Vascular Hand Injury Workup
- Author: Zubin J Panthaki, MD, CM, FACS, FRCSC; Chief Editor: Joseph A Molnar, MD, PhD, FACS more...
Please see Indications section above.
Conventional arteriography (CA) remains the criterion standard for radiologic evaluation of the peripheral vascular system.
Advantages to CA include the following:
May demonstrate arterial lesions that can undergo sequential endovascular treatment; diagnostic and therapeutic modality
Can provide accurate localization of the lesion, which can assist with surgical planning
Can distinguish between intimal disruption and spasm through the use of vasodilators
Disadvantages to CA include the following:
It is an invasive diagnostic procedure.
It is a time-intensive procedure.
It requires transfer to a specialized angiography suite for evaluation.
It is a costly procedure.
Iatrogenic injuries can result, especially contrast-induced nephropathy and arterial access injuries (1-3%).
However, CA is usually unnecessary for the diagnosis of upper extremity vascular injuries. Some patients, such as those with shotgun injuries or complex wounds and fractures at multiple levels, may need to undergo arteriography to define the precise anatomic location of the arterial injury. In the trauma setting, most arteriographic evaluations can be completed intraoperatively once proximal and distal vascular control is obtained.
Noninvasive diagnostic modalities including duplex ultrasonography and CT angiography can aid in the diagnosis of peripheral vascular injuries, particularly those with equivocal, or “soft” signs.
Duplex sonography is a portable, rapid, and inexpensive tool that can be as accurate as conventional arteriography. Duplex sonography additionally aids in the diagnosis of major venous injuries. Performed by expert operators, duplex ultrasonography is an accurate and noninvasive study that allows the diagnosis of occult arterial injuries. According to Meissner and colleagues, no major injuries were missed in 60 scans. Fry and colleagues reported that duplex ultrasonography offered 100% sensitivity and 97% specificity for identifying major extremity arterial injuries. The limitations of duplex sonography are its expert operator dependence and the potential for missed injuries due to open wounds, large hematomas, bulky dressings, or splints that hinder access of the ultrasound probe. A recent large cohort study suggests that color-flow duplex sonography is of low yield in the diagnosis of upper extremity vascular injuries.
Helical CT angiography (CTA) is rapidly gaining crucial ground as an alternative noninvasive, diagnostic modality in the management of suspected extremity vascular trauma. Advancements in the scanning technology of helical CT scanners allow acquisition of detailed images that rival those of CA.[31, 32] Current studies suggest that CT angiography (CTA) may replace conventional angiography as the diagnostic study of choice for vascular injuries of the extremities. Sensitivity (95.1%) and specificity (98.7%) of diagnostic CT angiography for the detection of clinically significant extremity vascular injury in blunt and penetrating trauma was noted in one study. In addition to providing high-resolution vascular images comparable to conventional arteriograms (see image below), helical CT scanners can simultaneously provide detailed images of the bone and soft tissue.
CTA simplifies the logistics of monitoring the trauma patient with potential extremity vascular injury, eliminates the risks associated with arterial puncture seen with CA, and results in a substantial cost savings to the patient and hospital. Cost analysis of the study conducted at Temple University by Seamon et al demonstrated a reduction of patient charges by $12,922 and reduction in hospital costs by $1166 compared to conventional arteriography. Busquets and colleagues reported 97 cases evaluated for extremity vascular injury with CT angiography without any missed injury.
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