Management of the Mangled Extremity
Annotation for Point G
In the stable patient with evidence of vascular injury on examination, additional imaging should be obtained to characterize the location and nature of the injury. Computed tomographic angiography (CTA) has emerged as the primary evaluation tool at many trauma centers. If feasible, CTA should be included in the initial CT screening of these patients. The sensitivity and specificity of this modality has proven comparable with traditional angiography in the detection of vascular injury25–27 and the rapidity with which it can be obtained assists in limiting ischemic time.
In the ischemic limb, it is important to consider the potential delays that may be associated with the choice of diagnostic imaging. In many centers, extremity CTA adds ~20 minutes to the imaging time of a patient with multiple injuries. The patient must be brought out of the gantry, turned around, and placed back into the gantry to obtain the CTA. Utilization of traditional angiography may be associated with even more substantial logistical challenges. The surgeon must weigh carefully the need for vascular evaluation against the cost to the individual patient in terms of delay and contrast load risks.
If CTA is not available, traditional or intraoperative angiography can be used to identify and exclude vascular injury in the mangled extremity.28 Angiography can provide a dynamic assessment of the vasculature. This allows the surgeon to visualize the vascular injury, the adequacy of collateral flow, and back filling of vessels. Traditional angiography can be time consuming, however, if performed in the angiogram suite. Newer hybrid operating rooms may decrease the interval to diagnosis of the vascular injury, even allow for this imaging to be performed as the operating team begins the exploration.
In most centers, direct operative exploration may provide for the most expedient identification and treatment of injury. Intraoperative angiography can be used to assess the adequacy of the distal vasculature as an adjunct of emergent operative intervention if appropriate facilities and expertise are available.
Level of Supporting Evidence: Level 2A