Delayed diagnosis of arterial injuries

Delayed diagnosis of arterial injuries

SCIENTIFIC PAPERS Delayed Diagnosis of Arterial Injuries David V. Felkiano, MD, Pamela A. Cruse, PA, Jon M. Burch, MD, and Camel G. Bibndo, PA, Hous...

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Delayed Diagnosis of Arterial Injuries

David V. Felkiano, MD, Pamela A. Cruse, PA, Jon M. Burch, MD, and Camel G. Bibndo, PA, Houston, Texas

When an asymptomatic patient presents with trauma to an extremity or the neck, especially a penetrating wound, there is always some question about injury to the contained arteries. At present, the three most common approaches to such patients are observation alone, mandatory operation, and arteriography [I 1, None of these, however, has been shown to be uniformly successful in preventing the problem of delayed diagnosis of an arterial injury when large numbers of patients have been evaluated [2]. In an attempt to determine why a delayed diagnosis of an arterial injury occurs in certain patients, the records and arteriograms of all patients with this diagnosis at one hospital for an 8% year period were reviewed. The hospital is unique in that it has long been the only public hospital in a large urban area that routinely accepts indigent patients who have been injured. After treatment, indigent patients who have been evaluated or operated upon and continue to reside in the county must return to the same institution for follow-up care, unless there has been a marked improvement in their economic situation. Also, indigent patients who have been injured and initially treated on an emergent basis at other institutions in the area are often referred to the public hospital for follow-up care. Material and Methods During the period of review, patients admitted to the emergency center with active hemorrhage, absence of pulse in a distal extremity, a rapidly expanding hematoma, or a palpable thrill or audible bruit after trauma to an From the Cora and Webb Mading Department of Surgery, Baylor College of Medicine, Ben Taub General Hospital, Houston, Texas. Requests for reprints should be addressed to David V. Feliciano, MD, Department of Surgery, Baylor College of Medicine. One Baylor Plaza, Houston, Texas 77030. Presented at the 39th Annual Meeting of the Southwestern Surgical Congress, Coronado, California, April 26-29, 1967.

Volume 154, December 1987

extremity or the neck underwent immediate or early operation, occasionally after an arteriogram was obtained to precisely locate the injury. Other patients with a history of bleeding before arrival, injury proximal to an artery, a nonexpanding hematoma, an adjacent neurologic injury, a diminished pulse, or a shotgun wound to an extremity underwent immediate evaluation by arteriography in the emergency room [3,4]. Proximity of injury was not precisely defined during the period of the review. Emergency room arteriograms were evaluated by senior surgical residents, often without staff consultation if the arteriographic findings were normal. On occasion, the location of a suspected peripheral or proximal cervical arterial injury or a questionable result on an emergency room arteriogram prompted the use of formal arteriography in a radiology suite. Formal arteriograms were interpreted by radiology residents with staff consultation. Patients with presumed arterial injuries diagnosed by physical examination, arteriography, or both underwent operation by senior surgical residents and staff with extensive experience in peripheral and cervical arterial trauma [5]. After operation, all patients received follow-up care in the surgical clinics of the same hospital. Patients with normal arteriograms after injuries to the extremities were discharged home unless injuries to adjacent structures such as bones or joints or truncal injuries were present. Patients with normal arteriograms after cervical injury were usually admitted for evaluation of possible injuries to adjacent structures such as the esophagus. After discharge, all patients with normal arteriographic findings received follow-up care in the surgical clinics of the same hospital. The records and arteriograms of all patients admitted to the surgical services with a delayed diagnosis of arterial injury over an 8% year period were reviewed by an experienced vascular trauma surgeon, usually during the hospitalization. Based on this review, patienti with a delayed diagnosis were placed in one of five different groups according to the reason for the delay. The five groups were


Feliciano et



Arteries InJured Arteries


Upper extremity Subclavian Axillary Brachial Radial or ulnar Lower extremity Tibioperoneal Deep femoral Popliteal Neck fnternal carotid


Symptoms Prompting Reevaluation Symptoms

Abnormal physical examination Pseudoaneurysm Arteriovenous fistula Combination Arterial occlusion Hemorrhage Hemorrhage, then occlusion Suspicious arteriogram

n 22 12 7 3 2 2 1 1

follows: Group 1, no arteriogram obtained despite proximity; Group 2, misreading of an arteriogram or judgment error based on the arteriogram; Group 3, false-negative arteriographic finding; Group 4, injury not detected at first operation; and Group 5, patient factors. In addition, epidemiologic factors, the time interval between injury and the delayed diagnosis, type of presentation, treatment of the arterial injury, and perioperative morbidity were recorded. as

