Arteriography is gold standard for evaluating occult vascular injury

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At the SVS annual meeting, Major Charles J Fox discussed how liberalised use of arteriography is appropriate for military blast associated neck injury in his presentation ‘Delayed Evaluation of Penetrating Neck Trauma During Operation Iraqi Freedom’.

Fox, with co-authors David L Gillespie, Sean D O’Donnell, Michael A Weber, Mitchell W Cox, Jason S Hawksworth, Chad M Cryer and Norman M Rich from the Walter Reed Army Medical Centre, Washington, DC, said arteriography remains the gold standard for evaluation of occult vascular injury.

He discussed how penetrating injury to the head and neck is common with current wartime explosive delivery systems. The study, he said, showed how retained fragments produced suboptimal noninvasive imaging in the zone of injury.

Fox said the approach to penetrating trauma of the head and neck has undergone significant evolution and offers unique challenges during wartime. Military munitions, he said, produce complex injury patterns that challenge conventional diagnosis and management.

The object of the study was to review the delayed evaluation of combat related penetrating neck trauma following evacuation from Operation Iraqi Freedom to the US.

From February 2003 to August 2004 consecutive patients medically evacuated to a single institution, and evaluated by the Vascular Surgery Service with penetrating cervical trauma during Operation Iraqi Freedom, were prospectively entered into a database and retrospectively reviewed. Due to mass casualty situations not all soldiers with cervical blast injury were able to be explored.

Of 3,675 patients evacuated to this centre from Iraq, 792 were for direct battle injury. Suspected vascular injury from a penetrating neck trauma occurred in 27 (3%) patients. Thirty-seven percent were zone II, 33% zone III, 11% zone I, the remaining were diffuse injuries of multiple zones, including the lower face or posterior neck. All injuries were from explosive devices (75%) or high velocity gunshot wounds (25%).

Half had facial fractures or complex ocular trauma, 20% required tracheostomy for airway management, and 16% had intracranial injury, cervical spine fracture, or quadriplegia. Thirty-three percent (9/27) had a neurological deficit. Immediate neck exploration was peformed in 17/27 (63%). Procedures included ligation (eight), vein graft (three), PTFE bypass (one), and pericardial patch (one) for carotid (seven), vertebral (two), inominate (one), or jugular venous injuries (four). Delayed evaluation detected four (24%) occult injuries, and one graft thrombosis.

Indications for arteriography included an abnormal or indeterminant CT angiography or penetrating injury to zone I or III. Colour Flow Doppler was performed as an alternative to arteriography in five (19%) patients to evaluate a previous repair (three) or stable fragmentation injury (two). Computed Tomographic Angiography was performed in 19 (70%) patients including two zone II injuries without exploration.

Seventeen (63%) underwent diagnostic arteriography, detecting three pseudoaneurysms, and two occlusions, one with hemiparesis. All occult injuries detected by arteriogram had a negative or equivocal CT angiogram

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