ORIGINAL ARTICLE
A Prospective Validation of a Current Practice: The Detection of
Extremity Vascular Injury With CT Angiography
Mark J. Seamon, MD, David Smoger, MD, Denise M. Torres, MD, Abhijit S. Pathak, MD,
John P. Gaughan, PhD, Thomas A. Santora, MD, Gary Cohen, MD, and Amy J. Goldberg, MD
Introduction: Arteriography is the current “gold standard” for the detection of
extremity vascular injuries. Less invasive than operative exploration, conven-
tional arteriography (CA) still has a 1% to 3% risk of morbidity and may delay
definitive repair. Recent improvements in computed tomography (CT) tech-
nology has since broadened the application of CT to include the diagnosis of
cervical, thoracic, and now extremity vascular injury. We hypothesized that CT
angiography (CTA) provides equivalent injury detection compared with the
more invasive CA, but is more rapidly completed and more cost effective.
Methods: A prospective evaluation of patients, ages 18 to 50, with potential
extremity vascular injuries was performed during 2006 –2007. Ankle-
brachial indices (ABI) of injured extremities were measured on presentation in
all patients without hard signs of vascular injury. Patients whose injured extremity
ABI was ⬍0.9 were enrolled and underwent CTA followed by either CA or
operative exploration if CTA findings were limb threatening. Interventionalists
were blinded to CTA findings before performing and reading CAs.
Results: Twenty-one patients (mean age, 26.1 ⫾ 7.1 years) had 22 extremity
CTAs after gunshot (82%), stab (9%), or pedestrian struck by automobile (9%)
injuries to either upper (32%) or lower (68%) extremities. Eleven of 22 (50%)
extremities had associated orthopedic injuries while the mean ABI of the study
population was 0.72 ⫾ 0.21. Twenty-one of 22 (96%) CTAs were diagnostic and
all CTAs were confirmed by either CA alone (n ⫽ 18), operative exploration
(n ⫽ 2), or both CA and operative exploration (n ⫽ 2). Diagnostic CTAs had
100% sensitivity and specificity for clinically relevant vascular injury detection.
Unlike rapidly obtained CTA, CA required 131 ⫾ 61 minutes (mean ⫾ SD) to
complete. In our center, CTA saves $12,922 in patient charges and $1,166 in
hospital costs per extremity when compared with CA.
Conclusions: With acceptable injury detection, rapid availability, and a
favorable cost profile, our results suggest that CTA may replace CA as the
diagnostic study of choice for vascular injuries of the extremities.
Key Words: CT angiography, Conventional arteriography, Extremity vas-
cular injury.
(J Trauma. 2009;67: 238 –244)
Submitted for publication September 2, 2008.
Accepted for publication March 5, 2009.
Copyright © 2009 by Lippincott Williams & Wilkins
From the Department of Surgery (M.J.S., D.M.T., A.S.P., T.A.S., A.J.G.), Division of
Trauma and Surgical Critical Care; Department of Radiology (D.S., G.C.),
Division of Interventional Radiology; and Biostatistics Consulting Center
(J.P.G.), Temple University School of Medicine, Philadelphia, Pennsylvania.
Presented at the 67th Annual Meeting of the American Association for the Surgery
of Trauma, September 24 –27, 2008, Maui, Hawaii.
Address for reprints: Mark J. Seamon, MD, Department of Surgery, Temple
University Hospital, 3401 North Broad Street, Philadelphia, PA 19104; email:
mark.seamon@tuhs.temple.edu.