During the review period, 300 to 350 emergency center arteriograms were obtained annually, and 100 to 110 peripheral arterial injuries were treated annually at the hospital of record [3,5,6]. A delayed diagnosis of an arterial injury in an extremity or the neck was noted in 28 patients (23 male and 5 female patients) with an average age of 27.2 years. Twentyseven patients (96.4 percent) had penetrating wounds (14 gunshot wounds, 7 stab wounds, 5 lacerations, and 1 shotgun wound), and only 1 patient had blunt trauma. The delay in diagnosis from the time of injury ranged from 12 hours to 26 years (the latter due to patient delay), with a median delay of 10 days. The delay was from 12 hours to 5 days in 12 patients, from 10 days to 10 weeks in 14 patients, 8 years in 1 patient, and 26 years in 1 patient. There were 24 patients whose delayed diagnosis was caused by a problem related to arteriography (not performed, misread, or false-negative findings) or


Figure I. Late pseudoaneurysm and arferlovenous flstuia 3 weeks after neaatlve exn~oratlon of the ax//law arterv. The pafient presentes with a p&satlle mass and brach&l plexdpathy. Reprkded from [ II], with permission from the publisher.

patient factors. In this group, the median delay was 10 days. In the remaining four patients whose injuries were not detected at first operation, the average delay until diagnosis was 29 days. Arteries in the lower extremities were involved in 18 of 28 patients (64.3 percent), whereas arteries in the upper extremities or neck in 9 patients (32.1 percent) and 1 patient (3.6 percent), respectively, accounted for the remainder (Table I). Tibioperoneal arterial injuries were the most common ones noted in the entire series. A pseudoaneurysm, arteriovenous fistula, or a combination of both (Figure 1) was the finding on physical examination in 22 of 28 patients (78.6 percent), whereas arterial occlusion, bleeding, or an intimal defect which was originally questioned were present in the remaining 6 patients (Table II). The treatment of the injured arteries was segmental resection in 18 patients (64.3 percent), followed by an end-to-end anastomosis (7 patients) or insertion of a graft (11 patients). The remaining patients had ligation or radiologic occlusion of the vessel or a primary repair. The venous side of arteriovenous fistulas was ligated or had a lateral repair in 8 of 10 instances (Table III). Perioperative morbidity was significant in five patients, including two with preoperative shock, two with atelectasis, and one with adult respiratory distress syndrome. Local complications also occurred in five patients and included one brachial plexopathy from compression, one occlusion of the femoral vein from compression in combination with a Dacron graft infection postoperatively in the same patient, one wound infection, one breakdown of an arterial repair secondary to further trauma, and one case of tissue loss from the right first toe secondary to an arterial occlusion. After a careful analysis of patient records and arteriograms, it was found that failure to perform an arteriogram despite proximity of the injury oc-

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curred in 14 patients (50 percent) and was noted to be the most common cause of a delayed diagnosis. Five patients had arteriograms that were either misread (three patients) or an error in judgement was made despite a satisfactory arteriogram (two patients). The specific problems causing misreading included misplacement of the x-ray cassette away from the injury, ignoring an intimal injury, and confusing early venous filling from an arteriovenous fistula with regular venous return. In one of the two patients in whom an error in judgment was made, an injury to the anterior tibial artery was considered to be irreparable by a surgical subspecialty service. In the other patient, an obvious acute pseudoaneurysm in the distal profunda femoris artery was thought to be insignificant by two attending surgeons. Two patients had false-negative arteriographic findings. The first patient, who has previously been described, had a normal femoral arteriographic finding after a stab wound to the groin [3]. Continued hemorrhage prompted a second arteriogram which revealed occlusion of the superficial femoral artery. The other patient had a reading of spasm on his original emergency room arteriogram. A pseudoaneurysm of the posterior tibia1 artery subsequently developed in this patient. In four patients, the arterial injury detected on emergency room arteriogram (three patients) or radiology suite arteriogram (one patient) was not discovered at the first operation. In three of these patients, a problem of exposure of the vessel in question was a factor in the injury being missed. Included among these were an injury to the axillary artery in a muscular young man which was missed because of failure to detach the pectoralis minor muscle from the coracoid process, an injury to the tibioperoneal trunk of an obese man which was missed because of failure to completely expose the entire length of the vessel, and an injury to the internal carotid artery at the base of the skull which was never visualized in one patient. In the remaining patient, an injury to the popliteal artery was missed because the wrong area of the artery was exposed. It is disconcerting to note that the patients with injuries to the tibioperoneal trunk and carotid artery had normal intraoperative arteriographic findings prior to closure of the incision. In the remaining three patients in the series, patient factors were the cause of delayed diagnosis. One patient received no medical care after a gunshot wound to the groin 26 years previously. The other two patients had delayed presentation of arteriovenous fistulas 2 and 3 days after normal findings on emergency center arteriograms. Comments

