Extremity Vascular Injury
	Date: Fri, 22 Nov 1996 08:54:51 From: Robert Silbergleit, MD [silbergleitr@allegheny.edu] I am interested in how often people are using one shot ED angiography, and for what indications. Several centers, including Shock Trauma in Baltimore and Ben Taub in Houston, have reported there experience with this technique (1-3). With the increasing use of observation for proximity GSW of the extremity, how are one-shot angio's being used? To define/localize the injury in patients with hard signs of arterial injury? (those who presumably need surgical exploration anyway.) To determine the presence of arterial injury in patients with soft signs? (those who can possibly be formally studied or observed.) To screen patients with no sign of vascular injury but wounds in the proximity of major arteries? By hard signs I mean loss of distal pulse, expanding hematoma, bruit or thrill, visible arterial bleeding. By soft signs I mean distal neuroinjury, diminished distal pulse/ABI, stable hematoma, significant blood loss at scene. Finally how many centers have replaced angio with color flow doppler or other sonographic imaging? This has been recently described at a small number of centers (4,5). Lets see a quick show of hands.
	Date: Fri, 22 Nov 1996 14:35:26 -0500 From: Peter H. Bradshaw [phb@twave.net] Although color duplex is "recently described at a small number of centers" I think it is commonly practiced at a large number of centers. I would bet that most hospitals with a colorflow doppler (including ours) would use it as first line evaluation of vascular injury.
	Date: Fri, 22 Nov 1996 11:21:38 From: Ken Mattox [KMATTOX@aol.com] Of course we like it. We use it almost every day. IT has much greater utility than other forms of angiography and doppler studies.
	Date: Sat, 23 Nov 1996 14:54:28 From: John A. Aucar, M.D. [jaucar@bcm.tmc.edu] At the Ben Taub, we are still using one shot emergency center arteriography for all of the indications cited above. The third indication, proximity, is a judgement call and usually not enough by itself. Some individuals are more liberal with it's use than others. We also get formal grams frequently and in special circumstances. Some of have a distinct interest advancing the use non-invasive techniques for the evaluation of trauma, but I can't say that we are particularly good at it, yet.
	Date: Fri, 22 Nov 1996 15:54:24 From: Dr. Jay Smith [SSMITH4@surg.hmc.psu.edu] We use doppler, duplex, then real biplane angio if needed
	Date: Fri, 22 Nov 1996 12:38:55 From: Douglas Geehan [dgeehan@MEM.PO.COM] If you have 'hard' indications of vascular injury, your arteriogram should be best done in the OR AFTER you have completed your repair. For other patients, a good screening tool is the measurement of pressure distal to the injury. If there is systemic pressure, the likelihood of injury is low, and arteriography in any location ED, OR,or radiology will have a low yield. If the patient has a diminshed pressure in the injured extremity, then angiography can be done. If there are no other injuries of concern, the best picture will come from the angio suite. With the use of pressure as a threshold to do angiography, a cutoff value is needed. We use an index of 0.8. We recently had a patient with a shotgun injury to the arm who had intact pulse, but diminished pressure index (0.75). He had multiple arterial injuries to brachial, radial and ulnar arteries.
	Date: Mon, 25 Nov 1996 15:58:48 From: Jack M. Bergstein, M.D. [bergstei@post.its.mcw.edu] Pressure index (API per Johansen) has a definite miss rate: I have a patient with GSW to shoulder, fractured humerus, with pressure of 100mmhg in the injured arm, API <= 1.0. When humerus reduced for splinting, began to bleed, briskly. In OR, large lateral defect, requiring interposition for repair. Unfortunately, developed compartment syndrome. I think we would have missed the injury , for at least a few hours, had we relied on API and had the wound not bled. This is what I expect, as the API relies on flow disturbance sufficient to reduce the pressure... it seems that it would take a huge pseudoaneurysm to do this. Color-flow duplex also has its potential pitfalls, such as aberrant anatomy, and difficult to image areas such as proximal arm /thigh, not to mention operator variation, etc. (Bergstein, et al, Pitfalls in the use of Color-flow duplex ultrasound for screening of suspected arterial injuries in penetrated extremities, J Trauma 33:395-402, 1992