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Diagnosing Traumatic Arterial Injury in the

Extremities with CT Angiography: Pearls and
Pitfalls1

Article in Radiographics · November 2005

DOI: 10.1148/rg.25si055511 · Source: PubMed

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 PERIPHERAL VASCULAR DIAGNOSIS AND INTERVENTIONS S133

Diagnosing Traumatic
RadioGraphics

Arterial Injury in the

Extremities with CT
Angiography: Pearls
and Pitfalls1
CME FEATURE Michelle M. Miller-Thomas, MD ● O. Clark West, MD ● Alan M.
See accompanying Cohen, MD
test at http://
www.rsna.org
/education
/rg_cme.html Computed tomographic (CT) angiography is a reliable and convenient
imaging modality for diagnosing arterial injuries after blunt and pen-
LEARNING
etrating trauma to the extremities. It is a noninvasive modality that
OBJECTIVES
FOR TEST 4 could replace conventional arteriography as the initial diagnostic study
After reading this
for arterial injuries after trauma to the extremities. The technique re-
article and taking quires scanning with multidetector helical CT after rapid intravenous
the test, the reader
will be able to: injection of iodinated contrast material. The CT angiographic signs of
䡲 Describe the tech- arterial injuries in the extremities are active extravasation of contrast
nique for performing
CT angiography of material, pseudoaneurysm formation, abrupt narrowing of an artery,
the extremities to loss of opacification of a segment of artery, and arteriovenous fistula
detect traumatic arte-
rial injury.
formation. Metallic streak artifact, motion artifact, and inadequate ar-
䡲 Identify the five terial opacification may render a CT angiogram nondiagnostic. Studies
CT angiographic have shown the sensitivity of CT angiography to be 90%–95.1% and
signs of arterial injury
in the extremities. its specificity 98.7%–100% for detecting arterial injury to the extremi-
䡲 Discuss the pitfalls ties after trauma.
in CT angiography of ©
RSNA, 2005
the extremities in the
setting of trauma.

TEACHING
POINTS
See last page

RadioGraphics 2005; 25:S133–S142 ● Published online 10.1148/rg.25si055511 ● Content Codes:

1From the Department of Diagnostic and Interventional Imaging, University of Texas Medical School at Houston, 6431 Fannin St, Houston, TX
77030. Presented as an education exhibit at the 2004 RSNA Annual Meeting. Received February 17, 2005; revision requested March 22 and received
April 5; accepted April 15. All authors have no financial relationships to disclose. Address correspondence to M.M.M.T. (e-mail: Michelle.M
.Miller-Thomas@uth.tmc.edu).
©
RSNA, 2005
 S134 October 2005
RadioGraphics Introduction
Arterial injury may occur after blunt or penetrat-
ing trauma to the extremities. Clinical outcome
depends on rapid diagnosis and repair of the in-
jury. Conventional arteriography is the current
imaging method of choice for diagnosing trau-
matic arterial injuries to the extremities. Com-
puted tomographic (CT) angiography is a nonin-
vasive and rapid imaging technique that shows
high sensitivity and specificity in the detection of
arterial injuries in the extremities. We discuss the
clinical signs of such injuries, techniques for CT
angiography of the extremities, CT angiographic
signs of arterial injury, and the three most com-
mon pitfalls in CT angiographic imaging of the
extremities. Finally, we briefly summarize the sci-
entific literature on CT angiography of the ex-
tremities for the diagnosis of arterial injuries.
Background
According to the surgical and trauma literature,
prompt repair of arterial injuries to the extremities
improves outcome in terms of limb function and
mortality related to blood loss (1– 4). Conven-
tional arteriography was developed in the 1970s,
allowing for accurate diagnosis of arterial injury
with a less invasive procedure than open surgical
exploration of the vessels. It has an associated
morbidity of 1%–2%, but the benefits of its high
diagnostic accuracy and of early percutaneous
intervention for selected types of arterial injury
outweigh the risks of a missed diagnosis of acute
arterial injury in the extremities (2,3,5).
Three major disadvantages of conventional
arteriography are the cost of the procedure; the
delay that occurs before arteriography; and the
need for a specialized team comprising a physi-
cian, angiography technologist, and nurse. A non-
invasive, accurate, and easily accessible diagnostic
imaging test acquired by a single trained tech-
nologist would reduce the time to diagnosis of
traumatic arterial injury, facilitating rapid inter-
vention (6,7). Use of duplex ultrasonography
with Doppler evaluation for diagnosis in the
emergency setting has been explored but has not
RG f Volume 25 ● Special Issue
become widely used because its sensitivity is
lower than that of arteriography and because its
performance is highly dependent on the skill of
the operator (8 –11). Magnetic resonance angiog-
raphy is another possible modality for diagnosing
arterial injury, but it has not come into wide-
spread use because it is currently not practical to
perform in the setting of trauma (7,12).
Multidetector helical computed tomographic
(CT) scanners provide rapid acquisition of thin
axial images, enabling CT angiography. Com-
pared with conventional arteriography, CT an-
giography performs well for diagnosing occlusive
disease in the lower extremities and for imaging
other arteries of the body (13–19). CT technolo-
gists can be easily trained in CT angiographic
techniques. Since 1999, CT angiography has
shown excellent diagnostic performance for imag-
ing traumatic arterial injuries in the extremities
(20 –22). It is an attractive initial diagnostic imag-
ing technique in the trauma setting because of
rapid access to multidetector CT in trauma de-
partments.
Clinical Signs
Arterial injury may occur with either blunt or
penetrating trauma. Blunt trauma injures vessels
by crushing tissue, tearing tissue, dislocating
joints, or breaking bones near arteries. Penetrat-
ing injuries, caused by a sharp object or disrup-
tion of tissue by a high-velocity penetrating mis-
sile, may result in laceration of an artery. Signs of
arterial injury include loss of pulses in an extrem-
ity, expanding hematoma, thrill or bruit, active
pulsatile bleeding, and neurologic deficit in the
limb. Because there is a high correlation between
these clinical findings and the presence of arterial
injury, these “hard” signs warrant evaluation for
arterial injury (1,3). “Soft” signs of arterial injury
include a cool limb, change in color, nonexpand-
ing hematoma, and nonpulsatile bleeding. The
prevalence of arterial injury is lower when only
soft clinical signs are present (23). Table 1 sum-
marizes these clinical signs of arterial injury in the
extremities. Serious arterial injury is less frequent
in proximity injuries, that is, penetrating injuries
in which the trajectory of the penetrating object
through the tissue passes near arteries but in which
there are no hard signs of arterial injury (5,24).
 RG f Volume 25 ● Special Issue
RadioGraphics
Table 1
Clinical Signs of Arterial Injuries
in the Extremities
Hard Signs Soft Signs
Loss of pulses Cool limb
Expanding hematoma Nonexpanding hematoma
Thrill or bruit Change in color
Pulsatile bleeding Nonpulsatile bleeding
Neurologic deficit
Imaging
Multiple parts of the body can be rapidly exam-
ined with multidetector CT during the same
scanning session. CT angiography may be per-
formed in a trauma victim after scanning of the
head without contrast material and before scan-
ning of the abdomen and pelvis with contrast ma-
terial enhancement. Although we do not perform
combined chest and extremity CT angiography
with our equipment, CT scanners with 16 or
more detector rows may be able to perform both
studies with administration of one contrast me-
dium bolus. CT angiography allows for rapid di-
agnosis of arterial injuries in the extremities while
other injuries are being evaluated in patients who
have suffered trauma. This multisystem assess-
ment improves the efficiency of the radiologist
and reduces the delay in diagnosis that occurs
with conventional arteriography. Planning for
repair of an arterial injury in a patient who re-
quires emergency surgery for another life-threat-
ening condition may be expedited when CT an-
giography is performed before surgery.
CT angiography is performed with multidetec-
tor helical CT scanners. In trauma cases, we per-
form CT angiography with a GE Lightspeed QXi,
acquiring four rows of 1.25-mm sections at a
pitch of 1.5 (GE Medical Systems, Milwaukee,
Wis). These parameters allow for creation of di-
agnostic-quality reformatted images. An 18-gauge
venous catheter is placed routinely at the level of
the antecubital fossa and less commonly in the
common femoral vein. We administer 150 mL of
iohexol (Omnipaque, 300 mg of iodine per millili-
ter; Amersham, Ireland) intravenously with a
power injector, at a rate of 4 mL/sec. Scanning is
delayed for 25 seconds after the beginning of the
injection for upper-extremity scanning or 50 sec-
Miller-Thomas et al S135
onds for lower-extremity scanning. Sometimes,
an automated contrast monitoring protocol is
used (SmartPrep, GE Medical Systems), with the
region of interest placed over the common femo-
ral artery or axillary artery to detect arterial opaci-
fication before scanning is initiated. In cases of
upper-extremity trauma, intravenous contrast
material should be injected in the contralateral
arm to avoid streak artifact from a densely opaci-
fied vein adjacent to an injured upper-extremity
artery. Ideally, the upper extremities should be
raised above the head for scanning to limit the
streak artifact from the body, but this position
may not be possible with some injuries.
Image Interpretation
Teaching
Both axial and reformatted CT angiograms Point
should be reviewed. Between 150 and 300 axial
images with two to 10 reformatted images are
created for upper-extremity CT angiograms. Be-
tween 250 and 750 axial images with two to 10
reformatted images are created for lower-extrem-
ity CT angiograms. The interpreting radiologist
at our institution creates either two-dimensional
multiplanar reformatted images or maximum in-
tensity projection images from the 1.25-mm re-
constructed axial sections on a GE Advantage 4.2
workstation (GE Medical Systems). The radiolo-
gist should manipulate the image data to display
the artery in a plane that optimizes visualization
of the injury. An arterial injury may be more obvi-
ous when the reformatted images are reviewed
than when the axial images are interpreted alone.
We know of no published reports comparing
three-dimensional maximum intensity projection
reconstruction techniques with two-dimensional
multiplanar reformatting techniques for viewing
images, and radiology groups researching CT an-
giography for arterial injury in the extremities
have different preferences regarding reformatting
techniques (20 –22).
CT angiographic signs of arterial injury include
active extravasation of contrast material, pseudo-
aneurysm formation, abrupt narrowing of an ar- Teaching
tery, loss of opacification of an arterial segment, Point
and arteriovenous fistula formation. Examples of
these signs are given in Figures 1–5. Intimal flap
arterial injuries in the extremities are observed
 S136 October 2005 RG f Volume 25 ● Special Issue