DOI: 10.1097/TA.0b013e3181a51bf9
238 The Journal of TRAUMA® Injury, Infection, and Critical Care • Volume 67, Number 2, August 2009
E xtremity vascular injury is commonly encountered in busy
trauma centers. Historically, injured extremities with poten-
tial vascular injuries mandated operative exploration lead-
ing to excessive nontherapeutic exploration rates and
significant morbidity.1– 8 More recently, arteriography be-
came the “gold standard” for detection of potential extrem-
ity vascular injuries.9 –17 Although less invasive than operative
exploration, conventional arteriography (CA) still carries a
significant risk (1–3%) of morbidity and may delay defin-
itive operative repair.9 –19
Recent advancements in computed tomography (CT)
technology have now yielded detailed images rivaling those of
CA.20 –29 Improved CT technology has broadened the applica-
tion of CT to include the diagnosis of cervical, thoracic, and now
extremity vascular injury. We hypothesized that CT angiogra-
phy (CTA), performed with a precisely timed injection of
intravenous contrast through a standard peripheral intravenous
line, will provide the same injury detection capabilities as the
more invasive CA but in a rapid, cost-efficient manner.
Our primary study objective was to compare the capa-
bilities of CTA and CA in the diagnosis of extremity vascular
injuries. Secondary study objectives included the analysis of
the elapsed time until CA completion, the cost effectiveness
of our study interventions, protocol-related complications
including access site injury and contrast-induced nephropa-
thy, and clinical outcomes.
METHODS
After Institutional Review Board approval at Temple
University Hospital was obtained, a prospective evaluation of
patients aged 18 years to 50 years with potential extremity
vascular trauma was performed. From April 2006 to December
2007, 21 patients with 22 injured extremities were enrolled.
Upper extremities were defined by the following anatomic
boundaries: proximal, anterior or posterior axillary folds; and
distal, styloid process of the radius and ulna. Lower extrem-
ities were defined by the following anatomic boundaries:
proximal, inguinal crease or gluteal folds; and distal, malleoli
of the tibia and fibula. Both penetrating and blunt injury
mechanisms were included.
The study design is depicted in Figure 1. Patients
without “hard signs” of extremity vascular injury (defined by
arterial bleeding, absent distal pulses, limb ischemia, expand-
ing or pulsatile hematoma, bruit or thrill over injured area,
and hemorrhagic shock without other injury), underwent
ankle-brachial index (ABI) determination of the injured ex-
The Journal of TRAUMA® Injury, Infection, and Critical Care • Volume 67, Number 2, August 2009 Detection of Extremity Vascular Injury With CTA
Figure 1. Study design flow diagram. OR, operating room.
tremity on presentation. Physical examination and ABI de-
termination were performed by a senior surgical resident
under trauma faculty supervision. Only patients who’s ABI
was less than 0.9 in the injured extremity were considered for
study enrollment. Study exclusion criteria included patients
with hard signs of vascular injury, intravenous contrast dye
allergy or previous adverse contrast reaction, renal insuffi-
ciency (defined by creatinine clearance less than 50 mL/
min.), diabetes mellitus, hypertension, multiple myeloma,
and hyperuricemia. All study patients were hydrated with
intravenous fluids for 24 hours after the examinations to
reduce the potential risk of contrast-induced nephropathy.
Patients were later discharged from the hospital with follow-up
instructions for our outpatient trauma clinic.
Enrolled patients underwent CTA (multi-detector, Soma-
tom 16 or 64 CT system, determined by CT scanner availability,
[Siemens, New York, NY]) with 100 mL of Omnipaque (350
mg iodine/mL) nonionic IV contrast (GE Healthcare Medical
Diagnostics, Princeton, NJ) given as a dynamic bolus at 4
mL/second with bolus tracking in the arterial phase of the
CTA protocol. The maximum total “one-time” contrast dose
allowed for CT scans was 150 mL. All CTA images were
reformatted (16 slice, 1-mm intervals; 64 slice, 0.75-mm
intervals) in the axial plane and three dimensional volumetric
reconstructions performed utilizing the Siemens AG Leonardo
Syngo MMWP VE 25A Workstation (Siemens, New York,
NY). The study was then interpreted by an attending Interven-
tional Radiologist.
CA of the injured extremity followed in the interventional
radiology suite. Patients were sterilely prepped and draped.
