Extremity CTA for penetrating trauma: 10-year experience using a 64-detector row CT scanner

CTA Imaging of Peripheral Arterial Injuries

Traumatic vascular injuries consist of direct or indirect damage to arteries and/or veins and account for 3% of all traumatic injuries. Typical consequences are hemorrhage and ischemia. Vascular injuries of the extremities can occur isolated or in association with major trauma and other organ injuries. They account for 1-2% of patients admitted to emergency departments and for approximately 50% of all arterial injuries. Lower extremities are more frequently injured than upper ones in the adult population. The outcome of vascular injuries is strictly correlated to the environment and the time background. Treatment can be challenging, notably in polytrauma because of the dilemma of which injury should be prioritized, and treatment delay can cause disability or even death, especially for limb vascular injury. Our purposes are to discuss the role of computed tomography angiography (CTA) in the diagnosis of vascular trauma and its optimized protocol to achieve a definitive diagnosis and to assess the radiological signs of vascular injuries and the possible pitfalls.

Brazilian guidelines on diagnosis and management of traumatic vascular injuries

Trauma is a leading cause of death, permanent disability, and health care cost worldwide. The young and economically active are the most affected population. Exsanguination due to noncompressible torso hemorrhage is one of the most frequent causes of early death, posing a significant challenge to trauma and vascular surgeons. The possibility of limb loss due to vascular injuries must also be considered. In recent decades, the approach to vascular injuries has been significantly modified. Angiotomography has become the standard method for diagnosis, endovascular techniques are currently incorporated in treatment, and damage control, such as temporary shunts, is now the preferred approach for the patients sustaining physiological derangement. Despite the importance of this topic, few papers in the Brazilian literature have offered guidelines on vascular trauma. The Brazilian Society of Angiology and Vascular Surgery has developed Projetos Diretrizes (Guideline Projects), which includes this publication on vascular trauma. Since treating trauma patients is a multidisciplinary effort, the Brazilian Trauma Society (SBAIT) was invited to participate in this project. Members of both societies reviewed the literature on vascular trauma management and together wrote these guidelines on vascular injuries of neck, thorax, abdomen, and extremities.

Using Arterial Pressure Index to Predict Arterial Injuries in Penetrating Trauma to the Upper Extremities

BACKGROUND

Upper extremity (UE) vascular injuries account for 18.4% of all traumatic vascular injuries. Arterial pressure index (API) use in lower extremity injuries to determine the need for further investigations is well established. However, due to collateral circulation in UEs, it is unclear if the same algorithm can be applied. The purpose of this study was to determine if APIs can be used to determine the need for computed tomography angiogram (CTA) in penetrating UE trauma.

METHODS

All adult trauma patients with penetrating UE trauma and APIs from 2006 to 2016 were identified at 3 urban US level 1 trauma centers. Sensitivity, specificity, and positive and negative predictive values of APIs <.9 in detecting UE arterial injuries were calculated.

RESULTS

During the 11-year study period, 218 patients met our inclusion criteria. Gunshot wounds comprised 76.6% and stab wounds 17.9%. Median injury severity score and API were 9 and 1, respectively. Seventy-two of our patients underwent evaluation with CTA. Of the injuries, the most common were thrombus or occlusion (46.7%), transection (23.1%), and dissection (15.4%), radiographically. Ultimately, 32 patients underwent surgical.

Traumatic arterial injuries in upper and lower limbs: what every radiologist should know

Traumatic arterial injuries of the extremities are a rare but potentially fatal event. Computed tomography (CT) angiography of the extremities has become the technique of choice and can provide rapid accurate detection and characterization of vascular lesions. Vascular injuries can be classified in active hemorrhage, vasospasm, occlusion, post-traumatic arteriovenous fistula, pseudoaneurysm, and patterns of intimal injuries. The learning objectives of this pictorial essay are to review the normal arterial anatomy of the upper and lower limbs, describe the technique of CT angiography in vascular trauma of the extremities, describe and illustrate the CT-angiography findings of traumatic arterial injuries, and know the potential pitfalls when interpreting a CT-angiography of the extremities.

