound. Among the gunshot wounds, the injury was known to be due to a low-velocity (less than 1,800 ftlsec [550 m/sec]) missile at 59 of83 sites (71%). For 23 ofthe 83 gunshot wounds, the type of weapon used was either unknown or unspecified in the record (28%). However, the soft-tissue injuries in these 23 patients were not of the type expected from highvelocity rounds, which produce catastrophic soft-tissue (cavitation) injury. There were only three shotgun wounds in this series, representing 2% of all injuries, and only 4% of all gunshot wounds. Shotgun wounds are low velocity, but are caused by multiple and usually small individual missiles. There was only one injury documented to be due to a high-velocity missile, that from a .30 caliber rifle (1%). Among the 170 injury sites, 105 were associated with a major physical finding suggesting vascular injury (62%). At arteriography, significant injury was documented in 40 (38%) of these 105 sites. Among the 65 of 170 (38%) injury sites unassociated with any major physical finding, only two patients had a significant vascular injury at arteriography (3%). Of these two patients, only one underwent surgical repair of the injured
Table 1 Mechanism of Injury Mechanism No. of Injuries Gunshot wound 83 (49) 62 (36) Fracture/dislocation Laceration 25 (15) Total 170 (100) Note.-Numbers in parentheses are percentages.
vessel. The other patient was observed, and arterial repair was not performed (occluded posterior tibial artery following crush injury). Tables 1 and 2 summarize the mechanism of injury, the number of cases with or without major physical findings, and the number of cases in which significant vascular injury was identified. When the data from the three mechanisms of injury are combined, the positive predictive value of at least one major physical finding was 0.38, whereas the negative predictive value of absence of a major finding, that is, proximity-only cases was 0.97. The extremely low prevalence of significant vascular injury in the absence of major physical findings is statistically significant by means of X2 analysis at P < .05 level, whether the expected value versus the observed value chosen for analysis was chance, the prevalence of vascular injury for all patients, or the prevalence of injury among those with major physical findings. Of all 142 patients, 140 were admitted for a period of 12 hours or more (99%). Only two patients were discharged after the arteriogram was found to be normal (1%).
DISCUSSION The current controversy regarding the need to perform arteriography for possible vascular injury of an extremity in the absence of major physical findings reflects the continuing evolution of a long-standing controversy regarding the diagnosis and management of these injuries.
Smyth et al • 453 Volume 2 Number 4
Table 2 Relationship between Major Physical Findings and Significant Vascular Injury With Significant Without Significant Vascular Injury Vascular Injury No. ofInjury Sites 105 with at least one major physical finding 40 65 65 without any major physical finding 63 2
During World War II, the majority of extremity arterial injuries were treated by means of ligation of the vessel, with few attempts (5%) at vascular repair (29). From the Vietnam experience, a review of 1,000 extremity vascular injuries revealed that ligation was performed in only 1.5%, while primary vascular repair was attempted in 92.3% of all cases (30). These wartime experiences led to a heightened recognition of the catastrophic soft-tissue effects of highvelocity missiles (muzzle velocity > 1,800 ft/sec [550 m/sec]), specifically cavitation injury, which requires prompt and extensive surgical debridement (31). These principles of surgical exploration were initially extended to the civilian arena, with some surgeons advocating mandatory surgical exploration of all extremity injuries regardless of mechanism (21,23-28). However, since the late 1970s, the reliability of arteriography has resulted in its increased use for evaluating acute extremity vascular injury (1,4-6,8,11,22,32-34). Arteriography has, in great part, eliminated the need for surgical exploration in many patients. Now, surgeons tend to be advocates not of surgical exploration of every extremity injury, but of angiographic evaluation of all cases, regardless of the findings at physical examination. Recently, a number of studies have questioned the need for routine emergency angiography of injured extremities without signs of major vascular injury on physical examination (7,8,1215). In our study, we found a 3% prevalence of major vascular injury in patients without a major physical finding. This is at the low end of the