Access was obtained in the common femoral artery with 19-
gauge micropuncture, single-wall needle and then exchanged
over the wire for a 5-French vascular sheath. Selective catheter-
ization and injection of the injured extremity with 50 mL to 150
mL of Visipaque contrast (GE Healthcare, Princeton, NJ) was
performed. Digital subtraction angiography was staged with
multiple projections of the injured extremity.
Patients with limb-threatening vascular injuries de-
tected by CTA as analyzed by a staff trauma surgeon under-
went immediate operative exploration to verify and repair
these critical injuries. In these select patients only, CTA
findings were confirmed by operative exploration instead of
© 2009 Lippincott Williams & Wilkins
CA. All CTA studies were interpreted first by the trauma
service and then by an attending radiologist while all CA
were read by an attending interventionalist. Interventionalists
were blinded to CT angiogram findings before performing
and reading conventional arteriograms. Reported results are
based on “official” attending radiologist and interventional radi-
ologist reads.
Study patients were admitted to the trauma service and
followed with serial neurovascular examinations and serum
chemistries during their hospitalization. Data collected in-
cluded age, sex, injury mechanism, injury location, associated
orthopedic injuries, ABIs, attending radiologist interpreta-
tions of CTA and CA, elapsed time required for the perfor-
mance of CA, protocol-related complications, and survival.
Protocol-related complications including arterial access inju-
ries and contrast-induced nephropathy were collected and
reviewed. Contrast-induced nephropathy was defined by a
greater than 50% increase in baseline serum creatinine. Pa-
tient charges and hospital costs for the involved diagnostic
studies were obtained from the hospital office of finance.
RESULTS
Twenty-one patients were enrolled and 22 extremity
CTA studies were performed over 21 months (Table 1). The
study population consisted largely of young (26.1 ⫾ 7.1 years
[mean ⫾ SD]) men (90.5%) with penetrating (90.5%) inju-
ries. Of the 22 extremities studied, 18 (81.8%) suffered
gunshot wounds, 2 (9.1%) suffered stab wounds, and 2
(9.1%) were pedestrians struck by automobiles. Seven of 22
(31.8%) were upper extremity injuries and 15 of 22 (68.2%)
were lower extremity injuries. Eleven of 22 (50%) extremi-
ties had associated orthopedic injuries whereas the mean ABI
of the study population was 0.72 ⫾ 0.21.
Twenty-one of 22 (95.5%) CTAs were diagnostic and
all CTAs were then confirmed by either CA alone (n ⫽ 18),
operative exploration (n ⫽ 2) alone, or both CA and operative
exploration (n ⫽ 2). Despite the absence of “hard signs” on
physical examination, two (9.1%) extremity CTAs revealed
potentially limb-threatening vascular injuries. These two pa-
tients were emergently explored in the operating room where
TABLE 1. Demographics and Clinical Characteristics in the
Entire Study Population
n (%)
Age (yr) (mean ⫾ SD) 26.1 ⫾ 7.1
Sex (male) 19 (90.5)
Injury mechanism
Gunshot wound 18 (81.8)
Stab wound 2 (9.1)
Blunt 2 (9.1)
Extremity injury location
Upper 7 (31.8)
Lower 15 (68.2)
Associated orthopedic injury 11 (50)
Ankle brachial index (mean ⫾ SD) 0.72 ⫾ 0.21
Twenty-one patients had 22 studied extremities.
239
Seamon et al. The Journal of TRAUMA® Injury, Infection, and Critical Care • Volume 67, Number 2, August 2009

CT angiogram findings (study 9, popliteal artery transection;

study 17, complete superficial femoral artery occlusion) were
confirmed in both patients (Table 2). Two additional patients
underwent operative repair immediately following both CTA
and CA studies (study 4, superficial femoral artery pseudo-
aneurysm with arteriovenous fistula; study 16, popliteal ar-
tery transection with active contrast extravasation), although
the CA studies added no further clinical information.