Roles of Trauma CT and CTA in Salvaging the Threatened or Mangled Extremity

Extremity arterial injuries account for up to 50% of all arterial traumas. The speed, accuracy, reproducibility, and close proximity of modern CT scanners to the trauma bay have led to the liberal use of CT angiography (CTA) when a limb is in ischemic jeopardy or is a potential source of life-threatening hemorrhage. The radiologist plays a critical role in the rapid communication of findings related to vessel transection and occlusion. Another role of CT that is often overlooked involves adding value to surgical planning. The following are some of the key questions addressed in this review: How does CTA help determine whether a limb is salvageable? How do concurrent multisystem injuries affect decision making? Which arterial injuries can be safely managed with observation alone? What damage control techniques are used to address compartment syndrome and hemorrhage? What options are available for definitive revascularization? Ideally, the radiologist should be familiar with the widely used Gustilo-Anderson open-fracture classification system, which was developed to prognosticate the likelihood of a functional limb salvage on the basis of soft-tissue and bone loss. When functional salvage is feasible or urgent hemorrhage control is required, communication with trauma surgeon colleagues is augmented by an understanding of the unique surgical, endovascular, and hybrid approaches available for each anatomic region of the upper and lower extremities. The radiologist should also be familiar with the common postoperative appearances of staged vascular, orthopedic, and plastic reconstructions for efficient clinically relevant reporting of potential down-range complications. Online supplemental material is available for this article. ^©RSNA, 2022.

Interventional Treatment of Bronchiectasis Macrosomia Based on Multirow CT Tomography Monitoring

We present in this paper an in-depth study and analysis of bronchiectasis haemoptysis by multirow CT tomography and a multifaceted treatment and analysis of the interventions monitored by the scan. Although coronary CT is of great clinical value in the diagnosis and monitoring of coronary artery disease, the potential radiation damage caused by coronary CT should not be underestimated because CT imaging is based on X-rays and the actual effective dose is 5-30 mSv, which is reported in the literature to be high when using conventional imaging modalities for coronary CT. Although there is no direct evidence of a definite causal relationship between X-ray exposure during CT examinations and tumorigenesis, theoretically, even small doses of radiation exposure may pose some potential health risk. Therefore, in clinical practice, coronary CT examinations should be performed in strict compliance with the radiation protection rule "as low as reasonably achievable" (ALARA) recognized by the radiation industry. For longitudinal openings in the range of 0° to 59° and transverse openings in the range of 0° to 44°, the CB2 catheter is significantly more stable than the MIK catheter, and for longitudinal openings in the range of 60° to 119° and transverse openings in the range of 0° to 44°, the CB2 catheter is more stable than the MIK catheter. For longitudinal openings from 0° to 120° and lateral openings from 45° to 90°, there was no significant difference in cannulation stability between the CB2 and MIK catheters. There was a potential tendency for MIK cannulation stability to be higher than CB2 for longitudinal openings in the range of 120° to 180° and lateral openings in the range of 45° to 90°, but there was no significant difference.

Diagnostic Value of Multi-Row Spiral CT Imaging in Emergency Connoisseurs Injury Combined with Shock

In this paper, multi-slice spiral CT imaging is used to diagnose emergency connoisseurs injury hemorrhagic shock and brain perfusion scans in patients with the connoisseur’s injury. The EDS spectrum of multi-slice spiral CT obtained Perfusion imaging as the perfusion parameters. The patient’s CTA and volume reproduction images can be displayed at the same time. The patient’s diagnostic relationship can be visually observed. The best results set up two recommended schemes and compare the perfusion parameters and radiation dose with the standard control group. Ensuring the image quality required for diagnosis and effectively reducing the radiation, it had great diagnostic value in emergency connoisseurs injury which combined with shock. Three-dimensional image reconstruction results of this study can observe the anatomical positional relationship between intracranial lesions and surrounding skulls, skulls, and other important structures before surgery. The design of the bony window provides a more intuitive and convenient basis and guarantee for the preoperative evaluation of the neurosurgery operation and the smooth operation of the operation.

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.

Yield of CT angiography in penetrating lower extremity trauma

PURPOSE

CT angiography (CTA) has become a valuable tool in the assessment of suspected arterial injury in patients with penetrating lower extremity trauma. However, expensive imaging such as CTA should be judiciously utilized to ensure value-based care. We therefore assessed the yield of CTA in this setting at a level-1 trauma unit and correlated it with the clinical history provided.

METHODS

A retrospective descriptive study from 1 July 2013 to 31 June 2018 at a 1386-bed, tertiary-level, public-sector teaching hospital in Cape Town, South Africa.. All patients undergoing CTA for suspected arterial injury following penetrating lower extremity trauma were included. The imaging yield of clinically significant arterial injury and the predictive value of specific clinical signs were determined.

