Yield of CT angiography in penetrating lower extremity trauma

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 valuebased 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.

CTA Imaging of Peripheral Arterial Injuries

“…In comminuted fracture, radiologists must pay attention to individuating active bleeding among bony fragments, comparing the unenhanced and arterial phases. Satisfaction errors should be avoided because 12% of patients presents concomitant multiple vascular injuries [7,38,60,66,67,70,[76][77][78][79].…”

“…In hemodynamically stable patients with concerns of PVI, additional evaluation (ABI and ultrasound evaluation), but the presence of peripheral pulses alone cannot reliably exclude vascular injuries, and the presence of clinical signs requires further investigation [77]. Since 2012, the Eastern Association for the Surgery of Trauma (EAST) guidelines [7,79] considers CTA the first-line modality for investigating blunt and penetrating PVIs [78] with clinical suspect of PVI. DSA in these patients should be reserved for interventional purposes or if CTA is nondiagnostic or inconclusive due to artifacts from retained metallic objects [7,69].…”

CTA Imaging of Peripheral Arterial Injuries

“…In comminuted fracture, radiologists must pay attention to individuating active bleeding among bony fragments, comparing the unenhanced and arterial phases. Satisfaction errors should be avoided because 12% of patients present concomitant multiple vascular injuries [7,38,60,66,67,70,[76][77][78][79].…”

“…In hemodynamically stable patients with concerns of PVI, for additional evaluation (ABI and ultrasound evaluation), the presence of peripheral pulses alone cannot reliably exclude vascular injuries, and the presence of clinical signs requires further investigation [77]. Since 2012, the Eastern Association for the Surgery of Trauma (EAST) guidelines [7,79] have considered CTA the first-line modality for investigating blunt and penetrating PVIs [78] with clinical suspicion of PVI. DSA in these patients should be reserved for interventional purposes or if CTA is nondiagnostic or inconclusive due to artifacts from retained metallic objects [7,69].…”