Angiographic Findings of Patients with Blunt or Penetrating Extremity Injuries: Focus on Indications and Contraindications

Abstract

Objective:

To determine the etiology, signs and symptoms, angiography indications and angiography findings in patients with limb penetrating injuries suspected to have arterial injury.

Methods:

This was a cross-sectional study being performed in Imam Reza Hospital affiliated with Mashhad University of Medical Sciences, Iran between September 2011 and March 2013. We included those patients with extremity blunt and penetrating injuries who were referred for angiography according to standard indications including abnormal distal pulses, complex fracture or dislocation, vascular proximity, fixed hematoma, distal nerve deficit, arterial bruit, thrill and massive soft tissue injuries.

Results:

During the study period, 148 patients (15 women and 133 men) with a mean age of 31±14.9 (11-82) years were evaluated. The most common cause of injury was motor vehicle accident (127 patients 85%). Angiography indications included abnormal distal pulse examination (124, 83.8%), complex fracture or dislocation (7, 4.7%), near arterial trauma (4, 2.7%), fixed hematoma (3, 2%), nerve damage (1, 0.7%). The angiography was found to be normal in 49 (33.1%) patients. In patients with abnormal angiography findings, 60 (60.6%) had cutoff with distal runoff, 21 (21.2%) had cutoff without runoff, 14 (14.1%) had arterial spasm. Other uncommon findings included active bleeding in 2 patients (2%), pseudoaneurysm in 1 (0.7%) and arteriovenous fistula in 1 (0.7%). Out of 4 patients (2.7%) with vascular proximity, only 1 (0.7%) had abnormal angiography.

Conclusion:

The most  important  factor in prediction  of result of angiography was distal arterial pulses examination. But these data confirm the low incidence of vascular injury in asymptomatic patients with proximity. So the use of angiography when proximity is the sole indication in an asymptomatic patient with a normal vascular examination should be questioned.

Introduction

Arterial injury is one of most devastating injuries of extremity trauma. Peripheral injuries account for 80% of all cases of vascular trauma. Although most patients with vascular injuries have clear signs and  symptoms,  some  others  might  be  relatively asymptomatic   and   accurate   diagnosis  of  vascular injuries  may be problematic. Prompt  diagnosis  and treatment   of arterial  injuries  reduce  morbidity  and mortality especially amputation rates [1,2].Unlike many countries, due to high rate of motor vehicle accidents, blunt vascular injuries of extremities are common   in  Iran  and many  patients   are  referred for   angiography   in   order   to   diagnose   suspected arterial trauma  [3,4]. Despite advances in computed tomography angiography (CTA) and magnetic resonance angiography (MRA), conventional angiography  is still considered  the gold standard  for diagnosis and management of suspected arterial injury [5].

Certain clinical findings in extremity trauma increase the suspicion to arterial injury. Some of them such as severe ischemia and active hemorrhage  have very high diagnostic value and immediate  surgical exploration and  vascular  repair  are warranted  [1,4].  Abnormal distal pulse examination  is an absolute indication  of angiography [6]. There are some controversies about angiography in some other conditions including proximity of trauma to vascular anatomy and complex fracture or dislocation without  abnormal  distal pulse examination  [7,8]. Some surgeons suggest immediate operation and exploration of the penetrating and blunt extremity wounds with vascular proximity while others suggest angiographic evaluation [9]. Contrary to these two groups some others recommend conservative and watchful treatment without any diagnostic or surgical intervention [10,11]. We performed  this prospective study  in order  to  determine  the  etiology, signs and symptoms, angiography indications  and angiography findings in patients with limb penetrating injuries suspected to have arterial injury.

