M. R. Noorbakhsh1, M. J. Bradley1, B. Zahoor1, S. Kyere1, K. Shanmuganathan1, D. Stein1, T. M. Scalea1 1University Of Maryland,R A Cowley Shock Trauma Center,Baltimore, MD, USA
Introduction: The use of CT angiography for detection of extremity vascular injury has become widespread. We sought to further characterize the vascular injuries noted on CT angiogram of the lower extremity for blunt injury with the use of a novel grading system, and to use CTA grade of vascular injury to predict safe nonoperative management.
Methods: A prospectively collected institutional database was queried for all CT angiograms for blunt lower extremity injury between March 2006 and December 2013. Admission notes, CT angiograms, traditional angiograms, operative reports, discharge summaries, and post-discharge trauma and orthopedic clinic notes were reviewed. Data extracted included pulse exam, presence of threatened limb, extremity vascular injuries noted on CTA and in the operating room, and any delayed claudication. Those patients whose CT examinations revealed an injury to the common femoral, superficial femoral, profunda femoral, and/or popliteal arteries were submitted to an attending radiologist for further grading.
Results: 440 CTA examinations of the lower extremity were performed on 398 patients during the study period. 140 of these examinations revealed a vascular injury. The sensitivity of abnormal pulse exam in predicting a vascular injury noted on CTA was 69.6%, with specificity of 53.2%. 79 above-knee vascular injuries were identified and graded on 57 CTA examinations. 52 of these injuries were immediately addressed operatively. Results of operative and nonoperative management, stratified by injury grade, are summarized in table 1. 40/41 (98%) high grade (grades 3 and 4) injuries prompted immediate operative intervention. 32 isolated low-grade (grades 1 and 2) above-knee vascular injuries were identified, of which 25 (78%) were managed nonoperatively, with no adverse sequelae (delayed amputations or claudication).
Conclusion: CT angiography is an excellent test to assess the vasculature in blunt lower extremity injury. Grading of injuries, when combined with physical exam, can predict which above-knee vascular injuries are managed nonoperatively. Nonoperative management of low-grade injuries appears to be safe, even in the setting of a documented pulse deficit but not an acutely threathened limb, with no evidence of adverse sequelae in the 25 injuries managed nonoperatively. Grade 3b and grade 4 injuries were generally managed operatively, with a higher percentage of acutely threatened limbs requiring immediate vascular intervention.