Of 21 diagnostic CTAs, 9 vascular injuries, 1 episode of
arterial vasospasm, and 11 uninjured vascular structures were
identified (Fig. 2). All injuries (n ⫽ 9) were then confirmed by
CA (five of nine, 55.6%), operative exploration (two of nine,
22.2%), or both CA and operative exploration (two of nine,
22.2%). One patient had radial artery spasm detectable both by
CT and CA. Eleven CTAs had no findings suggestive of vas-
cular injury and all were then compared with CA. Of these 11
negative CTAs, CA detected 3 (27.3%) episodes of arterial

TABLE 2. A Comparison of CT Angiography and

Conventional Arteriography Findings
Figure 2. CTA (left) three-dimensional reconstructions and
Patient CTA (Slice) CA
CA (right) both revealing popliteal artery transection with
1 Radial artery spasm (16) Radial artery spasm pseudoaneurysm formation (white arrow).
2 No injury (64) No injury
3 No injury (64) No injury
4 Superficial femoral artery Superficial femoral artery
spasm not detected by CTA. These three patients were managed
pseudoaneurysm, pseudoaneurysm, expectantly and recovered without intervention or treatment.
AVF (64) arteriovenous fistula The sensitivity and specificity of diagnostic CTA for the detec-
5 No injury (16) No injury tion of clinically significant extremity vascular injury in our
6 No injury (64) No injury study population was 100% (95% CI, sensitivity, 0.63, 1.00;
7 No injury (64) No injury specificity, 0.72, 1.00).
8 No injury (64) No injury Although 21 of 22 (95.5%) of CTAs were diagnostic,
9 Popliteal artery transaction Operative exploration several studies were limited but interpretable. The single nondi-
10 No injury Brachial artery spasm agnostic CTA was flawed by contrast administration (study 15)
11 Brachial artery dissection Brachial artery dissection through a dysfunctional IV catheter. Two other CTAs were also
(1.5 cm, non-flow (1.5 cm, non-flow flawed by suboptimal intravenous contrast dosages (75 mL) but
limiting) (64) limiting) were deemed diagnostic by the interpreting radiologist. When
12 Posterior tibial trunk Posterior tibial trunk compared with CA, both of these CTAs had concordant inter-
occlusion (16) occlusion
pretations. Eight of 22 extremity CTAs were also limited by
13 No injury (64) Superficial femoral artery
spasm shrapnel or bullet artifact. Each of these eight studies was of
14 Lateral circumflex Lateral circumflex diagnostic quality and, when compared with CA, was diagnostic
dissection (64) dissection and concordant with the gold standard CA reads.
15 Nondiagnostic (16) Brachial artery spasm Elapsed time and cost analyses were performed. Unlike
16 Popliteal artery Popliteal artery rapidly obtained CTA, CA required 131 ⫾ 61 minutes to
transection, contrast transection, contrast complete (range, 55–267 minutes). Patient charges and hospital
extravasation (64) extravasation costs associated with both CTA and CA were assessed (Fig. 3).
17 Superficial femoral artery Operative exploration In our center, CTA saves $12,922 in patient charges (CTA,
occlusion (2.5 cm,
flow limiting) (16)
$2,486 vs. CA, $15,408) and $1,166 in hospital costs (CTA,
18 Posterior tibial artery Posterior tibial artery
$206 vs. CA, $1,372) per extremity when compared with CA.
intimal injury (16) intimal injury One study patient (4.8%) suffered a minor protocol-
19 No injury (16) No injury related complication. This patient developed contrast-induced
20 No injury (16) No injury nephropathy after receiving contrast during both CT and CA
21 No injury (16) Posterior tibial artery studies. After the serum creatinine peaked at 2.7 mg/dL, the
spasm patient was managed expectantly and recovered without fur-
22 Posterior tibial artery Posterior tibial artery ther intervention or treatment. The patient was discharged
transaction (64) transection from the hospital with a normal creatinine value. No access-
A comparison of diagnostic CT angiography and conventional arteriography re- site injuries were appreciated in this study population.
