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Peripheral Vascular Injuries Workup

  • Author: Niels K Rathlev, MD, FACEP; Chief Editor: Trevor John Mills, MD, MPH  more...
 
Updated: Oct 08, 2015
 

Laboratory Studies

The arterial pressure index is useful in detecting patients with major vascular injury and pulses that appear normal. Systolic blood pressure in the affected extremity is divided by systolic pressure in the contralateral normal extremity. A value of less than 90% is considered abnormal.

The sensitivity of the arterial pressure index for injuries requiring intervention ranges from 75-95%, depending on the circumstances. The arterial pressure index is highly sensitive in ruling out popliteal artery injury in patients with knee dislocation. Most injuries that present with an arterial pressure index greater than 90% heal spontaneously.[7]

The ankle-brachial index is equivalent to the arterial pressure index and may be used when multiple extremity injuries are present. This is calculated by dividing the higher of the systolic dorsalis pedis or posterior tibial artery pressure by the ipsilateral brachial artery pressure.

The Allen test is useful for detecting injuries distal to the brachial artery bifurcation. Persistence of pallor of the hand when the radial artery is manually compressed suggests occlusion of the ulnar artery and vice versa.

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Imaging Studies

Conventional angiography remains the criterion standard for evaluation of vascular injuries in trauma patients.[8, 9] The disadvantages include cost, significant time delay in preparation for the test, and a 0.6% major complication rate. Contrast dye load and renal function are important pre-study considerations. Only 1-1.5% of proximity angiograms performed in patients lacking "hard" signs of vascular injury reveal injuries that require intervention. Duplex ultrasonography is a noninvasive technique used to investigate injuries with a high-risk mechanism or location but without "hard" signs or obvious indications for surgical management.

Small, prospective studies suggest that the sensitivity of ultrasonography is 95-100% for diagnosing vascular injuries that lack "hard" signs but require intervention. These results were obtained by highly qualified teams that maintain a high clinical index of suspicion.[10] Recent studies have found color-flow duplex ultrasonography to be a low-yield strategy for predicting therapeutic intervention.[1] The examination is highly operator dependent, and the negative predictive value has been as low as 50% in some series. Duplex ultrasonography is of limited use in the evaluation of poorly accessible vessels, such as the subclavian, profunda femoris, and profunda brachii arteries. Duplex ultrasonography can play a role in the evaluation of patients presenting with "soft" signs of injury; however, its use has largely been supplanted by multidetector CT angiography.

Multidetector helical CT (MDCT) angiography is emerging as a highly sensitive method of diagnosing arterial injuries when compared with conventional angiography and surgical exploration as criterion standards.[11] Studies using 4- and 16-slice MDCT angiography have demonstrated a sensitivity of 90-95% for significant arterial injuries.[12, 13, 14] . A study by Seamon et al demonstrated a sensitivity and specificity of 100% for clinically significant injury using 16-slice and 64-slice technology.[15]

Higher-resolution (64-slice and greater) MDCT angiography and greater institutional experience will further improve the diagnostic accuracy of the modality. In comparison with conventional angiography, MDCT angiography is considerably faster, less expensive and less invasive, and does not require the involvement of interventional radiology. Studies support MDCT angiography as the diagnostic study of choice for blunt and penetrating vascular trauma patients who have do not have obvious indications for immediate operative intervention.[3]

In a retrospective evaluation of 51 patients with penetrating neck injury, MDCT angiography as initial evaluation was found to help guide management decisions if an external carotid artery injury was detected. Sensitivity of CTA for detecting arterial injuries ranged from 75.7% to 82.2%, and specificity ranged from 96.4% to 98.4%. However, according to the authors, negative findings should not preclude close clinical follow-up, repeat CTA evaluation, or, in the presence of high suspicion of arterial injury due to clinical findings or wound trajectory, evaluation with digital subtraction angiography.[16]

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Contributor Information and Disclosures
Author

Niels K Rathlev, MD, FACEP Professor and Chair, Department of Emergency Medicine, Tufts University School of Medicine and Baystate Medical Center

Niels K Rathlev, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, Massachusetts Medical Society, Society for Academic Emergency Medicine, Association of Academic Chairs of Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

David B Levy, DO, FAAEM Senior Consultant in Emergency Medicine, Waikato District Health Board, New Zealand; Associate Professor of Emergency Medicine, Northeastern Ohio Universities College of Medicine

David B Levy, DO, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, Fellowship of the Australasian College for Emergency Medicine, American Medical Informatics Association, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Trevor John Mills, MD, MPH Chief of Emergency Medicine, Veterans Affairs Northern California Health Care System; Professor of Emergency Medicine, Department of Emergency Medicine, University of California, Davis, School of Medicine

Trevor John Mills, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians

Disclosure: Nothing to disclose.

Additional Contributors

David A Peak, MD Associate Residency Director of Harvard Affiliated Emergency Medicine Residency; Attending Physician, Massachusetts General Hospital; Assistant Professor, Harvard Medical School

David A Peak, MD is a member of the following medical societies: American College of Emergency Physicians, Society for Academic Emergency Medicine, Undersea and Hyperbaric Medical Society, American Medical Association

Disclosure: Partner received salary from Pfizer for employment.

