Arteriography in the Delayed Evaluation of Wartime Extremity Injuries

Abstract

Recent combat casualties have stimulated a reassessment of the principles of management of high-risk extremity injuries with a normal vascular examination. Rapid evacuations have presented numerous U.S. soldiers to our service for evaluation in the early postinjury period. The objective of this single-institution report is to analyze the application of liberal arteriography in the delayed evaluation of modern wartime extremity injuries. Data from consecutive wartime evacuees evaluated for extremity injuries between March 2002 and November 2004 were prospectively entered into a database and retrospectively reviewed. Analysis was focused on arteriography and its role in our current diagnostic and therapeutic approach. Information including injury sites and mechanisms, associated trauma, battlefield repairs performed, arteriography technique, complications, findings, and need for further intervention were reviewed. Indications for imaging in this high-risk group included proximity to vascular structures, abnormal or equivocal physical examination, adjunctive operative planning, and evaluation of battlefield repair. Ninety-nine of 179 patients (55%) with extremity injuries underwent arteriography, with 142 total limbs studied. The majority of them were wounded by explosive devices (82%) or high-velocity rifle munitions (14%). Abnormalities were found in 75 of 142 (52.8%) imaged limbs in 46 of the 99 (46.5%) patients. Twenty-four of these patients (52.2%) required additional operative intervention. Occult vascular injury findings were associated with bony fracture in 68% and nerve injury in 16%. Median delay between injury and stateside evaluation was 6 days. Two thirds of these soldiers presented with a normal physical examination result. There were no access site complications or incidents of contrast-induced acute renal failure. The liberal application of arteriography is a low-risk method to provide high-yield data in the delayed vascular evaluation of extremities injured from modern military munitions. Physical examination findings remain the most useful indicator, but a normal examination can be misleading and should not guide the decision for invasive imaging. Lesions are found and require further intervention at a higher rate than expected from the typical civilian trauma experience.

A contemporary, 7-year analysis of vascular injury from the war in Afghanistan

“…Forward endovascular management at MTFs mimics the practice observed in civilian medicine, in which endovascular approaches are increasingly common and have been shown to provide improved survival and lower complication rates in certain situations. 22,23,[29][30][31] Johnson et al 31 reported finding an additional vascular injury in more than half (53%) of patients who had sustained a combat-related vascular injury by liberally using angiography after evacuation to the United States; 50% required surgical repair. In another review of injury patterns between 2001 and 2004 by Fox et al, 19 the most common indication for arteriography was mechanism of injury (42%), followed by abnormal examination finding (33%), operative planning (18%), or evaluation of a repair (7%).…”

The use of retrievable inferior vena cava filters in severely injured military trauma patients

“…The delay from injury to stateside evacuation has consistently been about 8 days. 19,20 It should be pointed out that a majority of our indications were therapeutic, meaning a DVT or PE may not have developed or manifested themselves early in the first week. Further, rapid mass casualty evacuations can lead to situations where injuries are initially missed and/or subsequently develop.…”

A Pulseless Limb Poorly Predicts an Arterial Injury in Combat Trauma

“…10,11 At a median of 6 days from injury to evaluation, Johnson et al found that the physical examination had a sensitivity of 38%, specificity of 90%, positive predictive value of 85%, and a negative predictive value of 51%. A normal physical examination did not accurately predict post-traumatic extremity arterial injuries sustained in combat, and the authors recommended liberal use of CTA and/or arteriography to assess for delayed or occult arterial injures.…”