RadioGraphics

Figure 1. Active contrast material extravasation after

penetrating upper-extremity injury. (a, b) Two sequen-
tial axial CT angiographic images (a obtained at a
higher level than b) show active contrast material ex-
travasation from the axillary artery (arrow). (c) Oblique
coronal reformatted image also demonstrates active con-
trast material extravasation (arrow).

Figure 2. Pseudoaneurysm
formation after penetrating
lower-extremity injury.
(a) Axial CT angiographic
image obtained at the level of
the popliteal fossa shows a
pseudoaneurysm arising from
the popliteal artery (arrow). A
bullet fragment (B) is also
present adjacent to the tibia,
causing mild metallic streak
artifact. (b) Sagittal reformat-
ted image also demonstrates
the popliteal artery pseudoan-
eurysm (arrow) with two me-
tallic bullet fragments (B)
proximal to the injury.
 RG f Volume 25 ● Special Issue Miller-Thomas et al S137

RadioGraphics

Figure 3. Abrupt narrowing

of an artery after a dog bite to
the upper extremity. (a) Axial
CT angiographic image of the
upper extremity shows that
the brachial artery is near
normal in caliber (arrow).
(b) Axial image obtained a
few sections distal to a shows
narrowing of the brachial ar-
tery (arrow). (c) Next distal
axial image shows loss of
opacification of the brachial
artery. (d) Coronal oblique
reformatted image shows
abrupt narrowing of the con-
trast material column in the
brachial artery (arrow).

