Computed tomography angiography is associated with low added utility for detecting clinically relevant vascular
Riley Brian1, Daniel J Bennett2, Woon Cho Kim1
1Department of Surgery, University of California San Francisco, San Francisco, California, USA.
Insights
CT angiography (CTA) is often overused in extremity trauma cases. Most patients with normal physical exams and no hard vascular injury signs do not require CTA, as interventions are rare.
Area of Science:
- Trauma Surgery
- Vascular Surgery
- Diagnostic Imaging
Background:
- Extremity CT angiography (CTA) is a common tool for diagnosing vascular injuries in trauma patients.
- The injured extremity index (IEI) aids in screening, but is not always calculable.
- Physical examination combined with IEI shows high sensitivity for vascular injury.
Purpose of the Study:
- To evaluate the benefit of CTA in patients with normal pulse examinations and no hard signs of vascular injury.
- To determine if CTA is overutilized in extremity trauma assessment.
- To identify vascular abnormalities requiring intervention that were missed by physical examination.
Main Methods:
- Retrospective review of trauma activation patients who underwent extremity CTA at a Level 1 trauma center.
- Data collected from September 1, 2019, to September 1, 2020.
- Analysis of vascular interventions in relation to physical examination findings and CTA results.
Main Results:
- 167 injured limbs were analyzed in 136 patients.
- Vascular intervention was performed on 4.8% (open) and 3.0% (endovascular) of limbs.
- Only 0.6% of limbs had a CTA-identified vascular injury requiring intervention despite normal pulse examination and no hard signs.
Conclusions:
- The majority of patients with normal pulse exams and no hard vascular injury signs undergoing CTA do not require intervention.
- Further prospective studies are needed to assess the utility of CTA in extremity trauma.
- Careful patient selection for CTA may reduce unnecessary imaging and associated costs.
Background:
Extremity CT angiography (CTA) is frequently used to assess for vascular injury among patients with extremity trauma. The injured extremity index (IEI), defined as the ratio of systolic occlusion pressure between injured and uninjured extremities, has been implemented to screen patients being considered for CTA. Physical examination together with IEI is extremely sensitive for significant extremity vascular injury. Unfortunately, IEI cannot always be calculated. This study aimed to determine whether patients with normal pulse examinations and no hard signs of vascular injury benefitted from further imaging with CTA. We hypothesized that CTA has become overused among patients with extremity trauma, as determined by the outcome of vascular abnormalities that underwent vascular intervention but were missed by physical examination.
Methods:
The charts of traumatically injured patients who underwent extremity CTA were retrospectively reviewed. This study was performed at a level 1 trauma center for patients who presented as trauma activations from September 1, 2019 to September 1, 2020.
Results:
One hundred and thirty-six patients with 167 injured limbs were included. Eight limbs (4.8%) underwent an open vascular operation, whereas five limbs (3.0%) underwent an endovascular procedure. One of the 167 limbs (0.6%) had a vascular injury seen on CTA and underwent intervention that was not associated with a pulse abnormality or hard signs of vascular injury. This patient presented in a delayed fashion after an initially normal IEI and examination. Proximity injuries and fractures alone were not highly associated with vascular injuries.
Discussion:
Many patients with normal pulse examination and no hard signs of vascular injury underwent CTA; the vast majority of these patients did not then have a vascular intervention. Given the consequences of missed vascular injuries, further work is required to prospectively assess the utility of CTA among patients with extremity trauma.
Level Of Evidence:
III.
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