© 2008 by the American Institute of Ultrasound in Medicine
J Ultrasound Med 27:95-107 • 0278-4297
Sonographic Evaluation of Vascular Injuries
Diana Gaitini, MD,
Nira Beck Razi, MD,
Eduard Ghersin, MD,
Amos Ofer, MD and
Michalle Soudack, MD
Department of Medical Imaging, Rambam Medical Center, Haifa, Israel.
Address correspondence to Diana Gaitini, MD, Unit of Ultrasound, Department of Medical Imaging, Rambam Medical Center, Ha’aliya 8, PO Box 9602, 31096 Haifa, Israel. E-mail: d_gaitini{at}rambam.health.gov.il
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Abstract
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Objective. The purpose of this presentation is to highlight the color Doppler duplex sonographic features of procedure-related and blunt or penetrating trauma-related vascular injuries. Methods. Different kinds of vascular complications such as pseudoaneurysms, arteriovenous fistulas, dissection, and thrombosis are discussed. Cases of vascular injuries in the extremities, neck, and abdomen are presented to illustrate the spectrum of sonographic appearances. Results. Color Doppler duplex sonography is valuable in the diagnosis and monitoring of most vessel injuries and in the treatment of pseudoaneurysms. It is useful for flow analysis and for follow-up after treatment. However, because of limitations inherent to sonography, such as bones, air, casts, skin burns, and relatively slow performance of the test, magnetic resonance imaging, computed tomography, and angiography are necessary for further evaluation in selected cases. Conclusions. Color Doppler duplex sonography is a widely available, noninvasive, and accurate technique for evaluating vascular injuries and should be the first-line imaging modality in most patients.
Key Words: arteriovenous fistula • diagnosis • false aneurysm • sonography • vascular injuries Abbreviations: AVF, arteriovenous fistula • CDDS, color Doppler duplex sonography • CTA, computed tomographic angiography • DSA, digital subtraction angiography • MRA, magnetic resonance angiography
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Introduction
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The prevalence of vessel injuries is on the rise because of increasing rates of invasive procedures and traumatic events. At a level I trauma center, iatrogenic injuries were the causes of one third of arterial damage.1 The complication rate in complex coronary procedures reaches 6%. Fibrinolytic therapy, anticoagulants, large-diameter vascular sheaths, and poor puncture or compression techniques increase the rate of vascular complications.2 Partial or complete thrombosis, intimal flaps, dissection, arteriovenous fistulas (AVFs), and pseudoaneurysms are the main vascular complications.
The neck, extremities, and abdominal organs are anatomic sites amenable to investigation with color Doppler duplex sonography (CDDS). Subcutaneous air, large hematomas, casts, and large skin wounds may impede CDDS performance. Aberrant vessels and anatomic areas difficult to scan, such as the thoracic inlet and the pelvis, lessen the accuracy of CDDS. Further limitations are derived from operator dependence and lengthy examinations, which may be inappropriate in the acute care setting.3 Despite these limitations, CDDS is presently considered the first-line examination for evaluation of vascular injuries, with reported sensitivity of 95% to 97% and accuracy of 95% to 98%.3–5 Magnetic resonance angiography (MRA) and computed tomographic angiography (CTA) are useful complementary examinations. Digital subtraction angiography (DSA) is shifting to a more therapeutic role for endovascular management.
