Penetrating extremity trauma: Identification of patients at high-risk requiring arteriography R o b e r t J. Anderson, M_D, R o b e r t W. H o b s o n , II, M D , Frank T. Padberg, jr., M D , Kenneth G. Swan, M D , Bing C. Lee, M D , Zafar Jamil, M D , Gary Breitbart, M D , and Joseph Manno, M D , Newark,NJ. Indications for arteriography in patients with penetrating trauma to the extremities remain controversial. Some clinicians have recommended universal use of arteriography, whereas others prefer to rely on physical findings alone. To better define our indications for contrast studies, we reviewed clinical data on 306 patients (349 extremities) with penetrating trauma who were admitted during a prior 2-year period (1985 to 1987). Injuries were caused by stab wounds in 50 (14.3%) extremities and by gunshot wounds in 299 (85.7%) extremities. Twenty-seven of the 50 stab wounds (54%) required urgent exploration based on physical findings, whereas 23 underwent arteriography. None of these studies showed unsuspected arterial injury. Twenty-nine of 299 gunshot wounds (9.7%) underwent mandatory exploration, and arteriograms were performed on 270 extremities; findings in 30 studies (11.1%) were positive for unsuspected arterial injuries. Gunshot wounds were categorized according to location and number of arteriograms with positive results. Arteriograms of lateral thigh and upper arm injuries resulted in no positive outcomes. Positive study results were recorded in 22.9% of calf injuries, 20% of forearm and antecubital injuries, 9.5% of popliteal fossa injuries, 9.0% of medial and posterior thigh injuries, and 8.3% of medial and posterior upper arm injuries. We recommend arteriography for penetrating injuries to these high-risk areas. However, clinical evaluation alone is accurate for identification of arterial trauma with lateral thigh or upper a r m wounds and stab wounds to the extremities. (J VAsc SURG 1990;11:544-8.)
The role of arteriography in the surgical management of penetrating injuries to the extremities in which the missile or sharp-edged instrument comes close to major vascular structures remains debatable. The standard of therapy in most institutions has been to explore surgically all suspected arterial injuries that present with pulsatile hemorrhage, a bruit, absent distal pulses, or an expanding hematoma. However, in other patients with penetrating injuries to the extremity close to a major artery, arteriography generally has been recommended to exclude the possibility of an unrecognized vascular injury and to reduce the morbidity of negative surgical explorations. However, this policy results in a large number of arteriograms with normal outcomes and some
authors 1,2have advocated reliance on clinical findings alone. We have used arteriography to exclude occult vascular injuries in patients with penetrating extremity trauma, while performing routine exploration of all injuries accompanied by classic signs of arterial il~ jury. We have analyzed data on patients admitted with gunshot and stab wounds from a recent 2-year experience to identify high-risk areas of injury where the yield from arteriography would justify such an approach. We have also compared the accuracy of relying on physical findings alone to identify vascular injuries caused by gunshot and stab wounds, thereby excluding the need for arteriographic evaluation in some patients.
From the Section of Vascular Surgery, Department of Surgery, University of Medicine and Dentistry of New Jersey, New Jersey Medical School. Presented at the Third Annual Meeting of the Eastern Vascular Society, Bermuda, May 4-7, 1989. Reprint requests: Robert W. Hobson, II, MD, Universityof Medicine and Dentistry of New Jersey-NewJerseyMedical School, MSB G532, 185 South Orange Ave., Newark,NJ 07103-2757. 24/6/16139
CLINICAL MATERIAL Patients admitted to the hospital with penetrating trauma to the extremities were evaluated for vascular injuries between December 1985 and December 1987. All patients were examined by one of the authors (R.J.A.) within 24 hours of admission, and the wounds and projectiles present were documented an
544
Volume 11 Number 4 April 1990
Patients at h~gh risk requiring arteriography 545
Table I. Stab wounds to extremities (n = 50) Results of mandatory explorations (n = 27, 54%) Positive for vascular injury Negative for vascular injury Results of arteriograms for proximity injuries (n = 23, 46%) Positive for vascular injury Negative for vascular injury
Table III. Results of arteriography and exploration for proximity injuries caused by gunshot wounds Location 21 (77.8%) 6 (22.2%)
0 (o%)
23 (100%)
Table II. Gunshot wounds to extremities (n = 299) Results of mandatory explorations (n = 29, 9.7%) Positive for vascular injury Negative for vascular injury Results of arteriograms for proximity injuries (n = 270, 90.3%) Positive for vascular injury Negative for vascular injury
28 (96.6%) 1 (3.4%)
Upper extremity Medial/posterior arm Antecubital fossa Forearm
No.