vealed 100% concordance with all clinically significant injuries. Study patient 15 had a Although all study patients survived hospitalization,
nondiagnostic CTA that was flawed by inadequate contrast administration.
only 11 patients who had undergone 12 extremity CTAs

240 © 2009 Lippincott Williams & Wilkins

The Journal of TRAUMA® Injury, Infection, and Critical Care • Volume 67, Number 2, August 2009 Detection of Extremity Vascular Injury With CTA
$18,000 CTA
$15,408
$15,000 Conventional
Arteriography
$12,000
$9,000
$6,000
$2,486
$3,000 $1,372
$206
$0
Patient Charges Hospital Costs
Figure 3. Both patient charge and hospital cost savings
were realized when CTA was compared with CA. US dollar
amounts are charges and costs per extremity studied.
returned for outpatient trauma clinic follow-up. Among these
were four patients who had undergone operative repair after
their initial diagnostic studies, five (study 11, 12, 14, 18, 22)
with vascular injuries who were managed nonoperatively,
and three (study 13, 19, 20) who were discharged from the
hospital after negative studies and 24-hour observation
periods. None of these eight patients who underwent non-
operative management presented with signs or symptoms
of delayed or progressive vascular injury on follow-up.
Furthermore, no study patients returned to our emergency
department with delayed manifestations of extremity vas-
cular injury.
DISCUSSION
The most important finding of this prospective trial is
that diagnostic CTA had 100% sensitivity and specificity for
extremity vascular injury detection when compared with CA
in our study population. The addition of either CA or oper-
ative exploration to extremity CTA studies revealed no ad-
ditional clinically significant diagnostic information.
The diagnosis of potentially life and limb threatening
extremity vascular injuries has been evolving since World
War II when DeBakey and Simeone1 reported an amputation
rate of 40% in 2471 arterial battle injuries. Mandatory oper-
ative exploration and arterial repair was initiated in the
Korean War, resulting in a decrease in amputation rate to
13% after extremity arterial battlefield injuries.2 Military
results were soon translated to civilian practice, when all
“proximity” injuries were then operatively explored.3– 8 At
that time, operative exploration was believed to eliminate
missed vascular injuries while an increased nontherapeutic
exploration rate and its associated morbidity was accepted.3– 8
The diagnosis of vascular injuries has evolved from the
times of mandatory operative exploration based on anatomic
proximity to selective exploration based on physical exami-
nation or adjunctive vascular studies.30 Currently, the diag-
nostic “gold standard” for extremity vascular injury detection
in patients without hard vascular signs is CA.9 –17 This inva-
sive procedure is not without its own complications including
damage to access vessels, thrombosis, infection, and local
© 2009 Lippincott Williams & Wilkins
hematoma formation.18,19 More significant complications
such as pseudoaneurysm formation, postangiography dissec-
tion and emboli occasionally requiring extremity amputation
have been reported.18,19 Furthermore, the performance of CA
necessitates a team of specialists who often require significant
time to assemble at a substantial cost both to the patient and
hospital.
CTA offers several advantages over CA; it is noninva-
sive, readily available in most hospitals, and cost effective.
These advantages have already been appreciated and CTA is
now used for several anatomic injury patterns. CTA is cur-
rently the initial diagnostic study of choice for blunt or
penetrating cervical or thoracic vascular injury and has ren-
dered CA nearly obsolete in these instances unless endovas-
cular therapy is required.
CTA has been reported as an alternative to CA for the
diagnosis of extremity vascular injury. To our knowledge, five
prior reports have analyzed extremity vascular injuries with
CTA and all have concluded that this modality is reliable,
sensitive, and specific.20 –22,25,26 In these reports, only 53% of all
CTAs were confirmed by either CA or operative exploration and
three of these five reports were retrospective in design.22,25,26
Two prospective reports by Soto et al.20,21 enrolled a total of 180
patients who had extremity CTAs for “hard” or “soft” signs of
vascular injury. Overall, 57% of these 180 patients had a con-
firmatory study after CTA and 76% of all negative CTAs were
confirmed by either chart review or clinical follow-up without
comparison study.20,21 In the present study, all enrolled patients
underwent both CTA and CA or operative exploration to con-
firm CTA findings.
