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Vascular and Interventional Radiology |
1 From the Departments of Radiology (J.A.S., F.M., J.E.L., D.H., O.G., G.C.) and Surgery, Divisions of Trauma Surgery (C.M., A.S.) and Vascular Surgery (G.G.), Universidad de Antioquia, Hospital Universitario San Vicente de Paúl, Calle 64 x Carrera 51D, Medellín, Colombia. From the 1999 RSNA scientific assembly. Received January 12, 2000; revision requested February 12; revision received March 20; accepted May 1. Supported in part by Química Schering, Colombia. Address correspondence to J.A.S. (e-mail: jorgeasoto@aol.com).
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMATERIALS AND METHODS RESULTS DISCUSSIONREFERENCES |
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MATERIALS AND METHODS: During 19 months, 142 arterial segments in the proximal portions of the extremities of 139 patients with trauma were evaluated with helical CT arteriography. CT arteriograms were interpreted on site by the radiologist in charge of emergency procedures and retrospectively with consensus interpretation between two radiologists. CT study quality and the presence of arterial injuries were noted. CT arteriographic findings were compared with those of surgery, conventional arteriography, and/or clinical follow-up.
RESULTS: Five (3.6%) patients had nondiagnostic studies and underwent conventional arteriography. In the remaining 137 arterial segments in 134 patients, helical CT arteriography demonstrated arterial injuries in 61 segments and normal arteries in 76 segments. These segments were treated initially with surgery (55 segments) or endovascular intervention (four segments) or were observed (78 segments); 77 of the 78 observed segments remained stable at 3–18 months (mean follow-up, 5.2 months). There were no differences between the on-site and consensus interpretations (
= 1.0). The sensitivity of CT arteriography was 95.1%, and the specificity was 98.7%.
CONCLUSION: Helical CT arteriography can be performed as the initial diagnostic method in most patients suspected to have focal arterial injuries of the proximal portions of the extremities.
Index terms: Arteries, injuries, 91.411, 91.412, 91.4124, 91.494, 92.411, 92.412, 92.4124, 92.494, 92.732 • Arteries, peripheral, 91.411, 91.412, 91.4124, 91.494, 92.411, 92.412, 92.4124, 92.494, 92.732 • Computed tomography (CT), angiography, 91.12916, 92.12916, 91.12912, 92.12912, 91.12917, 92.12917
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODS RESULTS DISCUSSIONREFERENCES |
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Although generally considered safe, catheter-based arteriography may be associated with complications that result from the procedure itself. Therefore, it would be useful to have an alternative noninvasive and reliable diagnostic examination that could limit the performance of arteriography mostly to therapy and diagnosis in a minority of patients. For this purpose, imaging modalities such as duplex ultrasonography (US) with Doppler evaluation (20–23), magnetic resonance (MR) arteriography (24), and helical computed tomographic (CT) arteriography (25) have been used to diagnose arterial injuries, with variable results. At our institution, we have performed helical CT arteriography at the initial examination in many patients suspected of having focal arterial injuries in the proximal portions of the extremities during the past 19 months.
The purpose of this study was to report our experience with helical CT arteriography as the initial diagnostic examination in patients who had sustained penetrating or blunt trauma to the proximal portions of the extremities and in whom arterial integrity was doubted.
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MATERIALS AND METHODS |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODS RESULTS DISCUSSIONREFERENCES |
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During 19 months (March 1998 to September 1999), all patients aged 16 years or older who had penetrating or blunt trauma to the upper or lower extremities and indications for arteriography were candidates for enrollment in this study. At our institution, trauma surgeons perform immediate surgical exploration of these types of injuries when there are one or more definite signs of arterial involvement: an absent pulse with a reconstructable trajectory of the penetrating lesion, pulsatile bleeding, a rapidly expanding hematoma, or a bruit or thrill over the wound. Patients are referred for arteriography when there is no indication for immediate surgery and at least one of the following is present: a diminished but appreciable pulse, a large nonexpanding hematoma, excessive nonpulsatile bleeding, or a major neurologic deficit, all of which are possible signs of arterial injury. Patients with gunshot injuries who have diminished pulses and lesions in more than one segment of the involved extremity, with multiple bullet fragments in the affected extremity or a single bullet but an unreconstructable trajectory, also are referred for arteriography. A penetrating wound in proximity to vascular structures but without the presence of other clinical abnormalities is not considered a valid indication for arteriography.
