Physical Address
304 North Cardinal St.
Dorchester Center, MA 02124
Nonarteriographic Diagnosis of Penetrating Vascular Trauma
Massive bleeding, acute limb ischemia, or a pulsatile hematoma can make the diagnosis of penetrating vascular trauma straightforward, and the first diagnostic procedure is often an appropriate operative exploration. However, the vast majority of vascular injuries arising from penetrating trauma are not so clinically obvious, manifesting signs that are subtle, evanescent, and minimal. Even more vexing are clinical scenarios in which there is no evidence for an underlying arterial injury at all, but the nature of the wounding mechanism obliges concern about a silent arterial or venous disruption. Basic initial noninvasive vascular diagnostic methods to assess the extent of injury in victims of penetrating trauma are an essential element of current best practice.
Historical Background
Deliberate efforts to repair arterial injuries arose during the Korean conflict in the early 1950s, and the pioneering work of Rich and colleagues during the Vietnam war catalogued the predictability of successful outcomes for major vascular trauma, particularly in the extremities, presuming that an accurate diagnosis was made early and that operative management was timely and effective.
Routine operative exploration was initially promoted for occult vascular trauma but was found to have a very low yield. Physical examination was thought, except when the diagnosis was obvious, to be inadequately sensitive for identifying many occult arterial injuries. Accordingly, the introduction of routine exclusion arteriography in settings where signs of vascular injury were minimal, or where clinical suspicions were high, was advocated in the 1970s in numerous urban trauma centers, particularly by Perry, Thal, and colleagues at Parkland Hospital in Dallas. These workers were particularly concerned that early identification of silent or minimal arterial injuries be accomplished owing to concerns for subsequent delayed hemorrhage, dissection, or acute arterial occlusion. Indeed, contrast arteriography proved to be quite highly accurate, with several studies demonstrating false positive and false negative rates of less than 2% for such studies performed to detect or rule out occult arterial injuries.
However, routine use of contrast arteriography in this setting is invasive, expensive, and time consuming, and it requires transfer of the patient, who often needs ongoing evaluation, surveillance, and resuscitation, to an angiography suite that is outside of, and often remote from, the emergency department.
Most importantly, several studies demonstrated that when contrast arteriography was performed for exclusion indications, in only a very few of these trauma victims—less than 5%—were arterial injuries identified that were so serious they required operative intervention. For this reason, alternative diagnostic measures were investigated in this patient population.
You're Reading a Preview
Become a Clinical Tree membership for Full access and enjoy Unlimited articles
If you are a member. Log in here