Computed tomography angiography of lower extremities in the emergency room for evaluation of patients with gunshot wounds

Editor's Choice -- European Society for Vascular Surgery (ESVS) 2025 Clinical Practice Guidelines on the Management of Vascular Trauma

OBJECTIVE

The European Society for Vascular Surgery (ESVS) has developed clinical practice guidelines for the care of patients with vascular trauma with the aim of assisting physicians in selecting the optimal management strategy.

METHODS

The guidelines are based on scientific evidence completed with expert opinion. By summarising and evaluating the best available evidence, recommendations for the evaluation and treatment of patients have been formulated. The recommendations are graded according to the ESVS evidence grading system, where the strength (class) of each recommendation is graded from I to III, and the letters A to C mark the level of evidence.

RESULTS

A total of 105 recommendations have been issued on the following topics: general principles for vascular trauma care and resuscitation including technical skill sets, bleeding control and restoration of perfusion, graft materials, and imaging; management of vascular trauma in the neck, thoracic aorta and thoracic outlet, abdomen, and upper and lower extremities; post-operative considerations after vascular trauma; and paediatric vascular trauma. In addition, unresolved vascular trauma issues and the patients' perspectives are discussed.

CONCLUSION

The ESVS clinical practice guidelines provide the most comprehensive, up to date, evidence based advice to clinicians on the management of vascular trauma.

Experiencing cardiac arrest during surgical exploration in hemodynamically stable patients with multiple stab wounds, including lower extremity in Korea: a case report

Stab wounds, particularly those affecting multiple body regions, present considerable challenges in trauma care. This report describes a case of sustained self-inflicted stab injuries to the abdomen and thighs of a 23-year-old male patient. Although the patient's vital signs were stable and bleeding was minimal from thigh wounds without overt signs of vascular injury, the patient experienced a sudden, profound hemorrhage from the right thigh, leading to cardiac arrest. Successful resuscitation was followed by surgical repair of a right superficial femoral arterial injury accompanying a resuscitative endovascular balloon of the aorta. Subsequent lower extremity computed tomography angiography revealed no additional vascular abnormalities. The patient was discharged in stable condition on the 12th postoperative day. This case underscores the unpredictability of stab wound trajectories and the potential for hidden vascular injuries, even in the absence of immediate life-threatening signs. It also emphasizes the critical role of advanced imaging modalities, such as computed tomography angiography, in identifying concealed injuries, and the importance of strategic intraoperative techniques, including resuscitative endovascular balloon occlusion of the aorta, in achieving favorable patient outcomes.

Computed Tomography in Limb Salvage and Deformity Correction-3D Assessment, Indications, Radiation Exposure, and Safety Considerations

Computed tomography (CT) is an essential tool in orthopedic surgery but is known to be a method with that entails radiation exposure. CT increases the risk of developing fatal cancer, which should not be underestimated. However, patients with bone defects and/or deformities must frequently undergo numerous investigations during their treatment. CT is used for surgical planning, evaluating callus maturation, alignment measurement, length measurement, torsion measurement, and angiography. This study explores the indications in CT scans for limb lengthening and deformity correction and estimates the effective radiation dose. These results should help avoid unnecessary radiation exposure by narrowing the examination field and by providing explicit scanning indications. For this study, 19 posttraumatic patients were included after the bone reconstruction of 21 lower limbs. All patients underwent CT examinations during or after treatment with an external ring fixator. The mean effective dose was 3.27 mSv, with a mean cancer risk of 1:117,014. The effective dose depended on the location and indication of measurement, with a mean dose of 0.04 mSv at the ankle up to 6.8 mSv (or higher) for vascular depictions. CT evaluation, with or without 3D reconstruction, is a crucial tool in complex bone reconstruction and deformity treatments. Therefore, strict indications are necessary to reduce radiation exposure-especially in young patients-without compromising the management of their patients.