As previously noted, observation or physical examination alone, mandatory operation, or arteriography is used in most trauma centers when there is a

Volume 154,December 1987


Diagnosisof Arterial InjurIes

Methodot Treatment n

Method Artery Resection End-to-end Craft Ligation Coil or balloon occlusion Arteriorrhaphy Vein Ligation Venorrhaphy 8 patch Resection, end-to-end Balloon occlusion

18 7 11’ 7 2 1 4+ 4 1 1

Polytetrafluoroethylene in five patients, saphenous vein graft in three patients, Dacron in two patients, and cephalic vein graft in one patient. 7 Axillary, brachial, radial, and anterior tibia1 in one patient each. l

potential arterial injury in an extremity or the neck. Observation, which has the advantage of avoiding invasive techniques in the asymptomatic patient, is based on the premise that all arterial injuries will cause symptoms. Although such a conservative approach has been utilized when small numbers of patients are treated and complete follow-up data can be obtained, it completely ignores the 5 to 15 percent incidence of proximity injury noted in every large review of civilian peripheral arterial injuries [3,7-131. Ignoring proximity injury in one large series would have led to a delay in diagnosis of an arterial injury (missed injury) in 45 patients over an 18 month period [3]. In the series reported herein, 50 percent of the arterial injuries diagnosed late were originally overlooked on physical examination. Based on proximity as an indication for arteriography, all 14 patients in this group should have had an arteriogram. In like manner, if physical examination alone without arteriography is used as the sole criterion for operation in patients with soft signs of an arterial injury such as a history of bleeding, proximity of injury to artery, nonexpanding hematoma, or an adjacent neurologic injury, an unacceptable rate of negative explorations as high as 29.2 percent will occur [3,7,11]. Mandatory operation for proximity of injury has been suggested as another technique to eliminate the problem of delayed diagnosis of arterial injuries [9,14-161. The rationale given is that an operation on an extremity causes few sequelae and allows the surgeon to directly visualize the artery in question. Unfortunately, such an approach led to a 64 percent negative exploration rate, a 5 percent morbidity rate, and a 0.4 percent mortality rate in one 5 year review [16]. Also, as noted in this series and others, arterial injuries can still be missed at operation by residents and staff with extensive experience in vascular trauma surgery [2,17,18].


Feliciano et al

Preoperative arteriography to document the presence and location of an arterial injury in an asymptomatic patient or a patient with soft signs is the approach favored by many trauma centers. Patients with normal arteriographic findings have less than a 1 to 2 percent incidence of missed injuries. This has been documented in a long-term follow-up study by Richardson et al [2], who noted that eight late injuries were detected from a series of 440 arteriograms. In the series reported herein, only 2 of 28 patients with a delayed diagnosis of arterial injury had a false-negative arteriographic finding as the cause. It should also be noted that extensive recent clinical experience in patients undergoing exclusion arteriography in many centers has documented that it is much more accurate than the often quoted figure of 40 percent reported by Lain and Williams [19] in a study of mongrel dogs carried out 17 years ago [2,3,11-131. If arteriography is to be used to immediately diagnose a peripheral or cervical arterial injury, a variety of techniques are available. Included among these are percutaneous emergency room arteriography, percutaneous radiology suite arteriography, intravenous or intraarterial digital subtraction angiography, and intraoperative arteriography [20]. Radiology suite arteriography remains the standard for most centers, whereas emergency room arteriography continues to be the method of choice in our center based on patient volume and the ease and accuracy of the method [3,4,1.2]. Digital venous angiography has been used successfully by Fabian et al [21] in Memphis, whereas other groups have noted problems with the large volumes of dye required, the timing, and the quality of the films obtained [22]. Digital subtraction angiography performed after intraarterial injection of dye appears to have an accuracy rate similar to that of conventional arteriography [23]. No matter which arteriographic technique is chosen, the timing of the one-shot film (emergency room arteriography) or multiple films (radiology suite standard or digital arteriography) is critical. The major reason is that missed injuries to arteries in the shank were the most common ones noted in this series, as well as in the series of Rich et al [24] of 558 traumatic arteriovenous fistulas and false aneurysms studied during the Vietnam conflict. If the tibioperoneal vessels are not clearly visualized during studies performed on patients with trauma below the knee, either more radiologic dye or a change in the timing of the films is necessary [4]. When satisfactory arteriograms of this area cannot be obtained immediately after admission, the asymptomatic patient with proximity injury should have a repeat arteriogram performed within 7 days to rule out a previously missed injury. Patients with shotgun wounds below the knee should also have repeat arteriograms within 7 days, as a delayed presenta-