Patients with injuries distal to the ankles and/or elbows were excluded because spatial resolution at helical CT arteriography, as compared with that at catheter arteriography, in the evaluation of the small-caliber arteries in these locations is limited (25). Because the volume of contrast material used for helical CT arteriography usually is greater than that required for catheter arteriography, patients with known diabetes or renal disease also were excluded to decrease the risk of contrast material–induced renal dysfunction. Given the limited anatomic length that can be evaluated with one helical CT acquisition and a single injection of contrast material by using the equipment available at our institution, we did not include patients with injuries in more than one anatomic segment in one extremity or with indications for arteriography in more than one extremity. However, patients with injuries in both thighs (above the knees) or legs (knees or below) were included, since it is possible to study these regions simultaneously with a single helical CT acquisition. Finally, we did not include patients in whom radiographs of the region that was to be imaged at CT arteriography demonstrated excessive metal fragments, because metal creates artifacts that hinder the evaluation of arterial integrity (25).
During the 19-month study period, 403 patients with trauma and possible arterial injuries were admitted to our institution. Of these, 141 had proximity injuries and were observed without undergoing arteriography or surgery. Based on clinical findings, immediate surgical intervention was performed in 95 patients who were not referred for imaging evaluation. Nine other patients died of massive trauma before any diagnostic procedure was completed. The remaining 158 patients had an indication for arteriography. Nineteen (12%) of them were excluded because of injuries in the feet, forearms, or hands (n = 6); known diabetes (n = 1) or renal dysfunction (n = 1); injuries in more than one anatomic segment (n = 5); or excessive metal fragments (n = 6). These patients underwent diagnostic arteriography.
Helical CT arteriography was performed in the remaining 139 patients (120 men and 19 women), who constituted the focus population in this study. The mean patient age was 28.6 years (age range, 16–77 years). Seventy-six patients had gunshot wounds, 19 had stab wounds, 39 had displaced fractures, and five had dislocations with or without associated fractures. The distribution by anatomic segment was the thigh (59 patients), knee or leg (45 patients), arm (19 patients), and shoulder or axilla (16 patients). Three patients had injuries in both thighs; the segments in the thighs were imaged by performing a single helical CT acquisition. Therefore, 142 arterial segments with clinical suspicion of injury were imaged with CT arteriography in 139 patients. The main indication for CT arteriography in the three patients with bilateral thigh injuries (six arterial segments) was a diminished distal pulse. The main indication for CT arteriography in the 136 patients with an injury in a single segment was a diminished pulse (86 patients), a large nonexpanding hematoma (17 patients), excessive nonpulsatile bleeding (eight patients), a major neurologic deficit (four patients), an ischemic extremity with an appreciable pulse (11 patients), or an absent pulse with an unreconstructable trajectory of a single bullet (10 patients).
Imaging
All helical CT was performed by using a Prospeed unit (GE Medical Systems, Milwaukee, Wis). For CT arteriography, we administered 120 mL iopamidol (Iopamiron [300 milligrams of iodine per milliliter]; Schering, Bogotá, Colombia) at 4.5 mL/sec through an 18-gauge catheter in an antecubital vein by using a power injector. The delay between the beginning of contrast material injection and the acquisition of the helical scans depended on the specific anatomic area that was studied: in the axilla, 10–12 seconds; in the arm, 10–12 seconds; in the thigh, 14–18 seconds; and in the leg, 16–20 seconds. These scanning delay times had been reported to be appropriate by investigators in a previous study (25). In patients with injuries to the upper extremities, contrast material was administered in the contralateral arm to avoid beam-hardening artifacts from the high-attenuating contrast material in the veins.