2 Intimal flap, brachial artery (2) 1 Brachial artery pseudoaneurysm (1) 3 Extravasation, radial artery (1) Occlusion of radial artery (1) Occlusion of ulnar artery (1)
Lower extremity Medial/posterior thigh 11 Partial transection, superficial femoral artery (3) Extravasation, profimda femoris (2) Intimal flap, superficial femoral artery (4) Superficial femoral arteriovenous fistula (2) Popliteal fossa 2 Intimal flap, popliteal artery
(1)
30 (11.1°,6)
Popliteal arteriovenous fistula
24O (88.9%)
(1)
Calf (leg)
atomically in the patients' data files. All patients with pulsatile hemorrhage, bruits, expanding hematomas, or absent distal pulses were considered to have clinically apparent vascular injuries and were explored promptly. Proximity injury was defined as a pene: trating wound in which the path of the projectile or sharp object was near a major arterial structure without classic signs of vascular trauma. These patients were referred for biplanar arteriography to identify any unsuspected vascular injuries. Three hundred six patients with 349 extremity injuries as a result of penetrating trauma were included in this study. Two hundred ninety men (94.8%) and 16 women (5.2%), with an average age ,~127 years (range: 9 to 65) participated. In patients with proximity injuries, arteriography was performed before any surgical procedure. These patients were subsequently compared with regard to preoperative physical findings, arteriographic findings, and clinical follow-up. RESULTS Individual extremities were categorized with respect to whether a mandatory surgical exploration was indicated or arteriography for an injury close to a major artery was performed. Fifty extremities sustained penetrating trauma as a result of stab wounds. Mandatory exploration was performed on 27 (54%) of these extremities; results of 21 were positive for a significant vascular injury, and six had extensive soft tissue damage only (Table I). Arteriograms were obtained on the remaining 23 extremities (46%) with
Injury identified
5 Partial transection, posterior tibial artery (2) Transection of posterior and anterior tibial arteries (1) Intimal flap, tibioperoneal trunk (1) Occlusion of tibioperoneal
trunk (1)
Total
24
proximity injuries; none had positive findings for a significant vascular injury (Table I). Gunshot wounds were responsible for 299 extremity injuries in this study. Twenty-nine (9.7%) underwent mandatory exploration, with 28 having a significant vascular injury and only one having isolated soft tissue damage (Table II). Arteriography was performed on 270 (90.3%) extremities with proximity injuries caused by gunshot wounds; 240 had a negative result, and 30 had evidence of a vascular injury (Table II). Surgical exploration was performed in 24 of these 30 extremities, and all had confirmation of a significant vascular injury (Table III). Two examples of positive results of arteriograms in patients with proximity injuries and palpable peripheral pulses are presented and demonstrate an intimal flap (Fig. 1) and arteriovenous fistula (Fig. 2). Six extremities in which vascular injuries were demonstrated arteriographically were not explored (Table IV) based on clinical judgment. Proximity gunshot wounds were subsequently categorized with respect to entry and exit sites and the location of projectiles on plain radiographs. The anatomic location of the wound and its course were
546
Journal of VASCULAR SURGERY
Anderson et al.
Fig. 1. Brachial artery intimal flap (arrow) in 14-year-oldboy after gunshot wound to left arm.