tion of a tibioperoneal arterial injury from a pellet wound is rare. When an operation is performed based on a positive preoperative arteriographic finding and no arterial injury is found, several options are available. The first option is to review the preoperative arteriogram and verify that the segment of artery thought to contain the injury is actually the segment that has been exposed. The second option is to completely separate the segments of the artery and vein in the area in question in order to rule out a transiently thrombosed arteriovenous fistula. The third option is to obtain an operative arteriogram, which was unsuccessful in preventing two of the four injuries not detected at operation in this series. Finally, if the adventitia of the vessel is discolored or contused and this discoloration is not readily removable by sharp dissection, an arteriotomy should be performed. This should rule out an intimal tear or flap or subintimal hematoma with intact distal flow. The civilian patient whose arterial injury is not detected at first admission or during operation will generally return to the hospital within a short period of time. In this series, the median delay until symptoms brought the patient back to the hospital was 10 days, and 26 of 28 patients returned within 10 weeks. These figures are similar to those reported in other civilian series [25,26] but somewhat shorter than those reported by Rich et al [24] for patients in the Vietnam Vascular Registry. Access to medical care was surely limited on occasion during the Vietnam conflict, and 47.2 percent of patients had a diagnosis of either an arteriovenous fistula or false aneurysm made 1 month or more after injury. When the patient returns to the hospital, a pulsatile mass or pseudoaneurysm with or without an associated arteriovenous fistula will be the most common finding [2,24,27]. If the mass is large and compresses adjacent nerves or the brachial plexus, a severe neuropathy may be present as well [28,29]. On occasion, there may also be a venous occlusion secondary to compression, as was noted in one patient in the present series. Arterial insufficiency is generally rare when a pseudoaneurysm is the presenting complaint, but it can occur if an arteriovenous fistula is also present [29]. The treatment of arterial injuries that have been diagnosed after some delay will vary depending on the vessel involved and the presentation. For major proximal vessels in the extremities, either pseudoaneurysms or arteriovenous fistulas can be repaired primarily when the diagnosis has been made within 1 or 2 weeks of the injury. If the diagnosis is delayed beyond this point, splaying of the involved artery coupled with surrounding fibrosis will usually mandate segmental resection and insertion of a graft. If an arteriovenous fistula is present in a proximal artery of the extremity, it may grow rapidly

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before a delayed diagnosis is made. Vascular control at operation is often challenging in such patients. When a noncritical vessel such as the circumflex vessels of the shoulder and groin, peroneal artery, or one of the tibia1 arteries is found to have an injury after a delay, therapeutic embolization performed by an invasive vascular radiologist is the preferred therapy [30,31]. The same can be said for distal cervical lesions such as carotid-cavernous or vertebral arteriovenous fistulas [26].

During an 8% year period, 28 patients with a delayed diagnosis of an arterial injury in an extremity or the neck were treated. The median delay between injury and diagnosis was 10 days. The tibioperoneal arteries were the most commonly injured vessels. After extensive analysis of the records and arteriograms of the involved patients, the following conclusions were drawn: Arteriograms are mandatory for penetrating wounds proximal to major arteries of the extremities because of the 5 to 15 percent incidence of occult injuries; the timing of arteriography in the distal leg is critical if subtle injuries to the tibia1 and peroneal vessels are to be detected; when experienced radiologists are not available, interpretation of exclusion arteriograms is best performed by experienced trauma surgeons; false aneurysms, arteriovenous fistulas, or a combination of both continue to be the most common manifestations of missed arterial injuries; failure to find an injury previously diagnosed by a preoperative arteriogram mandates an intraoperative arteriogram and, on occasion, an arteriotomy; and, late arterial repairs usually require segmental resection with an end-toend anastomosis or insertion of a graft. for the technical

