In Iraq War, Arteriography Optimal for Neck Trauma

By Mark S. Lesney

CHICAGO -- Fragment injuries are a leading cause of death in surgical field hospitals in Iraq, especially injuries to the head and neck. In these cervical wound cases, which generally involve metallic fragments, arteriography is optimal for diagnosis of vascular trauma, according to a presentation by Charles J. Fox, M.D., at the Vascular Annual Meeting.

Modern military munitions produce complex injuries, including those to the vascular system, that challenge diagnosis and management, especially in field situations.

Where mass casualties occur in wartime, not all soldiers who have sustained cervical blast injuries can be immediately explored, leading to delayed evaluation of those patients who have stable neck injuries, according to Dr. Fox of the Walter Reed Army Medical Center and the Uniformed Services University, Washington.

For this reason, he and his colleagues instituted a prospective database to retrospectively review patients with cervical trauma occurring during Operation Iraqi Freedom from 2003 to early 2005.

Suspected vascular injury from penetrating neck trauma occurred in 63 patients, who were treated and stabilized at field hospitals in Iraq and then evacuated to the vascular center at Walter Reed Army Medical Center, Dr. Fox said. Most of the wounds were from explosive devices, and the rest (21%) were high-velocity gunshot wounds. One-third of the patients had neck injuries in zone II, one-third in zone III, and about 10% in zone I, with 23% showing diffuse multiple-zone injuries (see graphic).

Indications for arteriography were a penetrating injury to zone I or III or an abnormal or inconclusive CT angiogram. In 38 patients who underwent diagnostic arteriography, physicians detected 5 pseudoaneurysms and 8 occlusions.

Of the 63 patients, 11 (over 17%) had occult injuries, and 1 had graft thrombosis. Injuries to the carotid artery were the most common vascular injury.

All occult injuries detected by arteriogram had a negative or equivocal CT angiogram, most likely because retained fragments produced suboptimal noninvasive imaging in the zone of injury, according to Dr. Fox.

For this reason, arteriography remains the preferred method for the evaluation of occult vascular injury and should be used liberally, Dr. Fox said. In particular, patients in the military with blast-associated neck injuries treated in the field should have reevaluation upon arrival in the United States, he added.

In response to a question on the applicability of these observations to civilian life, Dr. Fox stated that the usefulness of arteriography should hold true for any similar forms of fragmentation injury or bullet wounds to the neck.