Angiography in patients with arterial trauma: correlation between angiographic abnormalities, operative findings, and clinical outcome.

The arteriograms and clinical course of 280 consecutive patients with suspected arterial trauma were reviewed to correlate the angiographic abnormalities with operative findings and to assess the impact of these findings on surgical management and prognosis. Major angiographic abnormalities were found in 77 patients. Arterial occlusion (46 patients) was caused by intimal flap injury or arterial transection with subsequent thrombosis and frequently presented with an acutely ischemic extremity (27 patients, three of whom required subsequent amputations). Intraluminal defects typical for intimal flaps (20 patients) were the most difficult pathologic entity to diagnose, accounting for two false-positive angiograms and the sole false-negative examination. Focal luminal widening (five patients) corresponded with a partial-thickness injury of the arterial wall. Major angiographic extravasation of contrast material (19 patients) was caused by arterial laceration or transection and usually presented with clinical signs of acute hemorrhage; massive pelvic hemorrhage was the cause of death in three patients. Acute arteriovenous fistulas (four patients) were from arterial laceration with venous communication. Arterial narrowing with a smooth margin (50 patients) was a finding associated with a benign clinical course, except when combined with slowed arterial flow--a characteristic finding of compartment syndrome (six of 13 patients). An irregular beaded pattern of arterial narrowing (23 patients) was associated with severe injuries, subsequent poor fracture healing, and wound infection. A detailed angiographic map is of considerable value in planning surgical management. The absence of major angiographic abnormalities usually eliminates the need for surgical exploration; the location of injury and routes of distal blood flow affect the feasibility of conservative therapy; the length of occlusion influences the necessity of saphenous vein harvesting; the location of arterial extravasation determines the advisability of surgical ligation or transcatheter embolization; and the need for fasciotomy may be suggested first by the angiographic features of compartment syndrome.