Table IV. Vascular injuries identified on arteriography but not explored Injury
No.
Branch occlusion superficial femoral artery Branch occlusion deep femoral Occlusion peroneal artery Occlusion anterior tibial artery Total
2 1 1 2
then correlated with the presence or absence o f a vascular injury on arteriography (Table V). Lateral thigh and upper arm injuries resultedin no positive arteriographic findings, whereas positive study results were recorded in 22.9% of calf (leg) injuries, 20% of forearm and antecubital injuries, 9.5% of popliteal fossa wounds, 9.0% of medial and posterior thigh wounds, and 8.3% of medial and posterior arm injuries. DISCUSSION Surgical management of penetrating extremity injuries has evolved during the last 3 decades based on concepts of wound debridement and availability of high resolution arteriography. Early during this period most authors advocated, surgical exploration?-1 °
Table V. Correlation of the location of proximity injuries and arteriographic evidence of occult vascular trauma Location Upper extremity Medial/posterior arm Lateral arm Antecubital fossa Forearm Lower extremity Medial/posterior thigh Lateral thigh Popliteal fossa Calf (leg)
Incidence of vascular injuries 2/24 0/4 1/ 5 3/15
(8.3%) (0%) (20%) (20%)
14/156 0/10 2/21 8/35
(9%) (0%) (9.5%) (22.9%)
As arteriography became increasingly available for evaluation of proximity injuries, surgeons n-~6 used these diagnostic studies to avoid the morbidity of negative explorations while identifying occult vascular trauma. More recently, authors have suggested that physical examination alone may be reliable enough to identify these injuries. 1,2Recognizing that a reduction in the number of arteriograms with negative findings would be desirable, this investigation has identified high-risk areas of injury in which the yield from arteriography in proximity injuries is inz
Volume 11 Number 4 April 1990
Patients at high risk requiring arteriography
547
Fig. 2. Superficial femoral arteriovenous fistula in 29-year-old man after gunshot wound to left thigh. creased, while identifying those injuries in which clin..jal evaluation alone is accurate. Historically, penetrating injuries of the extremities were explored surgically when close to a major vascular structure. However, Spencer ~7 suggested a possible role for arteriography in patients with suspected vascular trauma associated with indefinite clinical signs on physical examination. A decade later, Snyder et al? 6 confirmed the value of arteriography in evaluating proximity injuries and reported a sensitivity of 97% and a specificity of 90% for this diagnostic study. Numerous authors have recommended its use to obviate needless surgical exploration with its associated morbidity and resultant prolonged hospital stay, while allowing the identification o f a significant number of occult arterial injuries. The yield of positive arteriographic results was reported to be 20% by McCormick and Burch, ~212% by Menzoian et al., ~a 9.8% by Perry et al., 8 and 9.5%
in a previous report from our group? 8 These data are consistent with the 11.1% yield from arteriography in the current series. Consequently, we routinely have performed arteriography in penetrating trauma to extremities close tO major vascular structures. However, evaluation of stab wounds to arteries with arteriography was questioncd with regard to its validity in 1970. Mufti et al., ~9 and Lain and Williams 2° using canine models presented arteriograms with falsely negative results after stab wounds m femoral arteries in 75% and 60% of cases, rcspectivcly. Furthermore, a review of the literature and the data presented in this clinical series would support evaluation of proximity stab wounds by physical examination alone. McCorkell et al., 2~ evaluated 12 patients with proximity injuries using arteriography and identified no arterial injuries. Similarly, Hartling et al., 2 found no arterial injuries in 36 patients with