The acquisition parameters for helical CT that were common to all extremities and segments were 250 mA, 120 kVp, and a 36-second exposure at one image per second. Other parameters varied slightly, depending on the anatomic region imaged (Table 1). The images were reconstructed by using a 180° linear interpolation reconstruction algorithm. In patients with penetrating injuries, we marked the entry and exit orifices with barium sulfate (Barosperse; Mallinckrodt Medical, Mexico City, Mexico). After a digital scout image was obtained, these radiopaque markers were set at the center of the region to be included in the helical acquisition. In patients with blunt trauma and associated fractures or dislocations, the center of the helical scan was set at the main fracture line or affected joint.
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Image Interpretation
At our institution, in-house emergency medicine radiologists are available on a 24-hour basis for emergency diagnostic examinations and procedures. These radiologists, who are in charge of the emergency radiology department, provided on-site interpretation of the CT arteriograms immediately after acquisition. This interpretation was used for clinical patient care and determination of subsequent treatment. These on-site radiologists were aware of the patients’ clinical data, such as demographics, physical examination findings, and mechanism of injury. The radiologists initially determined whether the quality of the helical CT arteriograms was sufficient for interpretation. If the quality was degraded substantially by patient motion or artifacts from metal fragments, the study was considered nondiagnostic and conventional arteriography was performed. If the study was of diagnostic quality, the arterial segments in each study were evaluated for injuries.
For the purposes of this investigation, a second interpretation of the CT arteriograms that were initially deemed adequate for diagnosis was performed with consensus between two radiologists (J.A.S., F.M.) who were involved in the study. This second interpretation was performed within 72 hours of acquisition at the same workstation that was used for the initial evaluation. These radiologists, who are both fellowship trained in body imaging and experienced in interpreting body CT arteriograms, were unaware of the clinical and demographic characteristics of the patients and the official report from the initial interpretation. Because these radiologists were blinded to all clinical patient information, their interpretation of the CT arteriograms was used for comparison with the surgical and conventional arteriographic findings and the clinical outcome.
Both interpretations were performed in an interactive manner at the workstation. The raw data was postprocessed by using software provided with the workstation by the manufacturer (Advantage Windows Release version 3.1) with the following algorithms: maximum intensity pixel projection, volume rendering, shaded surface display, and multiplanar reformatting. Although in both cases the radiologists were free to generate as many two- and three-dimensional renderings as they considered necessary for interpretation, at least one frontal reformation (created with the volume rendering algorithm) of the pertinent arterial segment was generated for every patient. Images were reconstructed by the radiologists themselves, but the number or type of reformations obtained per patient was not recorded. The mean reconstruction time was 10 minutes per patient. At interpretation, the radiologists used the raw data and postprocessed the images that they had generated.
The radiologists responsible for the initial (prospective) and second (retrospective) interpretations evaluated the same parameters. If an abnormality was detected, it was classified as a partial or complete obstruction (occlusion), pseudoaneurysm (extravascular collection of contrast material), arteriovenous fistula (evidence of early filling of venous structures), or intimal flap (intraluminal linear contrast-material filling defect). We determined interobserver agreement between both interpretations by calculating statistics (26).
Follow-up
The patients’ clinical outcomes were determined by means of review of their charts by one of three investigators (D.H., O.G., or G.C.). In patients in whom surgery or conventional arteriography was required after CT arteriography, the data were acquired while the patients were still in the hospital. For these patients, the findings of surgery or conventional arteriography (the official description of findings by a surgeon or arteriographer, respectively) were used as the standard of reference for comparison with CT arteriographic results. For patients in whom further diagnostic procedures or surgery was not required after the completion of CT arteriography, follow-up information was obtained from either the patients’ charts or the treating surgeons. This clinical follow-up, which included a physical examination, was accomplished by one of two investigators (C.M. or A.S.) and was the standard of reference for comparison with CT arteriographic results in these patients.
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RESULTS |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODS RESULTS DISCUSSIONREFERENCES |
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Arterial Findings and Outcome
Findings at CT arteriography in the 137 arterial segments (in 134 patients) in which adequate images were obtained are listed in Table 2. Three patients had a clinical indication for CT arteriography in both thighs. Two of these patients had normal findings in both arterial segments; the third had normal findings in the right thigh and a superficial femoral arterial pseudoaneurysm with an associated arteriovenous fistula in the left thigh.