American Association for the Surgery of Trauma-World Society of Emergency Surgery guidelines on diagnosis and management of peripheral vascular injuries

The peripheral arteries and veins of the extremities are among the most commonly injured vessels in both civilian and military vascular trauma. Blunt causes are more frequent than penetrating except during military conflicts and in certain geographic areas. Physical examination and simple bedside investigations of pulse pressures are key in early identification of these injuries. In stable patients with equivocal physical examinations, computed tomography angiograms have become the mainstay of screening and diagnosis. Immediate open surgical repair remains the first-line therapy in most patients. However, advances in endovascular therapies and more widespread availability of this technology have resulted in an increase in the range of injuries and frequency of utilization of minimally invasive treatments for vascular injuries in stable patients. Prevention of and early detection and treatment of compartment syndrome remain essential in the recovery of patients with significant peripheral vascular injuries. The decision to perform amputation in patients with mangled extremities remains difficult with few clear indicators. The American Association for the Surgery of Trauma in conjunction with the World Society of Emergency Surgery seeks to summarize the literature to date and provide guidelines on the presentation, diagnosis, and treatment of peripheral vascular injuries. LEVEL OF EVIDENCE: Review study, level IV.

CT angiography of lower extremities from anatomy to traumatic and nontraumatic lesions: a pictorial review

After the introduction and the quick improvement of multidetector computed tomography technology, computed tomographic angiography (CTA) has become the imaging examination of choice for the first assessment of patients affected by lower extremities acute disorders. The widespread availability of CT equipment, the high temporal and spatial resolution with post-processing reformation possibilities represent the main advantages of this technique, which can reliably identify different findings related to arterial vessel pathology, such as occlusion, dissection, active bleeding, and pseudoaneurysm. Radiologists should know the anatomy, the acquisition protocols, and the CTA appearances of the different vascular lesions. The right interpretation of CTA findings is essential to establish the best treatment management of each patient.

Over-utilization of computed tomography angiography in extremity trauma

Objectives:

Widespread availability of computed tomography angiography (CTA) for diagnosing arterial injury in injured extremities has created the possibility of overuse. The objective of this study was to evaluate CTA utilization, indications, ordering personnel, and rate of significant findings for blunt or penetrating extremity trauma at a level I trauma center.

Methods:

We performed a retrospective chart review of 1440 consecutive CTAs of upper and lower extremities from 2010 to 2012 at a large level I trauma center, and included only those done for acute trauma. Data were collected with regard to injury, initial exam, reason given for ordering a CTA, specialty of physician ordering CTA, results, and vascular interventions needed. CTAs were categorized as appropriately ordered based on if there was a documented abnormal distal pulse or ankle-brachial index (ABI). Study indication was classified as inconclusive if no vascular exam was documented or physical exam varied.

Results:

A total of 481 CTAs were performed after blunt or penetrating trauma in the emergency room with 31.0% appropriately indicated, 48.0% without indication, and 21.8% inconclusive. Mechanism of injury was most commonly a gunshot wound (40.3%), followed by motor vehicle accidents (39.5%). Overall, 61.5% of the studies had normal arterial flow and only 15.8% of CTAs required vascular operative intervention. Of the studies appropriately indicated, 76.5% had positive findings, with 43% needing operative intervention compared to the inappropriately indicated studies only 11.6% had positive findings, with 0.4% needing operative intervention (P < .0001).

Conclusion:

CTA for blunt or penetrating trauma at a level I trauma center may be over-utilized. Often, this advanced imaging is ordered prior to orthopaedic evaluation or limb reduction, without exam-based indication, and most do not affect patients’ treatment. From our study, CTA utilization based on more stringent exam findings at our hospital could eliminate 48% of all CTA studies for trauma.

[Pediatric post-traumatic limb pseudoaneurysm: Case report and literature review]

INTRODUCTION

Pediatric post-traumatic pseudoaneurysms are a rare complication of arterial limb injuries. Management modalities in children are poorly defined. We report on a case of post-traumatic pseudoaneurysm of the right anterior tibial artery after minimal penetrating trauma, treated with surgery.

CASE REPORT

A 14-year-old boy presented in consultation with a limp and right calf pain 3 months after a penetrating trauma. On physical examination, a painful mass in the middle third of the right leg was found, without inflammatory signs, but with a pulsatile character and a palpable thrill. Ultrasonography revealed a hypoechoic cystic structure, adjacent to the anterior tibial artery with a characteristic ying-yang flow on color Doppler, suggesting a post-traumatic pseudoaneurysm. The diagnosis was confirmed by CT angiography. The treatment was surgical, including flattening of the pseudoaneurysm and interposition of an autologous graft.

CONCLUSION

Management of pediatric post-traumatic pseudoaneurysm of the limbs is surgical. Currently however, new alternatives exist: endovascular techniques, ultrasound-guided compression, and embolization by thrombin injection.