Figure 4. Loss of opacification of a seg-

ment of artery after blunt lower-extremity
injury. (a) Sagittal reformatted CT angio-
graphic image of the lower extremity
shows loss of opacification of the popliteal
artery (arrow) with distal reconstitution of
arterial opacification. (b) Conventional
arteriogram helps confirm loss of opacifi-
cation of the popliteal artery (arrow).
 S138 October 2005 RG f Volume 25 ● Special Issue

RadioGraphics

Figure 5. Arteriovenous fistula formation after penetrating lower-extremity injury. (a) Coronal
oblique reformatted CT angiographic image of the lower extremity demonstrates an arteriovenous
fistula arising from the superficial femoral artery that occurred after a gunshot wound to the thigh.
(b) Digital subtraction image from conventional arteriography displays the injury in a similar pro-
jection. Both the CT angiogram and the arteriogram demonstrate the communication point be-
tween the artery and the vein (thin arrow) as well as the draining vein (thick arrow). A pseudoaneu-
rysm (P) arising from the communication point is seen on both images.

with conventional arteriography. We have not
observed intimal flap injuries in our 3 years of
experience with extremity CT angiography, per-
haps because the resolution of CT angiography
with a four-row multidetector CT scanner is less
than that required to image an intimal flap in the
extremities.
Pitfalls in CT
Angiography of the Extremities
Teaching Poor arterial opacification may render a CT an-
Point giogram uninterpretable. Poorly timed initiation
of scanning, either before the contrast material
bolus has reached or after it has passed the arte-
rial system in the extremity, may result in inad-
equate arterial opacification and render the CT
angiogram nondiagnostic. Intravenous contrast
material may circulate more slowly in patients
with heart failure than in those in good cardiovas-
cular health. A preset scanning initiation interval
may not be long enough for these patients, and
automated bolus tracking is desirable. However,
the typical patient with a trauma-induced injury
to an extremity is young and does not have co-
morbid conditions that interfere with the timing
of an intravenous contrast material bolus, so the
preset time is adequate for most such patients.
We have occasionally observed technologists
sampling the incorrect artery or sampling a vein
with the automatic monitoring protocol for CT
pulmonary angiograms. This mistake results in
incorrect timing of scanning. CT angiography
cannot be repeated with the same intravenous
contrast material bolus after this mistake is dis-
covered, because the bolus quickly leaves the ar-
terial system. Opacification of the veins may in-
terfere with interpretation of the CT angiogram if
a second bolus is administered within several
minutes of the mistimed initial bolus. We elect to
perform conventional arteriography when there
are errors in the administration of a contrast ma-
terial bolus and scanning initiation. Each radiol-
ogy department will have to decide whether it will
have more success with preset scanning times or
automated monitoring protocols similar to those
used for CT pulmonary angiography. Contrast
 RG f Volume 25 ● Special Issue Miller-Thomas et al S139

RadioGraphics

Figure 6. Nondiagnostic CT angiogram with metallic streak artifact after shotgun injury to the lower extremity.
(a) Axial CT angiographic image of the proximal portion of the thigh shows streak artifact from metallic shot pellets
obscuring the arteries of the thigh. This CT angiogram is nondiagnostic. (b) Coronal reformatted image shows mul-
tiple segments of the superficial femoral artery obscured by streak artifact (arrow). (c) Conventional arteriogram
clearly shows that the superficial femoral artery is intact and uninjured by the shot pellets.

