Digital venous angiography. A prospective evaluation in peripheral arterial trauma

Late development of renal arteriovenous fistula following gunshot trauma--a case report

A 43-year-old man presenting with symptoms of congestive heart failure, cardiomegaly, and impaired left ventricular (LV) function was diagnosed as having a huge left renal arteriovenous (AV) fistula. The AV fistula might be attributed to a gunshot wound suffered during his military service twenty years ago. Percutaneous transcatheter arterial embolization utilizing multiple spring coils in conjunction with cyanoacrylic glue successfully occluded the fistula, with subsequent improvement of LV function and reduction of LV size on his serial echocardiographic follow-up.

Traumatic arteriovenous fistula: experience with 202 patients

Experience with the management of 202 patients with 210 traumatic arteriovenous fistulas is reported. Penetrating trauma accounted for 98 per cent of injuries caused mainly by stabs (63 per cent) and missile wounds (26 per cent). Seven of 15 patients with shotgun wounds had multiple lesions. Over half of all fistulas occurred in the cervico-mediastinal vessels; abdominal and thoracic vessels were infrequently involved. The upper limbs were involved in 22 per cent and the lower limbs in 20 per cent. Some 133 patients were diagnosed and treated within 1 week of injury; 69 presented 1 week to 12 years later. Machinery murmur was noted in 61 per cent of the early presenters, but was an almost universal finding in those presenting late. Only three patients had cardiac failure and all had underlying cardiomyopathy. Active overt haemorrhage was not common. Arterial continuity was restored in 80 per cent of cases, usually by autogenous reconstruction. Venous injury was usually treated by ligation or lateral suture. Patients treated within 1 week of injury had a lower rate of perioperative mortality and morbidity than those treated late, due mainly to technical difficulties in controlling the vessels caused by fibrosis and massive venous dilatation. If a policy of selective exploration of penetrating trauma is to be followed, careful assessment for arteriovenous fistula must be made and the patient evaluated at regular intervals for several months. Shotgun injuries require routine angiography at the time of presentation. The earlier treatment is instituted, the better the results.

Rapid diagnosis of thoracic aortic transection using intravenous digital subtraction angiography

Rupture of the thoracic aorta associated with blunt trauma remains a frequently lethal injury. Although increasing numbers of patients with ruptured aortas are surviving to reach the hospital, the in-hospital mortality attending this injury remains high. Death due to transected aorta has been related to a delay in diagnosis. In an attempt to decrease the time necessary for diagnosis of this injury, we studied 50 patients using intravenous digital subtraction angiography (IVDSA) and conventional biplane angiography. We found that IVDSA was significantly faster than conventional biplane angiography, and that when IVDSA films are of diagnostic quality, they are sufficient to reliably demonstrate the presence of traumatic aortic transection. Our study was too small to establish whether IVDSA is a sufficiently sensitive test to exclude aortic injury. Further studies in this area need to be performed.

Intravenous digital subtraction angiography: its use in evaluating vascular injuries in children

Angiography is often essential in the evaluation of patients with suspected vascular injuries. However, arterial cannulation has a significant inherent complication rate, especially in small patients. Therefore, a less invasive method of evaluating children with such injuries is desirable. We report nine children (age range, 9 months to 16 years; median, 7 years) in whom intravenous digital subtraction angiography (IV-DSA) was used to evaluate suspected vascular injuries. IV-DSA showed a false aneurysm in two children, one managed by ligation alone and the other by resection with primary anastomosis. One child was found to have an arteriovenous fistula, which was treated by ligation. An iliac occlusion, following an arteriogram to evaluate a liver tumor, was documented by IV-DSA and successfully managed with aggressive anticoagulant therapy. Demonstration of a normal vascular tree avoided exploration in four children. A planned skin flap was abandoned in a child who suffered an electrical injury when IV-DSA showed lack of adequate vascular supply. In all nine cases, the IV-DSA obviated the need for intraarterial angiography. In addition to avoiding arterial cannulation, IV-DSA required significantly less radiation and less time to perform than conventional arteriography. Motion artifact, vessel overlap, and some loss of minute detail are some of its potential shortcomings. IV-DSA is an effective method of screening children with suspected vascular injuries. In addition, our experience has shown that IV-DSA can be the definitive diagnostic procedure, although intraarterial angiography may be necessary in selected cases.

Delayed diagnosis of arterial injuries

During an 8 1/2 year period, 28 patients with a delayed diagnosis of an arterial injury in an extremity or the neck were treated. The median delay between injury and diagnosis was 10 days. The tibio-peroneal arteries were the most commonly injured vessels. After extensive analysis of the records and arteriograms of the involved patients, the following conclusions were drawn: Arteriograms are mandatory for penetrating wounds proximal to major arteries of the extremities because of the 5 to 15 percent incidence of occult injuries; the timing of arteriography in the distal leg is critical if subtle injuries to the tibial and peroneal vessels are to be detected; when experienced radiologists are not available, interpretation of exclusion arteriograms is best performed by experienced trauma surgeons; false aneurysms, arteriovenous fistulas, or a combination of both continue to be the most common manifestations of missed arterial injuries; failure to find an injury previously diagnosed by a preoperative arteriogram mandates an intraoperative arteriogram and, on occasion, an arteriotomy; and, late arterial repairs usually require segmental resection with an end-to-end anastomosis or insertion of a graft.