Materials and Methods

Study population

This was a cross-sectional study being performed  in Imam Reza Hospital affiliated with Mashhad University of  Medical  Sciences, Iran  between  September  2011 and March 2013. The study protocol was approved by the institutional review board and research ethics committee of Mashhad University of Medical Sciences. All the  recruited  patients  provided  their  informed written  consents before inclusion in  the  study. All patients with extremity blunt or penetrating trauma who were referred for conventional angiography were examined about  possible associated vascular injury. We included those patients with extremity blunt and penetrating injuries who were referred for angiography according to standard indications including abnormal distal pulses, complex fracture or dislocation, vascular proximity, fixed hematoma, distal nerve deficit, arterial bruit, thrill and massive soft tissue injuries. Vascular proximity was defined as any wound, laceration or missile tract within one centimeter  of a major vessel being  measured  by a senior  surgical resident  or  an attending physician.

Study protocol

 All the eligible patients underwent a complete history taking and physical examination  by a senior surgery resident   or  an  attending   physician  on  admission. All  the signs and symptoms related to vascular diseases especially distal pulse examinations  as well as all demographic information was recorded  into a standard data gathering form. We also recorded etiology, angiography indications  and angiography results in separate questionnaire.  After completion  of treatment  and  discharge, treatment type was added. All the patients underwent  conventional  angiography (Siemens, Erlangen, Germany)  by a single attending interventional radiologist. The angiographic  findings were further  recorded  and  entered  into  a computer database.

Statistical analysis

 Statistical analyses were performed  by SPSS version 16 (SPSS Inc., Chicago, Illinois, USA). Descriptive data analysis was performed and the results were presented as mean ± SD and proportion whereas appropriate.

Results

Overall we included 148 patients with extremity trauma  and vascular proximity. The mean age of the patients  was 31±14.9 (ranging  from  11 to 82) years. There were 133 (89.9%) men and 15 (10.1%) women among the patients. The angiography was performed in one lower limb in 105 patients  (70.9%), for both lower limbs  in 6 (4.1%), for one  upper  limb  in 35 (23.6%), for both upper limb in 1 (0.7%) and for both upper and lower limbs in 1 (0.7%). The most common cause of extremity trauma was motor vehicle accident (127  patients  85.8%)  following: 11 patients  (7.4%) with stab wound,  5 patients  (3.4%)  with gunshot,  3 patients  (2%)  with falling down and  2 (1.4%)  with other causes. Indications for angiography including: abnormal distal pulses examination in 124 patients (83.8%), complex fracture or dislocation with normal distal pulses examination in 7 patients (4.7%), near artery trauma in 4 patients (2.7%), fixed hematoma in 3 patients (2%) and distal nerve deficit in 1 patient (0.7%) (Table 1).

Table 1.

Indications for angiography in 148 patients with blunt or penetrating injuries of extremities referred for angiography

Variable	No. (%)
Abnormal distal pulse	124 (83.8%)
Complex fracture or dislocation	7 (4.7%)
Near artery trauma	4 (2.7%)
Fixed hematoma	3 (2.0%)
Nerve damage	1 (0.7%)
Undetermined	9 (6.1%)

Indications for angiography were undetermined in 9 patients (6.1%).

Regarding  the  angiographic  results,  49  patients (33.1%) had normal angiography and arterial injury was found in 99 patients (66.9%): 73 patients with lower extremity arterial injury and 26 patients with upper extremity arterial injury (Table 2). All of the patients with arterial injury in angiography were followed and  were  further categorized into  three subgroups:

Table 2.

The location of injury in 99 patients with abnormal angiography findings following blunt  or penetrating extremity injury

Variable	No. (%)
Superficial femoral artery	9 (9.1%)
Popliteal artery	11 (11.1%)
1 Lower limb artery a	37 (37.3%)
2 Lower limb arteries a	13 (13.1%)
3 Lower limb arteries a	3 (3.1%)
Subclavian artery branches	1 (1.0%)
Brachial & axillary	19 (19.1%)
Ulnar artery	2 (2.1%)
Radial artery	4 (4.1%)

^aLeg Arteries: Posterior Tibial Artery; Anterior Tibial Artery; Peroneal Artery

1. Patients with normal angiography report without arterial related therapy (49 patients, 33.1%)

2. Patients  with mild  arterial  injury  that  managed conservatively without surgical or radiological intervention (43 patients, 29.1%).