Additionally, extremity CTA was determined to be more
cost effective and likely more rapid than interventionalist-
performed CA. Had CTA been used exclusively without
CA, the overall savings for the 22 extremity studies would
total $284,284 in patient charges and $25,652 in hospital
costs. Although the actual elapsed time required for CTA
completion was not recorded, CTA is rapid and obtainable
within minutes. Alternatively, interventionalist-performed CA
required, on average, over 2 hours to perform. To our knowl-
edge, these cost and time analyses of CTA for extremity vascu-
lar injury have not been previously reported.
Examination of protocol-related complications revealed
one patient (4.8%) who suffered contrast induced nephropathy
after contrast administration during both CTA and conven-
tional arteriogram studies. Our study patients were carefully
selected to prevent nephropathy and all were hydrated for 24
hours. As most study patients received double contrast doses,
we cannot report the incidence of contrast induced nephrop-
athy after CTA alone. We may hypothesize though, that the
incidence of contrast-induced nephropathy is likely less than
4.8% after CTA alone. Moreover, no previous report describ-
ing the use of CTA for extremity vascular injury detection has
described its influence on renal function.20 –22,25,26
We readily acknowledge our study limitations. Strict
inclusion and exclusion criteria led to a small and relatively
homogenous study population. Only 21 extremity-injured
patients met inclusion criteria and were ultimately enrolled.
Of these, two had blunt injuries, making extrapolation of our
241
Seamon et al. The Journal of TRAUMA® Injury, Infection, and Critical Care • Volume 67, Number 2, August 2009
findings to the blunt injured patient difficult. Blunt injured
patients with multiple injuries may benefit most from an
interventional radiologist who is not only able to diagnose
extremity vascular injuries with CA, but also perform aor-
tography, embolize solid organ or pelvic bleeding, and place
vena caval filters during the same setting. Therefore, based on
our limited study data with this particular subset of patients,
we cannot make recommendations regarding the use of CTA
in the blunt injured patient.
In the present report, streak artifacts caused by the
retention of bullet fragments after extremity gunshot injury
limited several CTA studies. Although 8 of 18 extremities
injured by gunshot had CTA studies limited by shrapnel or
bullet artifact, all studies were diagnostic and correctly inter-
preted by the reviewing radiologist. Additionally, 3 of 22
extremity CTAs were limited by suboptimal contrast dose
administration, rendering one of these studies nondiagnostic.
Of these three studies, one was limited by a dysfunctional IV
and two by less than optimal contrast dosages (75 mL) in an
attempt to limit the total CT contrast load. Our results suggest
that a minimum of 100 mL of nonionic contrast is required
for optimal diagnostic images. Previous reports have docu-
mented a similar small but consistent nondiagnostic CTA
rate, often due to shrapnel streak artifact or inadequate con-
trast administration.20 –22,25,26 Although it seems unlikely that
CTA streak artifacts will ever be completely eliminated, diag-
nostic imaging software is continually improving and may
eventually reduce the nondiagnostic study rate further.
Fifty percent of the present CTAs were performed on a
16-slice multidetector CT system whereas 50% were performed
on a 64-slice multidetector system. CT scanner assignments
were based solely on availability, not preference. Moreover, all
CTAs (16 or 64 slice) were reformatted and reconstructed to
yield similar diagnostic data, regardless of the detector quantity.
Most importantly, all diagnostic CTAs (16 or 64 slice) generated
equivalent clinical data when compared with CA or operative
exploration.
