Penetrating proximity extremity
trauma (
PPET) was prospectively studied to clarify the role of routine arteriographic evaluation (AG). Over a 24-month period, 135 patients were identified with 152
injuries from
PPET. All patients underwent AG and were randomized to either immediate or delayed timing. There were 27 arteriographic abnormalities from these 152
wounds, of which 16 (10.5%) were in major arteries. One acute
arteriovenous fistula underwent immediate surgery. The remaining 15 major vessel
injuries were nonoperatively observed, including seven cases of segmental arterial narrowing, six intimal flaps, and two small
pseudoaneurysms (one of which enlarged and underwent surgical repair after 10 weeks of followup). Nine of the remaining 14 lesions resolved; two improved and three remained clinically unchanged over a mean followup interval of 2.7 months. Shotgun
trauma was the mechanism which carried the greatest risk of significant
vascular injury. Although "soft" clinical signs were significantly more predictive of
vascular injury following
PPET than proximity alone (p less than 0.0005), 50% of all
injuries to major arteries did not manifest soft signs. No extremity morbidity resulted from delayed AG or from
vascular injury management. We conclude from our study population: 1) the natural history of clinically occult arterial
injuries was predominantly benign; 2) AG could be safely delayed up to 24 hours; 3) "soft" signs were not clinically useful predictors of
vascular injury; and 4) with the exception of shotgun
wounds, AG did not appear to be a cost effective screening modality, since detection of a single
vascular injury requiring surgery cost $66,420.00.