Vascular Trauma: New Directions in Screening, Diagnosis and Management

Abstract

Major vascular injury following trauma is uncommon, however, it can result in extremely high mortality and morbidity, particularly if diagnosis or treatment are delayed. Physical examination has historically been the mainstay of diagnosis, and open repair the mainstay of treatment for these injuries. However, as advanced imaging technologies and endovascular treatment modalities become more common, and validated in the literature the diagnosis and treatment of traumatic vascular injuries has evolved. While patients with classic “hard signs” of vascular injury such as arterial bleeding, expanding hematoma, lack of pulses, bruit, thrill, or shock should still be taken immediately to the operating theater for open exploration with, or without on table angiography if necessary; patients with soft signs of injury or concerning mechanisms now have a myriad of screening options available. Additionally, in vascular injuries that are difficult to diagnose, expose and definitively treat, such as thoracic aortic and subclavian artery injury, minimally invasive diagnostic and treatment options have significantly altered the course of care of these trauma patients. One of the most important advancements in the diagnosis of vascular injury has been the development of computed tomography (CT), specifically CT angiography (CTA). CT scanning is widely available in most hospitals in the United States, is rapid, immediately and easily performed, and does not require the presence of specially trained radiologists and technologists as in traditional angiography. CT angiography has now become the screening tool of choice for traumatic aortic injury, and is becoming more commonly utilized in the diagnosis of upper and lower extremity vascular injury. In the therapeutic realm, minimally invasive endovascular techniques such as stent graft deployment and embolization with coils, glue or gelfoam are increasingly utilized in the treatment of vascular injury. This review will discuss the use of modern imaging techniques such as CT angiography and magnetic resonance imaging (MRI) in the screening and diagnosis of thoracic aortic and upper and lower extremity vascular injuries. We will also discuss the indications for, efficacy and complications of, and outcomes in endovascular therapies for traumatic vascular injuries.