material extravasation at the injection site and
failure of the injection equipment are other causes
of poor arterial opacification.
Motion artifact can degrade the quality of a
CT angiogram. Patients with trauma are more
likely to be moving because of pain, altered men-
tal status, or intoxication. To obtain a high-qual-
ity CT angiogram, it is important to immobilize
the extremities. If a patient is unable to cooperate
with CT angiography, we elect to perform con-
ventional arteriography and we use sedation if
necessary, monitored by the physician and nurse,
to obtain a diagnostic study.
Streak artifacts are the major limiting factor in
Teaching the ability of CT angiography to demonstrate ar-
Point teries after penetrating missile injuries. The de-
posited metallic fragments may create streak arti-
facts that obscure the arteries, commonly at the
exact location where the arterial injury is likely to
occur. Figure 6 shows an example of streak arti-
fact from metallic fragments obscuring the femo-
ral artery. Most of the signs of arterial injury re-
quire direct visualization of the segment of in-
jured artery. The performance of CT angiography
in patients with retained metallic fragments near
the injury has not been explored, because the
published studies to date have excluded these pa-
tients from undergoing CT angiography (20 –22).
In our experience, CT angiograms in a few
patients with deposited metal fragments in the
extremity were still diagnostic because there was
either loss of opacification distal to the site of in-
jury or massive contrast material extravasation
that could be seen despite the artifact, allowing
for the confident diagnosis of arterial injury. In
other cases, because of the trajectory of the bullet,
the metallic fragments came to rest either proxi-
mal or distal to the arterial injury, so the streak
artifact occurred in a different plane from the
level of the injury. Figure 7 shows an example of
an arterial injury that is easily seen despite metal-
lic streak artifact in the extremity. Strict exclusion
from CT angiography of patients with penetrating
trauma and retained metallic fragments might
eliminate patients who could benefit from diag-
nostic CT angiography. Conventional arteriogra-
phy can still be performed after a nondiagnostic
CT angiogram is obtained. The surgeons and
radiologists at each institution will need to decide
whether or not to attempt CT angiography or go
straight to conventional arteriography in such
cases.
 S140 October 2005 RG f Volume 25 ● Special Issue

