Arteriography and Intervention in Extremity Trauma

Abstract The role of arteriography has been central to the diagnosis and management of extremity vascular trauma for two decades. Arteriography can demonstrate the location and morphology of arterial injury, as well as the presence of multiple lesions. Present indications for arteriography reflect our current understanding of the natural history of arterial injury. While physical findings such as diminished distal pulse, expanding hematoma and bruit/thrill are accepted indications, arteriography based on proximity alone is controversial and yields few positive studies. Knowledge of the mechanism of injury can aid in the understanding of arterial lesions. Recently, noninvasive imaging studies have emerged as alternatives to arteriography in the initial diagnosis and follow-up of arterial injury. Duplex ultrasonography appears most promising in this respect. Major arteriographic abnormalities include: occlusion, extravasation, false aneurysm, and arteriovenous fistula (AVF). Minor abnormalities include: luminal defect, luminal narrowing, focal luminal widening, arterial deviation and slow arterial flow. Frequently, multiple arteriographic abnormalities are present in a single lesion. Management decisions are based on physical findings, and lesion morphology and location. Although the current trend is toward conservative management of many nonocclusive lesions, finding of occlusion or transmural injury usually warrants a more aggressive approach. Transcatheter embolization is an alternative to surgical ligation of certain lesions. This can be accomplished with Gelfoam (Upjohn Co., Kalamazoo, MI) or steel coils. Preliminary studies indicate that percutaneous endovascular repair may offer a viable alternative to primary surgical repair of proximal arterial injuries.