548 Anderson et al.
proximity stab wounds. Although Reid et al. 22 reported a 2.7% incidence o f arterial injury in 218 proximity injuries caused by stab wounds, our data are similar to the other authors in that no arterial injuries were identified in 23 arteriograms obtained for proximity stab wounds. The reason for this low injury rate with stab wounds close to major arterial structures is likely a result o f the mechanism o f injury in which the sharp-edged instrument must penetrate the wall o f the artery as opposed to the concussive effect seen with gunshot wounds, which may contuse the wall or disrupt the intima, while leaving the arterial wall intact. Anatomic locations o f gunshot wounds to the extremities with higher yields o f positive arteriographic outcomes have been identified in this report. It is our recommendation that arteriograms for extremity wounds close to major arterial structures be obtained in patients with gunshots to the calf (leg), forearm, antecubital fossa, popliteal fossa, medial/posterior thigh, and medial/posterior arm. However, clinical evaluation alone is accurate in evaluating lateral thigh and lateral arm gunshot wounds and all stab wounds to the extremities. Based on the criteria outlined in this report, reliance on arteriography may be reduced safely by 10% or more in patients with proximity injuries caused by gunshot wounds and perhaps all patients with proximity stab wound injuries. Further clinical investigation should be directed toward identification o f diagnostic techniques to further decrease dependency on arteriography for proximity extremity injuries. REFERENCES
1. Gomez GA, Kreis DJr, Ramer L, et al. Suspected vascular trauma of the extremities:the role of arteriographyin proximity injuries. J Trauma 1986;26:1005-8. 2. Hartling RP, McGahamIP, BlaisdellFW, LindforsKK. Stab wounds to the extremities:indicationsfor arteriography.Radiology 1987;162:465-7, 3. Bumett HF, Parnell CL, Williams GC, Campbell GS. Peripheral arterial injuries: a reassessment. Am Surg 1976; 183:701-9. 4. Kelly GL, Eiseman B. Civilian vascular injuries. J Trauma 1 Or',r~. 1 ~ . ~ N ~
1A
Journalof VASCULAR SURGERY
5. Lozman H, BeaufilsAT, Rossi G, SchwartzAM, Wolff WI. Vascular trauma observed at an urban hospital center. Surg GynecolObstet 1964;118:725-38. 6. Moore CH, Wolman FJ, Brown RW, Derrick JR. Vascular trauma: a reviewof 250 cases. Am J Surg 1971;122:576-8. 7. Patman RD, Poulos G, Shires GT. The management of civilian arterial injuries. Surg GynecolObstet 1964;118:72538. 8. PerryMO, Thai ER, Shires GT. Management of arterial injuries. Ann Surg 1971;173:403-8. 9. Reichle FA, Golsorkhi M. Diagnosis and management of penetratingarterialand venousinjuriesin the extremities.Am J Surg 1980;140:365-7. 10. Treiman RL, Doty D, Gaspar M. Acute vascular trauma: a fifteen-yearstudy. Am J Surg 1966;111:467-73. 11. Hardy JD, Raju S, Neely WA, Berry DW. Aortic and other arterial injuries. Ann Surg 1975;181:640-53. 12. McCormickTM, Burch BH. Routine angiographic evaluation of neck and extremity injuries. J Trauma 1979;19: 384-7, 13. Menzoian JO, Doyle JE, LoGerfo FE, Cantelmo N, Weitzman AF, SequieraJC. Evaluationand managementof vascular injuries of the extremities.Arch Surg 1983;118:93-5. 14. SirinekKR, LevineBA, GaskillHV, Root HD. ReassessmT"~.t of the role of routine operativeexplorationin vasculartrauma. J Trauma 1981;21:339-44. 15. Smith RF, Elliot JP, Hageman JH, SzilagyiDE, XavierAO. Acute penetratingarterialinjuriesof the neckand limbs. Arch Surg 1974;109:198-205. 16. SnyderWH, Thai ER, Bridges RA, GerlockAJ', Perry MO, Fry WJ. The validityof normal arteriographyin penetrating trauma. Arch Surg 1978;113:424-8. 17. Spencer AD. The reliabilityof signs of peripheral vascular injury. Surg GynecolObstet 1962;114:490-4. 18. Geuder JW, Hobson RW, Padberg FT, Lynch TG, Lee BC, Jamil Z. The role of contrast arteriographyin suspected arterial injuries of the extremities.Am Surg 1985;51:89=93. 19. Mufti MA, LaGuerreJN, PochaczevskyR, Kassner EG, Richter RM, Levowitz BS. Diagnostic value of hematoma in penetrating arterial wounds of the extremities. Arch Surg 1970;101:562-9. 20. Lain KC, Williams GR. Arteriography in acute peripheral arterial injuries: an experimental study. Surg Forut'~ 1970;179-81. 21. McCorkellSJ, Harley JD, Morishima MS, Cummings DK. Indications for angiography in extremity trauma. AJR 1985;145:1245-7. 22. Reid JDS, WeigeltJA, Thai ER, Hugh F III. Assessmentof proximity of a wound to major vascular structures as an indication for arteriography.Arch Surg 1988;123:942-6.