References
  1. Mollberg NM, Wise SR, Banipal S, et al. Color-flow duplex screening for upper extremity proximity injuries: a low-yield strategy for therapeutic intervention. Ann Vasc Surg. 2013 Jul. 27(5):594-8. [Medline].

  2. de Mooij T, Duncan AA, Kakar S. Vascular injuries in the upper extremity in athletes. Hand Clin. 2015 Feb. 31 (1):39-52. [Medline].

  3. Miller-Thomas MM, West OC, Cohen AM. Diagnosing traumatic arterial injury in the extremities with CT angiography: pearls and pitfalls. Radiographics. 2005 Oct. 25 Suppl 1:S133-42. [Medline].

  4. Neagoe RM, Bancu S, Muresan M, Sala D. Major vascular injuries complicating knee arthroscopy. Wideochir Inne Tech Maloinwazyjne. 2015 Jul. 10 (2):266-74. [Medline].

  5. White JM, Stannard A, Burkhardt GE, Eastridge BJ, Blackbourne LH, Rasmussen TE. The epidemiology of vascular injury in the wars in iraq and afghanistan. Ann Surg. 2011 Jun. 253(6):1184-9. [Medline].

  6. Van Waes OJ, Van Lieshout EM, Hogendoorn W, Halm JA, Vermeulen J. Treatment of penetrating trauma of the extremities: ten years' experience at a Dutch level 1 trauma center. Scand J Trauma Resusc Emerg Med. 2013 Jan 14. 21:2. [Medline]. [Full Text].

  7. Nassoura ZE, Ivatury RR, Simon RJ, et al. A reassessment of Doppler pressure indices in the detection of arterial lesions in proximity penetrating injuries of extremities: a prospective study. Am J Emerg Med. 1996 Mar. 14(2):151-6. [Medline].

  8. Espinosa GA, Chiu JC, Samett EJ. Clinical assessment and arteriography for patients with penetrating extremity injuries: a review of 500 cases with the Veterans Affairs West Side Medical Center. Mil Med. 1997 Jan. 162(1):19-23. [Medline].

  9. Gahtan V, Bramson RT, Norman J. The role of emergent arteriography in penetrating limb trauma. Am Surg. 1994 Feb. 60(2):123-7. [Medline].

  10. Knudson MM, Lewis FR, Atkinson K, Neuhaus A. The role of duplex ultrasound arterial imaging in patients with penetrating extremity trauma. Arch Surg. 1993 Sep. 128(9):1033-7; discussion 1037-8. [Medline].

  11. Hood DB, Weaver FA, Yellin AE. Changing perspectives in the diagnosis of peripheral vascular trauma. Semin Vasc Surg. 1998 Dec. 11(4):255-60. [Medline].

  12. Busquets AR, Acosta JA, Colon E, et al. Helical computed tomographic angiography for the diagnosis of traumatic arterial injuries of the extremities. J Trauma. 2004 Mar. 56(3):625-8. [Medline].

  13. Rieger M, Mallouhi A, Tauscher T, et al. Traumatic arterial injuries of the extremities: initial evaluation with MDCT angiography. AJR Am J Roentgenol. 2006 Mar. 186(3):656-64. [Medline].

  14. Soto JA, Munera F, Morales C, et al. Focal arterial injuries of the proximal extremities: helical CT arteriography as the initial method of diagnosis. Radiology. 2001 Jan. 218(1):188-94. [Medline].

  15. Seamon MJ, Smoger D, Torres DM, Pathak AS, Gaughan JP, Santora TA. A prospective validation of a current practice: the detection of extremity vascular injury with CT angiography. J Trauma. 2009 Aug. 67(2):238-43; discussion 243-4. [Medline]. [Full Text].

  16. Bodanapally UK, Dreizin D, Sliker CW, Boscak AR, Reddy RP. Vascular Injuries to the Neck After Penetrating Trauma: Diagnostic Performance of 40- and 64-MDCT Angiography. AJR Am J Roentgenol. 2015 Oct. 205 (4):866-72. [Medline].

  17. Hoffer EK, Sclafani SJ, Herskowitz MM, Scalea TM. Natural history of arterial injuries diagnosed with arteriography. J Vasc Interv Radiol. 1997 Jan-Feb. 8(1 Pt 1):43-53. [Medline].

  18. Mousa A, Chong B, Aburahma AF. Endovascular repair of subclavian/axillary artery injury with a covered stent. A case report and review of literature. Vascular. 2013 Mar 14. [Medline].

  19. Hafez HM, Woolgar J, Robbs JV. Lower extremity arterial injury: results of 550 cases and review of risk factors associated with limb loss. J Vasc Surg. 2001 Jun. 33(6):1212-9. [Medline].

  20. Criado E, Marston WA, Ligush J, et al. Endovascular repair of peripheral aneurysms, pseudoaneurysms, and arteriovenous fistulas. Ann Vasc Surg. 1997 May. 11(3):256-63. [Medline].

  21. Dennis JW, Frykberg ER, Veldenz HC, et al. Validation of nonoperative management of occult vascular injuries and accuracy of physical examination alone in penetrating extremity trauma: 5- to 10-year follow-up. J Trauma. 1998 Feb. 44(2):243-52; discussion 242-3. [Medline].

 
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