Physical exam and occult post-traumatic vascular lesions: Implications for the evaluation and management of arterial injuries in modern warfare in the endovascular era

Based on complexity of extremity wounds sustained in recent combat, arteriography had been used routinely in evaluations for delayed or occult arterial injuries. This report aims to quantitatively analyze the sensitivity and specificity of physical exam (PE) in predicting the presence of these injuries. United States servicemembers sustaining extremity trauma in the Global War on Terrorism were evacuated to our medical center and evaluated by a senior vascular surgeon. Those with an abnormal PE, at risk based on wounding patterns, or previously treated for vascular injury underwent arteriography. Data from each patient were prospectively entered into a Vascular Injury registry. Comprehensive information about the injuries, interventions, arteriogram results, and any periprocedural complications were analyzed. Twenty-five endovascular or open surgical interventions were performed in forty-six of 99 patients that had lesions on arteriography. Seventy-three patients had a normal PE, of which 36 had lesions that prompted 6 subsequent interventions. Twenty-two of 26 patients with an abnormal PE had lesions that prompted 19 interventions. For PE, sensitivity was 38%, specificity was 90%, and positive predictive value (PPV) and negative predictive value (NPV) were 85% and 51%, respectively. In proximity injuries, PPV improved to 100%, but was only 15% sensitive with a NPV of 60%. In conclusion normal PE did not reliably predict post-traumatic arterial lesions in these military extremity injuries. These lesions are amenable to endovascular therapies, and should be considered in cases of complex trauma involving high amounts of energy, penetrating mechanisms, or wounding patterns in proximity to named vessels.