The role of arteriography in the surgical management of penetrating injuries to the extremities in which the missile or sharp-edged instrument comes close to major vascular structures remains debatable. The standard of therapy in most institutions has been to explore surgically all suspected arterial injuries that present with pulsatile hemorrhage, a bruit, absent distal pulses, or an expanding hematoma. However, in other patients with penetrating injuries to the extremity close to a major artery, arteriography generally has been recommended to exclude the possibility of an unrecognized vascular injury and to reduce the morbidity of negative surgical explorations. However, this policy results in a large number of arteriograms with normal outcomes and some
authors 1,2have advocated reliance on clinical findings alone. We have used arteriography to exclude occult vascular injuries in patients with penetrating extremity trauma, while performing routine exploration of all injuries accompanied by classic signs of arterial il~ jury. We have analyzed data on patients admitted with gunshot and stab wounds from a recent 2-year experience to identify high-risk areas of injury where the yield from arteriography would justify such an approach. We have also compared the accuracy of relying on physical findings alone to identify vascular injuries caused by gunshot and stab wounds, thereby excluding the need for arteriographic evaluation in some patients.
From the Section of Vascular Surgery, Department of Surgery, University of Medicine and Dentistry of New Jersey, New Jersey Medical School. Presented at the Third Annual Meeting of the Eastern Vascular Society, Bermuda, May 4-7, 1989. Reprint requests: Robert W. Hobson, II, MD, Universityof Medicine and Dentistry of New Jersey-NewJerseyMedical School, MSB G532, 185 South Orange Ave., Newark,NJ 07103-2757. 24/6/16139
CLINICAL MATERIAL Patients admitted to the hospital with penetrating trauma to the extremities were evaluated for vascular injuries between December 1985 and December 1987. All patients were examined by one of the authors (R.J.A.) within 24 hours of admission, and the wounds and projectiles present were documented an
544
Volume 11 Number 4 April 1990
Patients at h~gh risk requiring arteriography 545
Table I. Stab wounds to extremities (n = 50) Results of mandatory explorations (n = 27, 54%) Positive for vascular injury Negative for vascular injury Results of arteriograms for proximity injuries (n = 23, 46%) Positive for vascular injury Negative for vascular injury
Table III. Results of arteriography and exploration for proximity injuries caused by gunshot wounds Location 21 (77.8%) 6 (22.2%)
0 (o%)
23 (100%)
Table II. Gunshot wounds to extremities (n = 299) Results of mandatory explorations (n = 29, 9.7%) Positive for vascular injury Negative for vascular injury Results of arteriograms for proximity injuries (n = 270, 90.3%) Positive for vascular injury Negative for vascular injury
28 (96.6%) 1 (3.4%)
Upper extremity Medial/posterior arm Antecubital fossa Forearm
No.