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In 13 arterial segments, CT arteriography showed pseudoaneurysms and/or fistulas without associated occlusion (Fig 3). The 13 patients with these segments were treated with surgery (10 patients) or endovascular therapy (three patients) without undergoing additional diagnostic procedures. In one patient, endovascular embolization of a large pseudoaneurysm of the right subclavian artery was attempted but unsuccessful; this patient subsequently underwent surgery. In 12 of the 13 patients, surgical or conventional arteriographic findings confirmed the presence and location of the pseudoaneurysm and/or fistula. In one patient, CT arteriography showed an arteriovenous fistula between the distal superficial femoral artery and vein; this fistula was confirmed at surgery, but an additional fistulous communication was found at a more proximal level (the common femoral artery and vein). At retrospective review of the CT images, we found that the region of the proximal fistula was not included in the segment studied at CT arteriography; this accounted for the second false-negative result.
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Statistical Findings
In accordance with these results, CT arteriography was sufficient to properly guide treatment in 130 of 139 patients (133 of 142 arterial segments). In five patients, additional conventional arteriography was required because of nondiagnostic CT arteriograms. Among the 137 segments for which an interpretation was provided, there were no differences between the prospective and the retrospective interpretations with regard to the presence and type of arterial injuries. Therefore, the interobserver agreement was perfect ( = 1.0). When compared with the standards of reference used, 75 interpretations were true-negative and 58 were true-positive. In four patients, findings at conventional arteriography or surgical exploration differed from those at helical CT arteriography, such that treatment was altered substantially. Three of these four patients’ findings were false-negative interpretations of helical CT arteriograms, and the fourth was a false-positive interpretation. Therefore, the sensitivity and specificity of the examination in this patient population were 95.1% (95% CI: 85.4%, 98.7%) and 98.7% (95% CI: 91.9%, 99.9%), respectively.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODS RESULTS DISCUSSIONREFERENCES |
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Although catheter-based arteriography is safe in patients with extremity trauma, it is invasive and costly. Alternative noninvasive imaging examinations include duplex Doppler US with Doppler evaluation (20–23) and MR arteriography (24). However, to our knowledge, these examinations have not gained widespread acceptance. US is operator dependent, and US evaluation of arterial segments in the presence of fractures or large hematomas can be difficult. MR imaging is not practical in patients with trauma because proper monitoring in the magnet may be difficult and many patients are connected to MR imaging–incompatible medical equipment. Furthermore, access to MR imaging systems for emergency studies can be limited.
More recently, helical CT arteriography was compared with conventional arteriography in 45 patients who were suspected to have arterial injuries (25). In that study, the sensitivity was 90% for reader 1 (17 of 19 segments) and 100% (19 of 19) for reader 2, the specificity was 100% for both readers, and the diagnostic performance and interobserver agreement in interpretation were very good.
Helical CT is being performed increasingly for the evaluation of medical and surgical emergencies (27). Many trauma centers have CT scanners close to the emergency department, which hereby decreases the transit time to the main radiology department. At most institutions, the availability of CT for emergency studies exceeds that of MR imaging. The advantages of helical CT in a trauma setting include short acquisition times, use of standard protocols that decrease dependence on the operator, and the ability to examine various body regions by using the same equipment (27). In patients with arterial trauma, helical CT is becoming the modality of choice for detecting aortic injuries (28,29) and has also been proposed for detecting injuries in the neck (30), renal arteries (31), and extremities (25).
In this article, we have reported our experience in performing CT arteriography as the initial examination to evaluate arterial integrity in a large population of patients with extremity trauma who were referred for arteriography. In a minority of patients (n = 6), additional conventional arteriography was required for diagnosis because of technically inadequate or inconclusive CT examinations. CT arteriographic findings were used to properly dictate treatment in 130 (93.5%) of 139 patients. We attempted to decrease the number of nondiagnostic examinations by directly referring for catheter-based arteriography those patients whose conventional radiographs demonstrated excessive metal fragments. However, there are still some patients in whom artifacts from a single fragment may obscure a segment of the artery.
Given the relatively young age of the patient population in our study (mean age, 28.6 years), we were able to use fixed scanning delay times for CT arteriography, with good results. These delay times may be inappropriate in patients who are older or have known preexistent cardiac or peripheral vascular disease. In these patients, the use of test injections or devices that start injection of contrast material when a threshold attenuation level is reached may be necessary to achieve adequate vascular opacification.
