Computed Tomographic Angiography as the Primary Diagnostic Modality in Penetrating Lower Extremity Vascular Injuries: A Level I Trauma Experience

Abstract

Computed tomographic angiography (CTA) has been established as a valid modality for the assessment of extremity vascular injury. Over the last several years at our institution, CTA has evolved as the primary diagnostic modality for penetrating extremity injuries, largely replacing diagnostic angiography. The purpose of this study was to evaluate the outcomes with this imaging modality at a high-volume Level I trauma center. A retrospective review was conducted of all patients presenting with penetrating lower extremity trauma between 2008 and 2009. Patient factors collected included demographics, mechanism of injury, injury severity, presence of hard signs of vascular injury, radiologic studies, operative intervention, and outcomes. There were 132 patients with penetrating lower extremity trauma. The average age of the patients was 25 years, with an average injury severity score of 10. The injuries were primarily gunshot wounds (89%). In all, 59 patients (45%) underwent CTA. CTA of the extremity was performed as a continuation of a computed tomography of the chest/abdomen/pelvis in 28 (47%) versus a targeted CTA of the extremity in 31 (53%) patients. In all, 34 (58%) CTAs were negative for vascular injury, 19 (32%) were positive, and six (10%) were indeterminate. Of the 34 patients with a normal CTA, none went to the operating room for repair of a major vascular injury; similarly, of the 19 patients with an abnormal CTA, there were no negative operative explorations. A total of 28 (21%) patients required operative intervention for the injured extremity; procedures performed included fasciotomy, venous and arterial ligation, primary repair, and interposition grafting. There were no amputations and no mortalities. Our results support the use of CTA as the primary imaging modality in evaluating penetrating lower extremity injury. Because of its proven accuracy in detecting major vascular injury, cost-effectiveness, and ease and rapidity of administration and interpretation, CTA should supplant conventional angiography in initial evaluation of the patient presenting with penetrating trauma.