2 Intimal flap, brachial artery (2) 1 Brachial artery pseudoaneurysm (1) 3 Extravasation, radial artery (1) Occlusion of radial artery (1) Occlusion of ulnar artery (1)
Lower extremity Medial/posterior thigh 11 Partial transection, superficial femoral artery (3) Extravasation, profimda femoris (2) Intimal flap, superficial femoral artery (4) Superficial femoral arteriovenous fistula (2) Popliteal fossa 2 Intimal flap, popliteal artery
(1)
30 (11.1°,6)
Popliteal arteriovenous fistula
24O (88.9%)
(1)
Calf (leg)
atomically in the patients' data files. All patients with pulsatile hemorrhage, bruits, expanding hematomas, or absent distal pulses were considered to have clinically apparent vascular injuries and were explored promptly. Proximity injury was defined as a pene: trating wound in which the path of the projectile or sharp object was near a major arterial structure without classic signs of vascular trauma. These patients were referred for biplanar arteriography to identify any unsuspected vascular injuries. Three hundred six patients with 349 extremity injuries as a result of penetrating trauma were included in this study. Two hundred ninety men (94.8%) and 16 women (5.2%), with an average age ,~127 years (range: 9 to 65) participated. In patients with proximity injuries, arteriography was performed before any surgical procedure. These patients were subsequently compared with regard to preoperative physical findings, arteriographic findings, and clinical follow-up. RESULTS Individual extremities were categorized with respect to whether a mandatory surgical exploration was indicated or arteriography for an injury close to a major artery was performed. Fifty extremities sustained penetrating trauma as a result of stab wounds. Mandatory exploration was performed on 27 (54%) of these extremities; results of 21 were positive for a significant vascular injury, and six had extensive soft tissue damage only (Table I). Arteriograms were obtained on the remaining 23 extremities (46%) with
Injury identified
5 Partial transection, posterior tibial artery (2) Transection of posterior and anterior tibial arteries (1) Intimal flap, tibioperoneal trunk (1) Occlusion of tibioperoneal
trunk (1)
Total
24
proximity injuries; none had positive findings for a significant vascular injury (Table I). Gunshot wounds were responsible for 299 extremity injuries in this study. Twenty-nine (9.7%) underwent mandatory exploration, with 28 having a significant vascular injury and only one having isolated soft tissue damage (Table II). Arteriography was performed on 270 (90.3%) extremities with proximity injuries caused by gunshot wounds; 240 had a negative result, and 30 had evidence of a vascular injury (Table II). Surgical exploration was performed in 24 of these 30 extremities, and all had confirmation of a significant vascular injury (Table III). Two examples of positive results of arteriograms in patients with proximity injuries and palpable peripheral pulses are presented and demonstrate an intimal flap (Fig. 1) and arteriovenous fistula (Fig. 2). Six extremities in which vascular injuries were demonstrated arteriographically were not explored (Table IV) based on clinical judgment. Proximity gunshot wounds were subsequently categorized with respect to entry and exit sites and the location of projectiles on plain radiographs. The anatomic location of the wound and its course were
546
Journal of VASCULAR SURGERY
Anderson et al.
Fig. 1. Brachial artery intimal flap (arrow) in 14-year-oldboy after gunshot wound to left arm.
Table IV. Vascular injuries identified on arteriography but not explored Injury
No.
