Hard signs of vascular injury may be sufficient to warrant operative exploration and revascularization in the lower extremity trauma setting
Clinton Protack, MD, Brian Wengerter, MD, Raymond Jean, MD, Kristine Orion, MD, Jonathan Cardella, MD, Timur Sarac, MD, Bauer Sumpio, MD, Alan Dardik, MD, Adrian Maung, MD, Young Erben, MD.
Yale University, Hew Haven, CT, USA.
OBJECTIVES: In an era of readily available diagnostic tools and managed care/cost savings, we are faced daily with the question whether another test is necessary to confirm our clinical suspicion. We hypothesized that very few computed tomography angiographies (CTA) are necessary to identify lower extremity vascular injuries (LEVI). We reviewed our level one trauma center’s experience in the management of LEVIs with the aim of looking at our overall outcomes
METHODS: A retrospective review of all trauma patients in the period 2012-2015 was performed. All patients with a suspected LEVI were identified and those that required operative intervention were carefully examined. Our primary end point was to analyze the utility of CTA in LEVI. Secondary end points included outcomes in those patients undergoing operative intervention
RESULTS: 3,789 trauma patients were evaluated. 33 patients were suspected with LEVI and underwent CTA and/or operative exploration. Mean GCS at presentation was 13. 28(86%) were male. 12 (36%) of these injuries were due to penetrating injuries. Mean ABI was 0.81. Out of the initial 33 patients, 31 (94%) had a CTA performed as part of their initial evaluation. Fourteen (45%) of the CTAs identified LEVI. 10 of the 14 patients found to have an injury on CTA were found to have hard signs of LEVI in the trauma bay. 17 patients underwent operative exploration: 3 patients were found to have no LEVI that was previously believed to be on CTA and operative exploration identified two missed injuries not identified on CTA. Thus, 5 of 33 (15%) CTA studies provided a false assumption LEVI. Only one patient (3%) underwent operative exploration and was found to have LEVI in the absence of hard signs, but with a CTA identifying vascular injury. CTA was accurate 71% of the times at determining LEVI. Operative interventions included: 6 bypasses using vein, 4 angiograms, 3 stents, 2 primary repairs, 1 embolization and 1 amputation
CONCLUSIONS: The recognition of hard signs via a thorough physical examination is paramount to assessing the need for operative intervention in the suspicion of LEVI. CTA should be reserved as an adjunct for identifying LEVI in those patients with high clinical suspicion in the absence of hard signs, rather than utilizing CTA as an initial screening tool for identification of LEVI
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