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Procedure-Related Vascular Injuries
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Vascular injuries may follow percutaneous procedures. Puncture site vascular injuries include perivascular hematomas, pseudoaneurysms, and AVFs. A perivascular hematoma is the most frequent complication at the puncture site. Clinically, it is a nonpulsatile focal swelling with ecchymosed skin. It appears as a complex solid and cystic soft tissue mass adjacent to the injured vessel, without blood flow on Doppler interrogation (Figure 1 ). A diffuse hematoma, even obvious clinically, may be unrecognizable on CDDS because of poorly defined infiltration of blood into the soft tissues. An AVF is a false vascular channel between an artery and the adjacent vein. A palpable thrill and a bruit on auscultation are often present. Color Doppler duplex sonography shows a mosaic color pattern due to high turbulent flow in the fistula, low-resistance arterial flow in the feeding artery, and a high-velocity, chaotic waveform in the draining vein. Extravascular color signals represent perivascular tissue vibration due to transmitted pulsation of turbulent continuous blood flow between the artery and the vein (Figure 2). A pseudoaneurysm or false aneurysm is a pulsatile hematoma that communicates through a channel (neck) with the injured artery. It follows total disruption in the arterial wall and continuous extravascular flow, contained by the surrounding tissues. It complicates 0.1% to 0.2% of diagnostic and 3.5% to 5.5% of interventional procedures, representing more than 60% of interventional vascular complications.6 Clinically, a pulsatile mass with a palpable thrill and an audible to-and-fro murmur is detected. Color Doppler duplex sonography is the diagnostic imaging modality of choice: it can delineate the cavity, the degree of clotting, the communication with the artery, and the blood flow pattern. The lumen has bidirectional, swirling, or "yin-yang" color flow and turbulent or pulsatile flow on a spectral display. The neck typically has a to-and-fro waveform due to flow entering during systole and exiting during diastole (Figure 3). Pseudoaneurysms vary in size and may have multiple compartments (Figure 4). A fluid-fluid level due to hematocrit layering may be seen in large pseudoaneurysms (Figure 5). They may involve surgical sites, most often bypass graft anastomosis (Figure 6). Sonographically guided thrombin injection is the treatment of choice for large pseudoaneurysms that do not clot spontaneously, converting them into thrombosed hematomas within seconds, with a 93% to 100% success rate.7,8 A flow void after injection confirms thrombosis (Figure 7). The neck width of the pseudoaneurysm is of prognostic value because a wide and short neck may carry a higher risk of failure and embolic complications during thrombin injection. Hypoechoic hypervascular lymph nodes, dilated varicose veins with slow swirling flow (Figure 8), and fluid containing femoral or inguinal hernias, with fluid movement due to respiratory motion, may mimic pseudoaneurysms.
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Figure 1. Image from a 70-year-old man with groin swelling after femoral catheterization. Color Doppler sonography shows a large hypoechoic heterogeneous mass (arrow) surrounding the femoral artery (fa) at the proximal thigh, consistent with a hematoma.
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Figure 3. Images from a 55-year-old man who had a pulsatile mass at the puncture site after coronary artery stent insertion. Color Doppler duplex sonography showed a femoral artery pseudoaneurysm. A, Color Doppler sonography shows bidirectional yin-yang color flow in the lumen of the pseudoaneurysm due to cyclic inflow and outflow during systole and diastole, respectively. B, Spectral Doppler sonography shows classic to-and-fro flow at the neck, appearing as a double trace on both sides of the baseline.
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Figure 4. Images from a 62-year-old woman with multiple compartment pseudoaneurysms after coronary arteriography. A, Gray scale sonography shows a chain of false aneurysms connected to the artery by a single neck. B, Power Doppler sonography shows the connecting neck.
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Figure 5. Image from a 78-year-old man with a large pulsatile inguinal mass after diagnostic coronary arteriography. Gray scale sonography shows a large pseudoaneurysm with hematocrit layering. The central echogenic line (arrows) is due to inflow of blood from the artery into the pseudoaneurysm through its neck.
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Figure 6. Images from a 67-year-old man with limb swelling after aortobifemoral and left femoropopliteal bypass graft surgery. Deep vein thrombosis was not seen on compression sonography. A surgical site pseudoaneurysm in the left groin was shown on CDDS (A) and DSA (B). A, Color Doppler sonography shows the pseudoaneurysm; surgical clips are shown posteriorly. A yin-yang pattern in the pseudoaneurysm cavity is shown. B, On DSA, both the pseudoaneurysm and an AVF are shown, with early venous filling. Because the clinical suspicion was deep venous thrombosis, pulsed Doppler imaging was not performed in the accompanying artery, thus missing the AVF.
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Figure 7. Sonographically guided thrombin injection for treatment of an anastomotic pseudoaneurysm. A, Power Doppler sonography shows the needle tip in the lumen (arrow) and partial thrombosis during thrombin injection. B, A completely thrombosed pseudoaneurysm is shown. Flow is shown in the femoral artery. Low-resistance flow is due to the presence of an AVF, as shown on DSA. Thrombin allowed rapid and successful therapy without complications despite the short and wide neck and without femoral artery circulation impairment.
