Historical Background

Deliberate efforts to repair arterial injuries arose during the Korean conflict in the early 1950s, and the pioneering work of Rich and colleagues during the Vietnam war catalogued the predictability of successful outcomes for major vascular trauma, particularly in the extremities, presuming that an accurate diagnosis was made early and that operative management was timely and effective.

Routine operative exploration was initially promoted for occult vascular trauma but was found to have a very low yield. Physical examination was thought, except when the diagnosis was obvious, to be inadequately sensitive for identifying many occult arterial injuries. Accordingly, the introduction of routine exclusion arteriography in settings where signs of vascular injury were minimal, or where clinical suspicions were high, was advocated in the 1970s in numerous urban trauma centers, particularly by Perry, Thal, and colleagues at Parkland Hospital in Dallas. These workers were particularly concerned that early identification of silent or minimal arterial injuries be accomplished owing to concerns for subsequent delayed hemorrhage, dissection, or acute arterial occlusion. Indeed, contrast arteriography proved to be quite highly accurate, with several studies demonstrating false positive and false negative rates of less than 2% for such studies performed to detect or rule out occult arterial injuries.

However, routine use of contrast arteriography in this setting is invasive, expensive, and time consuming, and it requires transfer of the patient, who often needs ongoing evaluation, surveillance, and resuscitation, to an angiography suite that is outside of, and often remote from, the emergency department.

Most importantly, several studies demonstrated that when contrast arteriography was performed for exclusion indications, in only a very few of these trauma victims—less than 5%—were arterial injuries identified that were so serious they required operative intervention. For this reason, alternative diagnostic measures were investigated in this patient population.

Arterial Pressure Measurements

The 1970s saw the introduction and development of ultrasonographic means of assessing arterial pressure measurement in patients with chronic arterial occlusive disease, usually of the lower extremities. Over the next 20 years we and others evaluated the use of Doppler pressure measurement and the calculation of ankle-to-brachial indices (ABIs) as means of carrying out noninvasive determination of the patency and vessel integrity of patients with penetrating trauma, predominantly to the extremities.

Some groups used an ankle pressure index (ratio of highest ankle arterial pressure to arm arterial pressure; ABI) of 0.90 as a threshold value below which the presence of an arterial disruption was possible and above which such an injury was unlikely (Figure 1). Others promoted the even greater sensitivity of an ABI of 1.0, accepting that such an approach resulted in the performance of many more negative arteriograms. Most importantly, whichever ABI threshold was chosen, these studies validated the use of a simple bedside diagnostic test, using a blood pressure cuff and a hand-held Doppler, to assess patients with potential occult penetrating arterial trauma of the extremities.

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