RESULTS

A total of 983 patients (median age 27 years, 91% male) were included; 90% (886/983) had gunshots, 9% (89/983) stabs, and 1% (8/983) other injuries. Despite an average 13% year-on-year increase in CTA performed, there was no change in the proportion demonstrating arterial injury. Thirty-four percent (23/68) of patients with strong (hard) signs of arterial injury (active pulsatile bleeding, rapidly expanding hematoma, absent pulse, palpable thrill, or audible bruit), 11% (49/459) with moderate (soft) signs (history of an arterial bleed, excessive non-pulsatile bleeding, large non-expanding hematoma, major neurological deficit, diminished but appreciable pulse, and arterial proximity), and 5% (24/456) with no indication for imaging had clinically significant arterial injuries. Significant positive correlations were rapidly expanding hematoma (p = 0.009), an absent pulse (p < 0.001), and a diminished pulse (p < 0.001). Significant negative correlations were proximity to a major artery (p = 0.005) and no clinical indication provided (p < 0.001).

CONCLUSION

There is poor correlation between clinical details provided and the presence of arterial injury at our institution. In this context, CTA serves a pivotal role in the definitive identification of arterial injury.

European Society of Emergency Radiology: guideline on radiological polytrauma imaging and service (short version)

BACKGROUND

Although some national recommendations for the role of radiology in a polytrauma service exist, there are no European guidelines to date. Additionally, for many interdisciplinary guidelines, radiology tends to be under-represented. These factors motivated the European Society of Emergency Radiology (ESER) to develop radiologically-centred polytrauma guidelines.

RESULTS

Evidence-based decisions were made on 68 individual aspects of polytrauma imaging at two ESER consensus conferences. For severely injured patients, whole-body CT (WBCT) has been shown to significantly reduce mortality when compared to targeted, selective CT. However, this advantage must be balanced against the radiation risk of performing more WBCTs, especially in less severely injured patients. For this reason, we recommend a second lower dose WBCT protocol as an alternative in certain clinical scenarios. The ESER Guideline on Radiological Polytrauma Imaging and Service is published in two versions: a full version (download from the ESER homepage, https://www.eser-society.org ) and a short version also covering all recommendations (this article).

CONCLUSIONS

Once a patient has been accurately classified as polytrauma, each institution should be able to choose from at least two WBCT protocols. One protocol should be optimised regarding time and precision, and is already used by most institutions (variant A). The second protocol should be dose reduced and used for clinically stable and oriented patients who nonetheless require a CT because the history suggests possible serious injury (variant B). Reading, interpretation and communication of the report should be structured clinically following the ABCDE format, i.e. diagnose first what kills first.

Pulse oximeter plethysmograph waveform and automated oscillometric sphygmomanometer for ankle-brachial index measurement

OBJECTIVES

There are limited non-invasive methods to assess lower extremity arterial injuries in the emergency department (ED) and pre-hospital setting. The ankle-brachial index (ABI) requires careful auscultation by Doppler, an approach made difficult in noisy environments. We sought to determine the agreement of the ABI measured using the pulse oximeter plethysmograph waveform (Pleth) with auscultation by Doppler in a controlled setting. A secondary outcome sought to examine the agreement of ABI by automated oscillometric sphygmomanometer (AOS) with Doppler.

METHODS

We measured blood pressure in the right upper and lower extremities of healthy volunteers using: (1) Doppler and manual sphygmomanometer; (2) Pleth and manual sphygmomanometer; and (3) AOS. The Bland-Altman approach to assessing agreement between methods was used comparing mean differences between ABI pairs to their means for Doppler versus Pleth and Doppler versus AOS. The intraclass correlation coefficient (ICC) from mixed effects models examined intra- and inter-rater reliability.

RESULTS

Among 100 participants with normal ABI the mean ABI (95%CI) were Doppler 1.11 (0.90-1.33), Pleth 1.10 (0.91-1.30), and AOS 1.10 (0.90-1.30). The ABI difference (95% CI for limits of agreement) were 0.01 (-0.20,0.18) for Doppler-Pleth and 0.02 (-0.26, 0.22) for Doppler-AOS. The ICC for the Doppler-Pleth comparison (ICC = 0.56, 95% CI 0.47-0.63) was greater than for the Doppler-AOS (ICC = 0.32, 95% CI 0.19-0.43).

CONCLUSIONS

The ABI measured using the Pleth has a high level of agreement with measurement by Doppler. The AOS and Doppler have good agreement with greater measurement variability. Pleth and AOS may be reasonable alternatives to Doppler for ABI.

Impact of iodine concentration and scan parameters on image quality, contrast enhancement and radiation dose in thoracic CT

Background

We investigated the impact of varying contrast medium (CM) densities and x-ray tube potentials on contrast enhancement (CE), image quality and radiation dose in thoracic computed tomography (CT) using two different scanning techniques.

Methods

Seven plastic tubes containing seven different CM densities ranging from of 0 to 600 HU were positioned inside a commercial chest phantom with padding, representing three different patient sizes. Helical scans of the phantom in single-source mode were obtained with varying tube potentials from 70 to 140 kVp. A constant volume CT dose index (CTDIvol) depending on phantom size and automatic dose modulation was tested. CE (HU) and image quality (contrast-to-noise ratio, CNR) were measured for all combinations of CM density and tube potential. A reference threshold of CE and kVp was defined as ≥ 200 HU and 120 kVp.