RadioGraphics Figure 7. Diagnostic CT angiogram with metallic streak artifact after penetrating lower-extrem-
ity injury. (a) Axial CT angiographic image of the middle portion of the thigh shows a metallic bul-
let fragment (B) causing a streak artifact that partially obscures the superficial femoral artery (ar-
row). (b) Axial image of the distal portion of the thigh shows a large pseudoaneurysm arising from
the superficial femoral artery (arrow). The filling defect within the pseudoaneurysm is thrombus.
(c) Axial image obtained a few sections distal to b shows either active contrast material extrava-
sation or the edge of the pseudoaneurysm coming from the superficial femoral artery (arrow).
(d) Oblique sagittal reformatted image of the thigh shows that the superficial femoral artery is ob-
scured by metallic streak artifact in the middle portion of the thigh (short arrow), but the injury in
the more distal part of the superficial femoral artery is clearly seen (long arrow). The bullet most
likely entered the distal portion of the thigh and traveled superiorly, inflicting an arterial injury in a
different axial plane than where the metallic bullet fragment rested and allowing for a diagnostic
CT angiogram.
 RG f Volume 25 ● Special Issue
RadioGraphics
Table 2
CT Angiographic Diagnosis of Arterial Injuries in Patients with Trauma
Study Year No. of Patients
Soto et al (21) 1999 45
Soto et al (20) 2001 139
Busquets et al (22) 2004 95
*The 95% confidence intervals are given in parentheses.
Slow blood flow distal to an arterial injury may
limit runoff visualization of the arterial system in
the distal part of the extremity at CT angiography
as it does at conventional arteriography. This
limitation may complicate planning for surgical
repair of the arterial injury. The detection of inju-
ries to distal, small-caliber arteries below the
ankle or elbow is limited by the spatial resolution
of CT angiography (14,21). Conventional arte-
riography still maintains a higher spatial resolu-
tion and continues to be the technique of choice
for these arterial segments.
Diagnostic Performance
Three studies reported in the radiology and
trauma literature have evaluated the performance
of CT angiography in diagnosing arterial injuries
to the extremities in trauma. In 1999, Soto et al
(21) described a study in which patients referred
for traditional arteriography after traumatic up-
per- and lower-extremity injury also underwent
CT angiography. The sensitivity of CT angiogra-
phy was 90%, and its specificity was 100%. Soto
et al followed that study with a second prospec-
tive study reported in 2001 (20). In that study,
CT angiography was used as the initial imaging
modality in the setting of trauma to the extremi-
ties and showed a sensitivity of 95.1% and a
specificity of 98.7% for proximal arterial injuries
in the upper and lower extremities. The authors
used long-term clinical follow-up, surgical explo-
ration, and conventional arteriography as confir-
mation for positive or negative CT angiograms
(20). In 2004 Busquets et al (22) published in the
trauma literature a retrospective review of pa-
tients undergoing CT angiography for trauma to
the extremities, reporting that 25 CT angiograms
were proved positive and 10 were proved negative
Miller-Thomas et al S141
Sensitivity (%)* Specificity (%)*
90 (80, 99) 100 (99, 100)
95.1 (85.4, 98.7) 98.7 (91.9, 99.9)
Not given Not given
(22). Table 2 summarizes the results in these
three series of cases. Our own experience with CT
angiography agrees with these results. The high
sensitivity and specificity of CT angiography of Teaching
the extremities demonstrated in the literature Point
show that this technique is a reliable initial diag-
nostic test for traumatic arterial injuries in the
extremities.
Summary
CT angiography can be used to diagnose arterial
injuries to the extremities rapidly and reliably in
the setting of trauma, reducing the delay before
repair of the injury. CT angiography is performed
with multidetector CT scanners and rapid injec-
tion of intravenous contrast material to opacify
the arteries. Signs of arterial injury include abrupt
narrowing of an artery, loss of opacification of an
arterial segment, pseudoaneurysm formation, ac-
tive extravasation of contrast material, and arte-
riovenous fistula formation. CT angiograms may
be rendered nondiagnostic by motion artifact,
lack of opacification of the arteries, and metallic
streak artifact. The resolution possible with four–
detector row CT scanners may not be high
enough to image intimal flap injuries and injuries
to arteries distal to the elbow and ankle. Studies
of CT angiography used to detect traumatic arte-
rial injuries to the extremities have shown its sen-
sitivity to be 90%–95.1% and its specificity to be
98.7%–100%. Radiologists and clinicians treating
patients with trauma should consider using CT
angiography to diagnose arterial injuries in the
extremities.
 S142 October 2005
RadioGraphics References
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 RG Volume 25 • Special Issue • October 2005 Miller-Thomas et al

Teaching Points for Diagnosing Traumatic Arterial Injury in the

Extremities with CT Angiography: Pearls and Pitfalls
Michelle M. Miller-Thomas, MD, et al
RadioGraphics 2005; 25:S133–S142 ● Published online 10.1148/rg.25si055511 ● Content Codes:

Page S135
Both axial and reformatted CT angiograms should be reviewed.

Page S135
CT angiographic signs of arterial injury include active extravasation of contrast material, pseudoaneurysm
formation, abrupt narrowing of an artery, loss of opacification of an arterial segment, and arteriovenous fistula
formation.

Page S138
Poor arterial opacification may render a CT angiogram uninterpretable.

Page S139
Streak artifacts are the major limiting factor in the ability of CT angiography to demonstrate arteries after
penetrating missile injuries.

Page S141
The high sensitivity and specificity of CT angiography of the extremities demonstrated in the
literature show that this technique is a reliable initial diagnostic test for traumatic arterial injuries in
the extremities.

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