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DOI: 10.1148/rg.25si055511
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Diagnosing Traumatic Arterial Injury in the Extremities with CT Angiography: Pearls and Pitfalls1

Michelle M. Miller-Thomas, MD, O. Clark West, MD and Alan M. Cohen, MD

1 From 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.


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  		Figure 1a.  Active contrast material extravasation after penetrating upper-extremity injury. (a, b) Two sequential axial CT angiographic images (a obtained at a higher level than b) show active contrast material extravasation from the axillary artery (arrow). (c) Oblique coronal reformatted image also demonstrates active contrast material extravasation (arrow).

 


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  		Figure 1b.  Active contrast material extravasation after penetrating upper-extremity injury. (a, b) Two sequential axial CT angiographic images (a obtained at a higher level than b) show active contrast material extravasation from the axillary artery (arrow). (c) Oblique coronal reformatted image also demonstrates active contrast material extravasation (arrow).

 


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  		Figure 1c.  Active contrast material extravasation after penetrating upper-extremity injury. (a, b) Two sequential axial CT angiographic images (a obtained at a higher level than b) show active contrast material extravasation from the axillary artery (arrow). (c) Oblique coronal reformatted image also demonstrates active contrast material extravasation (arrow).

 


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  		Figure 2a.  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 reformatted image also demonstrates the popliteal artery pseudoaneurysm (arrow) with two metallic bullet fragments (B) proximal to the injury.

 


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  		Figure 2b.  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 reformatted image also demonstrates the popliteal artery pseudoaneurysm (arrow) with two metallic bullet fragments (B) proximal to the injury.

 


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  		Figure 3a.  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 artery (arrow). (c) Next distal axial image shows loss of opacification of the brachial artery. (d) Coronal oblique reformatted image shows abrupt narrowing of the contrast material column in the brachial artery (arrow).

 


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  		Figure 3b.  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 artery (arrow). (c) Next distal axial image shows loss of opacification of the brachial artery. (d) Coronal oblique reformatted image shows abrupt narrowing of the contrast material column in the brachial artery (arrow).

 


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  		Figure 3c.  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 artery (arrow). (c) Next distal axial image shows loss of opacification of the brachial artery. (d) Coronal oblique reformatted image shows abrupt narrowing of the contrast material column in the brachial artery (arrow).

 


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  		Figure 3d.  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 artery (arrow). (c) Next distal axial image shows loss of opacification of the brachial artery. (d) Coronal oblique reformatted image shows abrupt narrowing of the contrast material column in the brachial artery (arrow).

 


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  		Figure 4a.  Loss of opacification of a segment of artery after blunt lower-extremity injury. (a) Sagittal reformatted CT angiographic 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 opacification of the popliteal artery (arrow).

 


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  		Figure 4b.  Loss of opacification of a segment of artery after blunt lower-extremity injury. (a) Sagittal reformatted CT angiographic 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 opacification of the popliteal artery (arrow).

 


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  		Figure 5a.  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 projection. Both the CT angiogram and the arteriogram demonstrate the communication point between the artery and the vein (thin arrow) as well as the draining vein (thick arrow). A pseudoaneurysm (P) arising from the communication point is seen on both images.

 


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  		Figure 5b.  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 projection. Both the CT angiogram and the arteriogram demonstrate the communication point between the artery and the vein (thin arrow) as well as the draining vein (thick arrow). A pseudoaneurysm (P) arising from the communication point is seen on both images.

 


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  		Figure 6a.  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 multiple 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.

 


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  		Figure 6b.  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 multiple 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.

 


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  		Figure 6c.  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 multiple 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.

 


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  		Figure 7a.  Diagnostic CT angiogram with metallic streak artifact after penetrating lower-extremity injury. (a) Axial CT angiographic image of the middle portion of the thigh shows a metallic bullet fragment (B) causing a streak artifact that partially obscures the superficial femoral artery (arrow). (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 extravasation 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 obscured 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.

 


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  		Figure 7b.  Diagnostic CT angiogram with metallic streak artifact after penetrating lower-extremity injury. (a) Axial CT angiographic image of the middle portion of the thigh shows a metallic bullet fragment (B) causing a streak artifact that partially obscures the superficial femoral artery (arrow). (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 extravasation 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 obscured 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.

 


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  		Figure 7c.  Diagnostic CT angiogram with metallic streak artifact after penetrating lower-extremity injury. (a) Axial CT angiographic image of the middle portion of the thigh shows a metallic bullet fragment (B) causing a streak artifact that partially obscures the superficial femoral artery (arrow). (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 extravasation 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 obscured 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.

 


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  		Figure 7d.  Diagnostic CT angiogram with metallic streak artifact after penetrating lower-extremity injury. (a) Axial CT angiographic image of the middle portion of the thigh shows a metallic bullet fragment (B) causing a streak artifact that partially obscures the superficial femoral artery (arrow). (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 extravasation 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 obscured 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.

 




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