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Procedures such as angioplasty, thrombolysis, and stent placement may be complicated by thrombosis, intimal flaps, aneurysms, arterial ruptures, and stent stenosis. Arterial thrombosis is the most frequent complication. Varying degrees of thrombus echogenicity may be detected depending on the thrombus age. A partially occluding thrombus causes alteration in the color flow pattern, waveform, and velocities (Figure 9). A totally occluding thrombus causes an abrupt cutoff of color flow and retrograde flow in a collateral pathway. A vasospasm and external compression without evidence of an intrinsic vessel injury may be correctly diagnosed by CDDS. Focal dissection resulting from guide insertion may be seen in a severely atherosclerotic artery (Figure 10). Color Doppler duplex sonography, at times in combination with MRA and CTA, can noninvasively show most arterial injuries.9 Vein thrombosis may complicate indwelling catheters, inferior vena cava filters, and venous stents and shunts. Thrombosed veins are typically noncompressible (Figure 11). When a thrombus is suspected in a central vein such as the brachiocephalic vein or the superior vena cava, both sides should be examined: bilateral dampening of the spectral waveform, converting the normal biphasic pattern into a nonpulsatile pattern, indicates superior vena cava thrombosis, whereas unilateral dampening is a sign of ipsilateral brachiocephalic thrombosis.10 Complications of transjugular intrahepatic portosystemic shunts may occur early because of stent dislodgement and hemorrhage or late because of stenosis and occlusion.
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Figure 9. Images from a 78-year-old man with a partially occluding thrombus after an angioplasty attempt. A, Gray scale sonography shows a hypoechoic thrombus on the anterior wall with substantial lumen stenosis (arrows). B, Color Doppler sonography shows a mosaic pattern due to a very high velocity in the narrowed residual lumen.
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Figure 10. Images from a 76-year-old man with severe atherosclerotic disease who had focal dissection in the femoral artery after guide wire insertion. A, Longitudinal color Doppler sonography shows a filiform canal parallel to the main lumen of the artery with a mosaic flow pattern (arrow). B, Transverse color Doppler imaging shows the dissecting lumen (arrow).
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Figure 11. Images from a 34-year-old woman with arm swelling after receiving a peripherally inserted central catheter. A thrombotic basilic vein and tributaries were found. A, On a transverse scan, the vein is noncompressible (right, without compression; left, with compression). B, On gray scale imaging, the catheter is clearly visible in the thrombotic lumen. Thrombotic tributaries of the main vein are also shown.
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Percutaneous nonvascular procedures such as kidney and liver biopsies may cause vascular injuries. Active hemorrhage may be detected during real-time examination as a jet from the biopsy tract to the organ capsule. Pseudoaneurysms and AVFs (Figure 12), more common complications, may be detected in up to 10% to 15% of transplant kidney biopsies, and large AVFs may cause renal dysfunction.11
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Figure 12. Arteriovenous fistulas in 2 patients after biopsy of kidney transplants. A, Color and spectral Doppler sonography shows turbulent high-velocity flow at the fistula in the renal parenchyma (first patient). B, Color and Doppler sonography shows an arteri-ovenous fistula at the renal hilum (second patient).
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Trauma-Related Vascular Injuries
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Vascular injuries following blunt or penetrating trauma are illustrated according to different body levels accessible to CDDS: the neck, extremities, and abdomen. Penetrating neck trauma leads to vascular injuries in 25% of casualties. Carotid artery injuries constitute 80% of penetrating trauma incidents, whereas vertebral artery injuries are more common in blunt trauma.12,13 Thrombosis is the most common injury. Other injuries include mild intimal irregularities, intimal flaps, pseudoaneurysms, and AVFs (Figure 13).14–16 Although CDDS was sensitive in evaluation of stable patients with neck zone II penetrating injuries (Figure 14)17,18 and accurately showed arterial injuries in 86% of examinations,16 CTA with multiplanar reformation is the first-line examination.19 Magnetic resonance angiography in the acute setting is restricted because of limited availability and lack of compatibility with life support devices.20,21 In limb artery injuries, CDDS is less sensitive than arteriography for detection of small intimal defects or small-vessel occlusions but is successful in detecting more substantial lesions such as pseudoaneurysms, AVFs, and major vessel occlusions (Figure 15), with reported specificity of 99%, sensitivity of 50%, and accuracy of 96% compared with arteriography.3,22,23 Blunt or penetrating abdominal trauma may result in visceral pseudoaneurysms and AVFs, which are increasingly detected because of the widespread use of diagnostic computed tomography for blunt trauma (Figures 16 and 17).24,25
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Figure 14. Anatomic division of the neck for classifying penetrating injuries. Zone I is from the sternal notch to the cricoid cartilage; Zone II, from the cricoid cartilage to the mandibular angle; and Zone III, from the mandibular angle to the skull base. Reproduced with permission from Radiographics.18
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In conclusion, CDDS is considered the imaging technique of choice for most vascular injuries. Computed tomographic angiography, MRA and DSA are reserved for selected cases or directed therapy.
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Footnotes
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Received June 21, 2007, from the Department of Medical Imaging, Rambam Medical Center, Haifa, Israel. Revision requested July 18, 2007. Revised manuscript accepted for publication August 1, 2007.
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Abstract
Introduction