References 1. Feliciano DV. Managing peripheral vascular trauma. Infect Surg 1986; 5: 659. 2. Richardson JD, Vitale GC, Flint LM Jr. Penetrating arterial trauma: analysis of missed vascular injuries. Arch Surg 1987; 122: 678-83. 3. O’Gorman RB, Feliciano DV, Bitondo CG, Mattox KL, Burch JM, Jordan GL Jr. Emergency center arteriography in the evaluation of suspected peripheral vascular injuries. Arch Surg 1984; 119: 568-73. 4. O’Gorman RB, Feliciano DV. Arteriography performed in the emergency center. Am J Surg 1986; 152: 323-5. 5. Feliciano DV, Bitondo CG, Mattox KL, et al. Civilian trauma in the 1980’s. A l-year experience with 456 vascular and cardiac injuries. Ann Surg 1984; 199: 717-24. 6. Rapaport A. Feliciano DV, Mattox KL. An epidemiologic profile of urban trauma in America-Houston style. Tex Med 1982; 78: 44-50. 7. Turcotte JK, Towne JB, Bernhard VM. Is arteriography necessary in the management of vascular trauma of the extremities? Surgery 1978; 84: 557-62. 8. Drapanas T, Hewitt RL, Weichert RF Ill, Smith AD. Civilian

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Acknowledgment: We are grateful assistance of Mary LeJeune.


14. 15. 16.

17. 18. 19.

20. 21.




25. 26.






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vascular Injuries: a critical appraisal of three decades of management. Ann Surg 1970; 172: 351-60. Perry MO, Thal ER, Shires GT. Management of arterial injuries. Ann Surg 1971; 173: 403-a. Burnett HF, Parnell CL, Williams GD, Campbell GS. Peripheral arterial injuries: a reassessment. Ann Surg 1976; 183: 701-9. Snyder WH Ill, Thal ER, Bridges RA, Gerlock AJ, Perry MO. Fry WJ. The validity of normal arteriography in penetrating trauma. Arch Surg 1978; 113: 424-8. Menzoian JO, Doyle JE, Cantelmo NL, Lo Gerfo FW, Hirsch E. A comprehensive approach to extremity vascular trauma. Arch Surg 1985; 120: 801-5. Ben-Menachem Y. Vascular injuries of the extremities: hazards of unnecessary delays in diagnosis. Orthopedics 1986; 9: 333-a. Dillard BM, Nelson DL, Norman HG Jr. Review of 85 major traumatic arterial injuries. Surgery 1968; 63: 391-5. Fomon JJ, Warren WD. Late complications of peripheral arterial injuries. Arch Surg 1965; 91: 610-6. Sirinek KR, Levine BA, Gaskill HV Ill, Root HD. Reassessment of the role of routine operative exploratlon in vascular trauma. J Trauma 1981; 21: 339-44. Feliciano DV. Pitfalls in the management of peripheral vascular injuries. Prob Gen Surg 1986; 3: 101-13. Graham JM, Mattox KL, Feliciano DV, DeBakey ME. Vascular injuries of the axilla. Ann Surg 1982: 195: 232-8. Lain KC, Williams GR. Arteriography in acute peripheral atterial injuries: an experimental study. Surg Forum 1970; 21: 179-81. Feliciano DV. Vascular injuries. Adv Trauma 1987; 2: 179206. Fabian TC, Reiter CB, Gold RE, Pate JW. Digital venous angiography. A prospective evaluation in peripheral arterial trauma. Ann Surg 1984; 199: 710-6. Goodman PC, Jeffrey RB Jr, Brant-Zawadzki M. Digital subtraction angiography in extremity trauma. Radiology 1984; 153: 61-4. Sibbitt RR, Palmaz JC, Garcia F, Reuter SR. Trauma of the extremities: prospective comparison of digital and conventional angiography. Radiology 1986; 160: 179-82. Rich NM, Hobson RW II, Collins GJ Jr. Traumatic arteriovenous fistulas and false aneurysms: a review of 558 lesions. Surgery 1975; 78: 817-28. Hegarty MM. Angorn IB, Gollogly J, Baker LW. Traumatic arteriovenous fistulae. Injury 1975; 7: 20-8. Kollmeyer KR, Hunt JR, Ellman BA, Fry WJ. Acute and chronic traumatic arteriovenous fistulae in civilians. Epidemiology and treatment. Arch Surg 1981; 116: 697-702. Escobar GA, Escobar SC, Marquez L, et al. Vascular trauma: late sequelae and treatment. J Cardiovasc Surg 1980; 21: 35-40. Raju S, Carner DV. Brachial plexus compression. Complication of delayed recognition of arterial injuries of the shoulder girdle. Arch Surg 1981; 116: 175-8. Feliciano DV, Mattox KL. Traumatic aneurysms. In: Rutherford RB, ed. Vascular surgery. Philadelphia: WB Saunders, 1984: 848-55. Ben-Menachem Y, Handel SF, Thaggard A Ill, Carnovale RL, Katragadda C, Glass TF. Therapeutic arterial embolization in trauma. J Trauma 1979; 19: 944-52. McNeese S, Finck E, Yellin AE. Definitive treatment of selected vascular injuries and ppst-traumatic arteriovenous fistulas by arteriographic embolization. Am J Surg 1980; 140: 252-9.