Branch occlusion superficial femoral artery Branch occlusion deep femoral Occlusion peroneal artery Occlusion anterior tibial artery Total
2 1 1 2
then correlated with the presence or absence o f a vascular injury on arteriography (Table V). Lateral thigh and upper arm injuries resultedin no positive arteriographic findings, whereas positive study results were recorded in 22.9% of calf (leg) injuries, 20% of forearm and antecubital injuries, 9.5% of popliteal fossa wounds, 9.0% of medial and posterior thigh wounds, and 8.3% of medial and posterior arm injuries. DISCUSSION Surgical management of penetrating extremity injuries has evolved during the last 3 decades based on concepts of wound debridement and availability of high resolution arteriography. Early during this period most authors advocated, surgical exploration?-1 °
Table V. Correlation of the location of proximity injuries and arteriographic evidence of occult vascular trauma Location Upper extremity Medial/posterior arm Lateral arm Antecubital fossa Forearm Lower extremity Medial/posterior thigh Lateral thigh Popliteal fossa Calf (leg)
Incidence of vascular injuries 2/24 0/4 1/ 5 3/15
(8.3%) (0%) (20%) (20%)
14/156 0/10 2/21 8/35
(9%) (0%) (9.5%) (22.9%)
As arteriography became increasingly available for evaluation of proximity injuries, surgeons n-~6 used these diagnostic studies to avoid the morbidity of negative explorations while identifying occult vascular trauma. More recently, authors have suggested that physical examination alone may be reliable enough to identify these injuries. 1,2Recognizing that a reduction in the number of arteriograms with negative findings would be desirable, this investigation has identified high-risk areas of injury in which the yield from arteriography in proximity injuries is inz
Volume 11 Number 4 April 1990
Patients at high risk requiring arteriography
547
Fig. 2. Superficial femoral arteriovenous fistula in 29-year-old man after gunshot wound to left thigh. creased, while identifying those injuries in which clin..jal evaluation alone is accurate. Historically, penetrating injuries of the extremities were explored surgically when close to a major vascular structure. However, Spencer ~7 suggested a possible role for arteriography in patients with suspected vascular trauma associated with indefinite clinical signs on physical examination. A decade later, Snyder et al? 6 confirmed the value of arteriography in evaluating proximity injuries and reported a sensitivity of 97% and a specificity of 90% for this diagnostic study. Numerous authors have recommended its use to obviate needless surgical exploration with its associated morbidity and resultant prolonged hospital stay, while allowing the identification o f a significant number of occult arterial injuries. The yield of positive arteriographic results was reported to be 20% by McCormick and Burch, ~212% by Menzoian et al., ~a 9.8% by Perry et al., 8 and 9.5%
in a previous report from our group? 8 These data are consistent with the 11.1% yield from arteriography in the current series. Consequently, we routinely have performed arteriography in penetrating trauma to extremities close tO major vascular structures. However, evaluation of stab wounds to arteries with arteriography was questioncd with regard to its validity in 1970. Mufti et al., ~9 and Lain and Williams 2° using canine models presented arteriograms with falsely negative results after stab wounds m femoral arteries in 75% and 60% of cases, rcspectivcly. Furthermore, a review of the literature and the data presented in this clinical series would support evaluation of proximity stab wounds by physical examination alone. McCorkell et al., 2~ evaluated 12 patients with proximity injuries using arteriography and identified no arterial injuries. Similarly, Hartling et al., 2 found no arterial injuries in 36 patients with
548 Anderson et al.