Results

For the medium-sized phantom, with a specific CE of 100–600 HU, the diagnostic CE (200 HU) at 70 kVp was ~ 90% higher than at 120 kVp, for both scan techniques (p < 0.001). Changes in CM density/specific HU together with lower kVp resulted in significantly higher CE and CNR (p < 0.001). When changing only the kVp, no statistically significant differences were observed in CE or CNR (p ≥ 0.094), using both dose modulation and constant CTDIvol.

Conclusions

For thoracic CT, diagnostic CE (≥ 200 HU) and maintained CNR were achieved by using lower CM density in combination with lower tube potential (< 120 kVp), independently of phantom size.

Penetrating Extremity Trauma Endovascular versus Open Repair?

Penetrating extremity trauma (PET) accounts for an estimated 5-15% of trauma with vascular injury and these injuries are accountable for a significant percentage of trauma-related deaths. Historically, vascular injuries were best treated by open repair. While a defined selection criteria and a comprehensive algorithm have not been validated, the advancement of endovascular techniques, embolotherapy, and stent grafting have become viable options for the treatment of penetrating arterial extremity trauma in select patients. Advantages endovascular repair offers include decreasing mortality and morbidity associated with open repair, decreasing blood loss, decreasing iatrogenic injury such as nerve injury, and lower rate of wound infection. Patients stability, type of vascular injury, and lesion location are main factors help deciding between endovascular and open repair. Patient selection between endovascular and open repair should be determined by on a case-by-case situation, individual hospital guidelines, a multidisciplinary approach, and technical expertise.

A novel rat model of tibial fracture for trauma researches: a combination of different types of fractures and soft tissue injuries

BACKGROUND

The outcomes for open tibial fractures with severe soft tissue injury are still a great challenge for all the trauma surgeons in the treatment. However, most of the existing open tibial fracture models can only provide minimal soft tissue injury which cannot meet the requirement of severe trauma research. Our goal is to investigate a novel tibial fracture model providing different fractures combined with soft tissue injury for better application in trauma research.

METHODS

A total of 144 Sprague-Dawley rats were randomly divided into 4 groups. With group 1 as control, the other groups sustained different right tibial fractures by the apparatus with buffer disc settings either 3 mm, 10 mm, or 15 mm. X-ray and computed tomography angiography (CTA) were performed at 6 h to evaluate the fracture patterns and vascular injuries. Peripheral blood and tibialis anterior muscle were harvested at 6 h, 1 day, 3 days, 7 days, 14 days, and 28 days for ELISA and histological analysis.

RESULTS

X-ray and μCT results indicated that different fractures combined with soft tissue injuries could be successfully provided in this model. According to OTA and Gustilo classification, the fractures and soft tissue injuries were evaluated and defined: 36 type I in group 2, 34 type II in group 3, and 36 type III in group 4. The CTA confirmed no arterial injuries in groups 1 and 2, 2 arterial injuries in group 3, and 35 in group 4. ELISA indicated that the levels of pro-inflammatory cytokines TNF-α and IL-1β were significantly higher in group 4 than in other groups, and the levels of anti-inflammatory cytokines TGF-β and IL-10 were significantly higher in surgery groups than in group 1 in later stage or throughout the entire process. HE, Masson, and caspase-3 stains confirmed the most severe inflammatory cell infiltration and apoptosis in group 4 which lasted longer than that in groups 2 and 3.

CONCLUSIONS

The novel apparatus was valuable in performing different fractures combined with soft tissue injuries in a rat tibial fracture model with high reproducibility and providing a new selection for trauma research in the future.

Diagnostic workup and endovascular treatment of popliteal artery trauma

Although management paradigms for certain arterial trauma, such as aortic injuries, have moved towards an endovascular approach, the application of endovascular techniques for the treatment of peripheral arterial injuries continues to be debated. In the realm of peripheral vascular trauma, popliteal arterial injuries remain a devastating condition with significant rates of limb loss. Expedient management is essential and surgical revascularization has been the gold standard. Initial clinical assessment of vascular injury is aided by readily available imaging techniques such as duplex ultrasonography and high resolution computed tomographic angiography. Conventional catheter based angiography, however, remain the gold standard in the determination of vascular injury. There are limited data examining the outcomes of endovascular techniques to address popliteal arterial injuries. In this review, we examine the imaging modalities and current approaches and data regarding endovascular techniques for the management popliteal arterial trauma.