3. Patients  with severe arterial  injury  whorequired surgical arterial repair or radiological intervention (59 patients, 37.8%).

In  patients  with  abnormal  angiography  results, 60 (60.6%)  had  cutoff  with  distal runoff,  21  (21.2%) had  cutoff  without  runoff,  14 (14.1%)  had  arterial spasm. Other uncommon findings included active bleeding  in  2 patients  (2%), pseudoaneurysm  in  1 (0.7%)  and  arteriovenous  fistula in 1 (0.7%). In  124 patients who  had  abnormal  pulses examination,  95 (76.6%)  patients  had  abnormal angiography  results and  arterial  injury. But in other  conditions,  rates of abnormal  angiography  were  much  lower.  In  those that  angiography  was performed because of arterial proximity,  reports  were normal  except  in  1 patient (0.7%) with pseudoaneurysm in thyrocervical branch of subclavian artery following stab wound injury. In 3 patients (2.1%) with fixed hematoma,  angiography was abnormal only in 1 patient (0.7%). All of patients with  complex  fracture  or  dislocations  and  normal distal pulses examination  had normal angiography results. In patients  who referred for unknown  cause, angiographies were normal except in 1 patient (0.7%) with blunt trauma and proximal tibial fracture. In this patient  anterior  tibial artery only had spasm and he was treated conservatively without any complication.

Discussion

This  series  was  aimed   to  target  indications   for ascular  imaging  of  patients  with  vascular  injury of  the  extremities  following trauma  and  validation of  indications  especially vascular roximity.  Similar to previous studies [4,9-11], in our study the largest group  of our  patients  was men ranging in age from 25 to 40 years. Vascular injury of the extremities was a complication  following both penetrating  and blunt trauma. The incidence of these mechanisms varies widely in  different  regions  according  to  the  rate  of trauma [5,12]. In our study, the most common cause of injury was blunt trauma due to motor vehicle accident. In Turkey [13,14], Britain [4], Georgia [11] and United States [15]penetrating trauma due to gunshot and stab wound was reported to be the most common  cause of peripheral vascular injury.

There are four hard signs for extremity vascular injury including a pulseless limb, an expanding hematoma, a palpable thrill or audible bruit, or pulsatile hemorrhage. Any of these signs often lead to surgical intervention without need to diagnostic procedure  [16]. Soft signs of vascular injury include a non-pulsatile  hematoma, history of hemorrhage  at seen of accident hematoma, unexplained  hypotension and    peripheral nerve deficit. A more difficult diagnostic problem  occurs in patients  who present  with these signs. In 3 patients with fixed hematoma  in our  study, angiography was abnormal  only in one patient who had arteriovenous fistula due to stab wound  injury in posterior  tibialis artery. Indications of angiography in diminished pulse situation   especially in  the  presence  of  penetrating trauma remain controversial [16]. That evaluation can occur using various diagnostic modalities. In our study, 76.6% of patients  with abnormal  pulse examination had abnormal  angiography results. Although many of these patients (44.21%) were managed non-surgically. Angiography was not useful for this group. Palpation of  a  pulse is a  subjective measure  prone  to  wide interobserver variation.

In our study four patients referred for angiography due to vascular  proximity  and similar  to  other studies they had normal angiography except for one patient. There is no  consensus about  management of extremity trauma  with proximity of the wound to vascular  structures.  The  recommendations  are not  evidence based, and actual practice patterns  at individual institutions vary [17]. Some studies believe that proximity related penetrating trauma  does not require routine arteriography and can be detected with physical examination and Arterial Pressure index [18]. Some studies rely on physical examination and duplex ultrasonography results, reserving angiograms only for patients  with inconclusive results [19]. Some studies propose  that  physical examination   and  observation should be the modality of choice in most instances of penetrating  extremity trauma without hard signs. The observation period for non-operative management  of proximity wounds studied in the literature is routinely 24 hours [17,20].

