The role of emergent arteriography in penetrating limb trauma

Routine arteriographic evaluation of patients with penetrating trauma in proximity to major limb arteries has been declining in popularity. Although some controversy still exists, management based on clinical examination alone has been advocated for those without overt signs of vascular injury. To better identify the need for invasive radiologic intervention, 453 limbs (394 patients) sustaining gunshot, shotgun, and stab wounds (331, 28, and 94, respectively) in proximity to a major artery underwent angiography from 1984 through 1990. An arterial injury was demonstrated in 37 (9.4%) of 394 limbs, with a normal vascular examination, but only eight (2.0%) were deemed to require operative intervention. By comparison, 45 (76%) of 59 patients with an abnormal vascular examination (diminished/absent peripheral pulses or decreased Doppler-derived limb blood pressures) had an arterial injury demonstrated by arteriography, with 33 (55.9%) undergoing operative repair. The presence of an associated long bone fracture increased the incidence of angiographically demonstrated vascular injury, but operative intervention was only increased for those with an abnormal vascular exam. A detailed physical examination including Doppler-derived limb blood pressures is essential. In the presence of a normal vascular exam, routine arteriography for proximity of injury is unnecessary. Arteriography should be reserved to identify those few patients with an abnormal vascular examination and an unclear injury who may require vascular repair.