Our reported mean elapsed time required for CA comple-
tion is likely underestimated. To ensure the safety of our study
patients, serum creatinine values were reported and informed
consent was obtained before patients were enrolled and CTA
performed. Thus, the reported elapsed CA time was calculated
by analyzing the mean time from CTA completion until CA
completion, but does not reflect the elapsed time from when
the interventionalist was first contacted until arteriography
completion—an actual elapsed time which is likely both greater
and more meaningful when limb ischemia is considered.
Lastly, outpatient follow-up was inconsistent. Although
no patient returned to our emergency department with signs
or symptoms of extremity vascular injury, only 50% of study
patients returned to our outpatient trauma clinic for planned
follow-up. None of these patients presented with either find-
ings suggestive of occult vascular injury or required further
diagnostic study. We recognize that our study patients may
have sought medical attention elsewhere at one of several
nearby trauma centers.
In conclusion, diagnostic CTA had 100% sensitivity
and specificity for clinically relevant vascular injury detection
242
in our prospective evaluation comparing CTA with CA or
operative exploration. Acceptable injury detection, rapid avail-
ability, and a favorable cost profile suggest that CTA may
replace CA as the diagnostic study of choice for vascular injuries
of the extremities in most clinical scenarios. With the exception
of either shotgun injured or blunt injured patients requiring CT
scans covering multiple body regions, CTA has now replaced
CA in our own institution.
ACKNOWLEDGMENTS
We thank Heather Kulp, RN, MPH and the entire
divisions of Trauma and Interventional Radiology for their
assistance in completing this project.
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DISCUSSION
Dr. David V. Feliciano (Atlanta, Georgia): Distin-
guished moderators, members and guests, I want to thank the
authors for the early submission of their manuscript and
congratulate Dr. Seamon on a very nice presentation.
The authors studied 22 injured extremities with 16 or
64 multi-detector helical CT followed by either conventional
arteriography or immediate operation, if needed. Twenty-one
of these studies were diagnostic and this was confirmed by
the above-mentioned modalities.
While the study population is quite small, the authors
state that this is the first report in which the results of all
CTAs in the extremities have been confirmed immediately.
Also, they have documented that there are substantial
cost savings when using CTA as compared to conventional
arteriography. So is CTA “ready for prime time” in patients
with possible peripheral vascular injuries?
My first question concerns the large volume of IV
contrast injected to complete an arterial study. This is, of
course, one of the problems that killed IV digital subtraction
arteriography in the past as a useful study.
What’s the concentration of the agent you use? Is it
non-ionic? How much can you inject in a patient with blunt
multi-system trauma and hypotension before injuring a kidney?
Secondly, what is this problem of sub-optimal intrave-
nous contrast administration as occurred in three of your 21
patients? Is this a local problem at Temple? Part of a learning
curve? Is this going to be a problem in my center? What,
exactly, are you talking about?
Thirdly, since metallic fragments compromised 8 of
your 22 CT studies, would you clearly recommend that CTA
not be used in patients with shotgun wounds in the extremi-
© 2009 Lippincott Williams & Wilkins
ties? And are you aware if there is any technology coming
that will prevent this in the future?
And, finally, as you stated in your discussion of limi-
tations, with only 55 percent out-of-hospital follow-up I think
you have an ethical problem and that is would you tell me
whether you are going to continue your study and get more
long-term follow up on more patients or have you now
jumped off the cliff and are you using only CTA?
I thank the authors again for early submission of the
manuscript and congratulate them on a nice prospective study
in an evolving area of technology. Also, I thank the AAST
and JAAM for the privilege of discussing this manuscript.
Thank you.
Dr. Babak Sarani (Philadelphia, Pennsylvania): Dr.
Seamon, that was a very interesting study. Just one quick
question for you.
You showed a very elegant 3D reconstruction of a CT
angiogram. Do you obtain 3D recons in all your patients,
including in the middle of the night? And how long does it
take to get the images if you do so?