The false-negative and false-positive interpretations in our study deserve further analysis. CT arteriography may be limited in depicting the exact site of the abnormal arteriovenous communication when there is indirect evidence of an underlying fistula. Premature venous enhancement with contrast material is a useful sign of a fistula, especially in the lower extremities, in which comparison with the contralateral side is possible. However, the fistula itself may be difficult to localize when there is no associated sign of vascular injury such as pseudoaneurysm; this occurred in one of the patients who was included in this study. Therefore, we recommend that catheter arteriography be performed whenever CT arteriography shows indirect evidence of an underlying fistula but no other direct sign of arterial injury. In another patient, a false-negative interpretation resulted from the limited possible anatomic coverage with a single acquisition when a single–detector row CT scanner was used. This limited coverage may also impede the detection of distal emboli originating in thrombus from a proximal partial injury. Careful planning of the examination is important to decrease the likelihood of excluding important findings. With the advent of multi–detector row helical CT scanners, this is no longer a limitation in a majority of patients.
Preliminary data (32) suggest that multi–detector row CT scanners increase the applications of CT arteriography in the lower extremities for the evaluation of occlusive disease. In our study, one patient with complex tibial and fibular fractures developed definite signs of ischemia and was proved to have extensive thrombosis of the run-off arteries in the leg after CT arteriography showed permeable vessels. Thrombosis may have occurred after CT, but it is also possible that partial lesions of these arteries could have been missed at CT arteriography. The spatial resolution of CT arteriography is lower than that of cut-film or digital subtraction arteriography, and evaluation of distal vessels and peripheral branches is difficult. For this reason, patients with injuries in the forearm, wrist, hand, ankle, or foot still undergo catheter arteriography as the initial diagnostic procedure at our institution. Likewise, patients with substantial discrepancies between physical signs and CT arteriographic findings should be referred for conventional arteriography. Finally, CT arteriography showed segmental interruption of flow in the brachial artery of a patient with a diminished radial pulse, but no injury was found at surgical exploration. We attributed this false-positive result to arterial spasm that abated prior to surgery.
There are other limitations of CT arteriography that must be acknowledged before the technique replaces catheter arteriography for the initial examination of patients suspected to have arterial injuries in the extremities. CT arteriography is purely a diagnostic procedure, whereas catheter-based arteriography provides a means of therapy in patients with certain types of injuries. Most of the reports on endovascular therapy of arterial injuries that had been published up to the time this article was written involved stent-graft repair of pseudoaneurysms or arteriovenous fistulas in the proximal arteries (10–12). In fact, four of the patients included in our study later underwent catheter arteriography and endovascular therapy, although surgery was eventually required in one of these patients. Therefore, catheter arteriography may still be preferable in patients with highly suggestive signs of pseudoaneurysm or fistula in proximal limb segments and at institutions in which endovascular intervention is an option.
We found that only two patients had isolated intimal injuries; neither one had confirmation at conventional arteriography. Because only a minority of patients had conventional arteriographic correlation, we may have underestimated the number of intimal injuries present. However, experience with intimal injuries that have been followed up over time has shown that most heal spontaneously without specific therapy (9,33,34). Therefore, if CT arteriography has limitations in the detection of these "minimal" arterial injuries, this shortcoming may not lead to clinically important long-term sequelae. However, to our knowledge, this remains to be proved.
Our results indicate that CT arteriography can be performed as the initial diagnostic imaging examination in a majority of patients who are suspected to have focal arterial injuries in the proximal portions of the extremities. Abnormalities such as arterial thrombosis, pseudoaneurysm, and arteriovenous fistula are well demonstrated at CT arteriography. If CT arteriography is performed as the primary method of diagnosis in this patient population, diagnostic catheter-based arteriography will be required in a few patients with technically limited examinations or equivocal findings. Technologic improvements may further expand the applications of CT arteriography in patients with extremity trauma. Further studies will be necessary to determine how this examination can be performed in combination with other noninvasive examinations.
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FOOTNOTES |
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REFERENCES |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODS RESULTS DISCUSSIONREFERENCES |
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