Discussion Brian McCroskey (Denver, CO): Dr. Feliciano, in your series, failure to obtain an arteriogram accounted for 50 percent of the 28 missed arterial injuries. Were there any


Feliciano et al

salient signs or symptoms present in this group that may have led to the suspicion of a vascular injury? At our institution, we reinforce the use of portable Doppler examination as an extension of the physical examination. Did your patients routinely have a Doppler examination as a simple screening maneuver? Furthermore, in your emergency room, who is responsible for deciding whether to obtain, or more importantly, not obtain an arteriogram? Are patients managed by surgical residents, emergency department physicians, or other staff? In terms of technique of angiography, conventional angiography has been well established in the literature as a reliable means of excluding arterial injuries. The false-negative rate in the Parkland series was less than 1 percent. In our recent experience with 300 consecutive arteriograms, we found only two false-negative findings. You have supported the use of emergency room angiography. In this series, however, there were two false-negative arteriographic findings, as well as two additional patients who were found to have arteriovenous fistulas 2 and 3 days after normal findings on emergency room angiograms. In these stable patients with nonthreatened limbs, is emergency room arteriography appropriate? In regard to the technique of single ejection, is single-view arteriography sensitive enough to visualize a small delayed defect due to a false aneurysm or small atrioventricular fistula in a tibia1 vessel, which comprised a significant portion of your series. Finally, in terms of graft selection, 7 of the 11 interposition graft procedures performed in your series were with prosthetic material. One of the patients with a Dacron graft had graft infection. Does this choice of graft selection reflect the bias of the attending surgeon? Joseph Hurley (St. Louis, MO): I would like to echo the fact that careful arteriography is very critical in these patients and, preferably, it should be performed preoperatively with rapid-sequence cassette changers. The standard indicator of successful peripheral arterial reconstruction is lack of claudication and amputation. Dr.


Feliciano, I assume there were no amputations in your study. Noninvasive blood flow studies might give us some hint as to the objectivity of repair. Which arteries were ligated or embolized? Ronald Jones (Dallas, TX): Dr. Feliciano, I believe you had four missed injuries intraoperatively. Could you briefly describe your technique of exploring an artery when attempting to avoid commonly missed arterial injuries? David V. Feliciano (closing): Dr. McCroskey, the patients who had missed injuries because of failure to perform an arteriogram had proximity as the only physical finding. We have not used the Doppler examination. At Ben Taub General Hospital, if the patient has a diminished pulse, he either goes to the operating room or an arteriogram is obtained. The decision to obtain an arteriogram comes from surgical residents at the PG-5 level, unless there is staff available at that time. There are no experienced vascular radiologists in our hospital at night, but the surgical services have learned how to perform and interpret emergency room arteriograms. What I have presented in my study is the problem of not obtaining arteriograms and how rare false-negative findings are with this technique. I don’t consider the two arteriovenous fistulas that presented at 48 to 72 hours as being representative of false-negative arteriographic findings. The polytetrafluoroethylene grafts were part of the study that ended in 1984. My primary choice as a conduit is a saphenous vein graft. Dr. Hurley, there were no amputations in the series. All of the ligations were in the tibioperoneal vessels, whereas the balloon and coils were placed in the carotid and profunda arteries, respectively. Dr. Jones, the injuries missed at operation were described in the study. Basically, inadequate exposure of the area of injury and exposure of the wrong part of the artery were the problems in all four patients.

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