Dr. Therese M. Duane (Richmond, Virginia): Where
does duplex ultrasound have a role in this algorithm? Thank you.
Dr. Michael Hawkins (Augusta, Georgia): This is a
fairly simple population with 82 percent gunshot wounds.
What about the “blue plate special” the blunt trauma
that you might want to look at the aorta and the dislocated
knee or the carotid or whatever? How do you time that? And
how much contrast does that take?
Dr. Rajan Gupta (Lebanon, New Hampshire): Did
you look at doing arteriograms in the OR at all, surgeon
performed versus radiologist performed? Would that have re-
duced your amount of time to get the confirmed arteriography?
Dr. Mark Seamon (Philadelphia, Pennsylvania): I
would like to thank everyone for their questions, especially
Dr. Feliciano, my discussant.
His first question dealt with contrast concentration, is it
ionic. We are currently using omnipac 350 which has an
iodine concentration of 350 milligrams per cc. It is, in fact,
non-ionic. The maximum dose we give in one setting is
150ccs of that agent.
Newer CT scan technology, the 64-slice CTs, are able
to scan multiple body parts with one single bolus. I do not
have the protocols on-hand. There is a recent article by Soto
who has described these protocols very well.
The second question, sub-optimal contrast administra-
tion, this could be due to several factors: 1, improper timing
of the bolus with the CT scanner; improper or inadequate
contrast bolusing or, quite simply, IV malfunction.
In fact, in the, our one non-diagnostic case was due to
a blown IV. I think there definitely is a learning curve involved
with CTA. Our own technicians are much more facile now at the
conclusion of the study than at the beginning of the study.
The use of CTA with shotgun injuries, we would not
recommend CTA be used with shotgun injuries if there are
still multiple retained shot within the injured extremity.
This causes a significant artifact when reading the
study. It often renders them non-diagnostic. We would still
recommend conventional arteriogram in these cases.
243
Seamon et al. The Journal of TRAUMA® Injury, Infection, and Critical Care • Volume 67, Number 2, August 2009
And then, lastly, I guess the most difficult question, are
you continuing your study now. The answer is no. We
stopped enrollment in this study after submitting to the
AAST.
I guess what Dr. Feliciano is really driving at was how
could we do this after only 22 extremities studied. There have
been five previous reports, all describing the use of CTA, to
diagnose extremity vascular injuries.
Three of these are retrospective; two, prospective. All
of them have larger sample sizes than we do, although there
are some study design limitations.
So we feel we have a strong study design, combine that
with all of the previous data, and we think the evidence is
very good that CTA is in fact an effective and safe tool for
diagnosing extremity vascular injuries.
There is also two additional factors working against us
in this study and that is Equipoise. Many centers out there are
already doing CTA for extremity trauma and also patient
safety.
We continually had to weigh adequate power for this
study with patient safety. We did have one episode of con-
trast-induced nephropathy that we treated without hemodial-
ysis or further treatment.
244
Dr. Sarani asked about 3D reconstructions. Yes, we do
perform 3D reconstructions on all of these imagines. The
techs do this with the radiology resident immediately after the
CTA is obtained.
There was a question about duplex fitting into our
management algorithm. Unfortunately duplex has many of
the same limitations that conventional arteriography does.
At least at our hospital we have to call the techs in at
night and these images are actually read the next day by the
vascular attendings.
Other than that, as I described, 50 percent of our
patients did have extremity bony injuries and had caths and
bulky dressings, making duplex imaging difficult.
What about blunt trauma, the use of CTA? Yes, I can’t
make any conclusions about blunt trauma being that we only
have two patients of 22.
And oftentimes these are the patients that benefit the
most, patients that can get an IVC filter, embolized pelvic
bleeding at the same time, in addition to their extremity
arteriogram.
And then, lastly, did we look at OR arteriography? No,
we did not for this study. All of these P grams were per-
formed by interventional radiology at the interventional suite.
Thank you all very much.
© 2009 Lippincott Williams & Wilkins