range reported in studies from the late 1970s and early 1980s (3.6%21%) (1,2,5,6,14,16,31). However, the 3% yield falls within the range (0%9%) reported in the most recent literature (12,16-20,35,36). While no good explanation for the changes in the prevalence of these injuries has been set forth, factors could include differences in study design (retrospective vs prospective), varying skills in the performance of physical examination, and different methods of injury. Concerns about failure to diagnose significant vascular injuries in patients lacking a major physical finding continue to drive surgeons to advocate arteriography. While the low prevalence of major vascular injury does not by itselfjustify elimination of arteriography, some authors maintain that such injuries are uncommon and the natural history of clinically silent arterial injuries is benign (36-38). This assertion will need additional validation before it is generally accepted. At the very least, however, the available data support the need to reassess the current standard of universal emergency arteriography. Shotgun wounds, which were uncommon in this series, may require a different approach than wounds inflicted by a single low-velocity projectile, such as a pistol, due to the sheer number of penetrating injuries and the greater likelihood of vascular insult. This is suggested in one study (38) in which arterial injuries from shotgun wounds (three of 17,17.6%) were almost twice as frequent as those from handgun wounds (24 of 247, 9.7%) or stab wounds (five of 54, 9.3%). This possibility will also re-
quire further study. The argument often presented to justify emergency arteriography is that a negative arteriogram will allow immediate discharge, as opposed to admission to the hospital. The findings of this study contradict that argument. Among the 51 patients with proximity injuries alone, 49 (96%) were admitted for observation for a minimum of 12 hours. Patients undergoing arteriography are typically observed for a period of several hours after the procedure, often for longer periods due to other injuries. On the basis of findings from this study, it is our position that the best approach for the majority of patients with extremity injuries without major physical findings is observation and/or elective arteriography. References 1. Snyder WH III, Thal ER, Bridges RA, et al. The validity of normal arteriography in penetrating trauma. Arch Surg 1978; 113:424428. 2. Geuder JW, Hobson RW II, Padberg FT, et al. The role of contrast arteriography in suspected arterial injuries of the extremities. Am Surg 1985; 51:89-93. 3. Ben-Menachem Y. Vascular injuries of the extremities: hazards of unnecessary delays in diagnosis. Orthopedics 1986; 9:333-335. 4. Redman HC. Thoracic, abdominal, and peripheral trauma: evaluation with angiography. JAMA 1977; 237: 2415-2418. 5. Keeley SB, Snyder WH III, Weigelt JA. Arterial injuries below the knee: fifty-one patients with 82 injuries. J Trauma 1983; 23:285-292. 6. O'Gorman RB, Feliciano DV, Bitondo CG, et al. Emergency center arteriography in the evaluation of suspected peripheral vascular injuries. Arch Surg 1984; 119:568-573. 7. McDonald EJ Jr, Goodman PC, Winestock DP. The clinical indications for arteriography in trauma to the extremity: a review of 114 cases. Radiology 1975; 116:45-47. 8. Rees R, BonnevaI M, Batson R, et aI. Angiography in extremity trauma: a prospective study. Am Surg 1978; 44:661-663. 9. Sirinek KR, Gaskill HV III, Dittman WI, Levine AL. Exclusion angiog-
454 • Journal of Vascular and Interventional Radiology November 1991
10.
11.
12.
13.
14.
15.
16.
17.
18.
raphy for patients with possible vascular injuries of the extremities. Surgery 1983; 94:598-603. Howard CA, Thal ER, Redman HC, Gibson P. Intra-arterial digital subtraction angiography in the evaluation of peripheral vascular trauma. Ann Surg 1989; 210:108111. Sclafani SJA, Cooper R, Shaftan GW, et al. Arterial trauma: diagnostic and therapeutic angiography. Radiology 1986; 161:165-172. Hartling RP, McGaham JP, Blaisdell FW, Lindfors KK. Stab wounds to the extremities: indications for angiography. Radiology 1987; 162: 465-467. McCorkell SJ, Harley JD, Morishima MS, Cummings DK. Indications for angiography in extremity trauma. AJR 1985; 145:1245-1247. Reid JDS, Weigelt JA, Thal ER, Francis H III. Assessment of proximity of a wound to major vascular structures as an indication for arteriography. Arch Surg 1988; 123: 942-946. Gomez GA, Kreis DJ, Ratner L, et al. Suspected vascular trauma of the extremities: the role of arteriography in proximity injuries. J Trauma 1986; 26:1005-1008. Rose SC, Moore EE. Trauma angiography: the use of clinical findings to improve patient selection and case preparation. J Trauma 1988; 28:240-245. Lipchik EO, Kaebnick HW, Beres JJ, Towne JB. The role of arteriography in acute penetrating trauma to the extremities. Cardiovasc Intervent Radio11987; 10:202-204. Reid JDS, Redman HC, Weigelt JA,
19.
20.
21. 22.
23.
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Comment From: Salvatore J.A. Sclafani, MD Department of Radiology, Kings County Hospital Center The article by Smyth et al is one of several recent reviews that have assessed the need for and timing of diagnostic arteriography in patients
who have sustained trauma resulting in wounds near vascular structures in the extremities. Smyth et al have reviewed the clinical records and ar-
teriograms of 142 patients with wounds at 170 sites in the extremities. One-half of the patients sustained penetrating trauma from gun-