proximity stab wounds. Although Reid et al. 22 reported a 2.7% incidence o f arterial injury in 218 proximity injuries caused by stab wounds, our data are similar to the other authors in that no arterial injuries were identified in 23 arteriograms obtained for proximity stab wounds. The reason for this low injury rate with stab wounds close to major arterial structures is likely a result o f the mechanism o f injury in which the sharp-edged instrument must penetrate the wall o f the artery as opposed to the concussive effect seen with gunshot wounds, which may contuse the wall or disrupt the intima, while leaving the arterial wall intact. Anatomic locations o f gunshot wounds to the extremities with higher yields o f positive arteriographic outcomes have been identified in this report. It is our recommendation that arteriograms for extremity wounds close to major arterial structures be obtained in patients with gunshots to the calf (leg), forearm, antecubital fossa, popliteal fossa, medial/posterior thigh, and medial/posterior arm. However, clinical evaluation alone is accurate in evaluating lateral thigh and lateral arm gunshot wounds and all stab wounds to the extremities. Based on the criteria outlined in this report, reliance on arteriography may be reduced safely by 10% or more in patients with proximity injuries caused by gunshot wounds and perhaps all patients with proximity stab wound injuries. Further clinical investigation should be directed toward identification o f diagnostic techniques to further decrease dependency on arteriography for proximity extremity injuries. REFERENCES
1. Gomez GA, Kreis DJr, Ramer L, et al. Suspected vascular trauma of the extremities:the role of arteriographyin proximity injuries. J Trauma 1986;26:1005-8. 2. Hartling RP, McGahamIP, BlaisdellFW, LindforsKK. Stab wounds to the extremities:indicationsfor arteriography.Radiology 1987;162:465-7, 3. Bumett HF, Parnell CL, Williams GC, Campbell GS. Peripheral arterial injuries: a reassessment. Am Surg 1976; 183:701-9. 4. Kelly GL, Eiseman B. Civilian vascular injuries. J Trauma 1 Or',r~. 1 ~ . ~ N ~
1A
Journalof VASCULAR SURGERY
5. Lozman H, BeaufilsAT, Rossi G, SchwartzAM, Wolff WI. Vascular trauma observed at an urban hospital center. Surg GynecolObstet 1964;118:725-38. 6. Moore CH, Wolman FJ, Brown RW, Derrick JR. Vascular trauma: a reviewof 250 cases. Am J Surg 1971;122:576-8. 7. Patman RD, Poulos G, Shires GT. The management of civilian arterial injuries. Surg GynecolObstet 1964;118:72538. 8. PerryMO, Thai ER, Shires GT. Management of arterial injuries. Ann Surg 1971;173:403-8. 9. Reichle FA, Golsorkhi M. Diagnosis and management of penetratingarterialand venousinjuriesin the extremities.Am J Surg 1980;140:365-7. 10. Treiman RL, Doty D, Gaspar M. Acute vascular trauma: a fifteen-yearstudy. Am J Surg 1966;111:467-73. 11. Hardy JD, Raju S, Neely WA, Berry DW. Aortic and other arterial injuries. Ann Surg 1975;181:640-53. 12. McCormickTM, Burch BH. Routine angiographic evaluation of neck and extremity injuries. J Trauma 1979;19: 384-7, 13. Menzoian JO, Doyle JE, LoGerfo FE, Cantelmo N, Weitzman AF, SequieraJC. Evaluationand managementof vascular injuries of the extremities.Arch Surg 1983;118:93-5. 14. SirinekKR, LevineBA, GaskillHV, Root HD. ReassessmT"~.t of the role of routine operativeexplorationin vasculartrauma. J Trauma 1981;21:339-44. 15. Smith RF, Elliot JP, Hageman JH, SzilagyiDE, XavierAO. Acute penetratingarterialinjuriesof the neckand limbs. Arch Surg 1974;109:198-205. 16. SnyderWH, Thai ER, Bridges RA, GerlockAJ', Perry MO, Fry WJ. The validityof normal arteriographyin penetrating trauma. Arch Surg 1978;113:424-8. 17. Spencer AD. The reliabilityof signs of peripheral vascular injury. Surg GynecolObstet 1962;114:490-4. 18. Geuder JW, Hobson RW, Padberg FT, Lynch TG, Lee BC, Jamil Z. The role of contrast arteriographyin suspected arterial injuries of the extremities.Am Surg 1985;51:89=93. 19. Mufti MA, LaGuerreJN, PochaczevskyR, Kassner EG, Richter RM, Levowitz BS. Diagnostic value of hematoma in penetrating arterial wounds of the extremities. Arch Surg 1970;101:562-9. 20. Lain KC, Williams GR. Arteriography in acute peripheral arterial injuries: an experimental study. Surg Forut'~ 1970;179-81. 21. McCorkellSJ, Harley JD, Morishima MS, Cummings DK. Indications for angiography in extremity trauma. AJR 1985;145:1245-7. 22. Reid JDS, WeigeltJA, Thai ER, Hugh F III. Assessmentof proximity of a wound to major vascular structures as an indication for arteriography.Arch Surg 1988;123:942-6.