Against theory for selective angiography are the occasional reports  of missed injuries in patients who present with late squeal [21]. Pseudoaneurysms, arteriovenous fistulas and arterial   occlusion are the described late complications of missed arterial injuries. Up to 23% of proximity wounds were found to have occult vascular injuries [22]. There is the potential for continued   hemorrhage with limb and life threatening scenarios [18]. Surgical repair was required only in 2% of clinically occult vascular injuries found on arteriography [23]. In our study, one patient had pseudoaneurysm in thyrocervical branch of subclavian artery following stab wound injury. This patient had normal pulse  examination and referred for angiography without any hard and soft signs of vascular injury. The physical examination and API are only useful for detecting vascular injury to the ‘main’ vascular system. Injury to the branches of subclavian artery will not alter distal pulses or cause distal ischemia, may not show active hemorrhage, and is difficult to assess for an expanding  hematoma  or thrill. Like this, a notable exception to the proximity to major vessels approach occurs in the thigh, specifically where the  wound  travels medial  to  the  femur,  thus traversing the anatomy of the deep femoral artery. Doppler  ultrasound, arteriography, or non-operative observation is  indicated for these injuries [17,18]. Some researchers recommend delayed vascular evaluation with Doppler ultrasound within 12 months in this situation [18].

For diagnosis of vascular injury in patients with penetrating proximity trauma to the extremities arteriography  has been  advocated in 80s researches [24]. With the widespread use of arteriography from the 1980s through the 1990s, however the rate  of finding abnormal lesions was reportedly low and clinical   significance uncertain [25]. Angiography itself has potential risks, morbidities and costs as well as any open surgical repair that might be required. Some surgeons questioned whether the   benefits of an aggressive approach were entirely justified. Angiography particularly is useful in blunt trauma due to the high incidence of associated bone, nerve, and soft tissue injuries that could be responsible for clinical hard signs and obscure an accurate diagnosis [26]. Some researchers recommend computed tomographic or conventional angiography in penetrating injuries with soft clinical signs to assist in injury location and extent and to aid in staged planning for reconstruction [27]. Also when the patient  presents  with multilevel trauma  to an extremity  (eg. a shotgun  injury  or an extremity with 2 fractures), the level of arterial injury may be in question and an arteriogram is indicated. We had 7 patients  with complex fracture  or dislocations without  diminished   distal  pulses. All of  them  had normal  angiography  results. Some orthopedic  injury patterns have been associated with a high incidence of arterial  damage include  knee dislocations, ipsilateral fractures  on  either  side of the  knee (floating  knee), open or segmental distal femoral shaft fractures and certain displaced tibia plateau fractures[28,29]. The popliteal artery becomes vulnerable to stretch, tear, or intimal damage when the knee becomes displaced by dislocation or widely displaced fracture. Despite major advances in vascular trauma  surgery, the  evaluation and diagnosis of patients with popliteal artery injury associated with posterior knee dislocation continue to challenge the surgeon [30,31].

Five patients in our study had knee dislocation due to trauma. Among them 2 patients had diminished distal pulses and  report  of angiographies  were abnormal. (Popliteal artery injury finally need to repair) 3 patients of them had normal distal pulses and in these patients the angiography reports were normal. Similar our findings, other studies confirmed  the role of physical examination in determining the need for arteriography. Arteriography  appears to be unnecessary in complex fracture  or  dislocations  when  physical examination is negative [32-35]. Indication  for  angiography  was unknown  in 9 patients in our research. Perhaps their pulse examinations  were abnormal  when they admit and  recovered  with or without conservative therapy before referred for angiography. Angiography in this group did not have any benefit.

In conclusion, the most important factor in prediction of result of angiography was distal arterial pulses examination. But these data confirm the low incidence of vascular injury in asymptomatic patients with proximity. So the use of angiography when proximity is the sole indication in an asymptomatic patient with a normal vascular examination should be questioned.

Conflict of Interest: None declared.

Funding/Support

This study was supported by the Faculty of Medicine and Deputy Research of Mashhad University of Medical Sciences.