Sonographic Evaluation of

Vascular Injuries
Diana Gaitini, MD, Nira Beck Razi, MD, Eduard Ghersin, MD,
Amos Ofer, MD, Michalle Soudack, MD
Objective. The purpose of this presentation is to highlight the color Doppler duplex sonographic
features of procedure-related and blunt or penetrating trauma-related vascular injuries. Methods.
Different kinds of vascular complications such as pseudoaneurysms, arteriovenous fistulas, dissection,
and thrombosis are discussed. Cases of vascular injuries in the extremities, neck, and abdomen are pre-
sented to illustrate the spectrum of sonographic appearances. Results. Color Doppler duplex sonog-
raphy is valuable in the diagnosis and monitoring of most vessel injuries and in the treatment of
pseudoaneurysms. It is useful for flow analysis and for follow-up after treatment. However, because of
limitations inherent to sonography, such as bones, air, casts, skin burns, and relatively slow perfor-
mance of the test, magnetic resonance imaging, computed tomography, and angiography are neces-
sary for further evaluation in selected cases. Conclusions. Color Doppler duplex sonography is a widely
available, noninvasive, and accurate technique for evaluating vascular injuries and should be the first-
line imaging modality in most patients. Key words: arteriovenous fistula; diagnosis; false aneurysm;
sonography; vascular injuries.
Received June 21, 2007, from the Department of
Medical Imaging, Rambam Medical Center, Haifa,
Israel. Revision requested July 18, 2007. Revised
manuscript accepted for publication August 1, 2007.
Address correspondence to Diana Gaitini, MD,
Unit of Ultrasound, Department of Medical Imaging,
Rambam Medical Center, Haaliya 8, PO Box 9602,
31096 Haifa, Israel.
E-mail: d_gaitini@rambam.health.gov.il
Abbreviations
AVF, arteriovenous fistula; CDDS, color Doppler duplex
sonography; CTA, computed tomographic angiography;
DSA, digital subtraction angiography. MRA, magnetic
resonance angiography
he prevalence of vessel injuries is on the rise
because of increasing rates of invasive procedures
and traumatic events. At a level I trauma center,
iatrogenic injuries were the causes of one third of
arterial damage.
1
The complication rate in complex coro-
nary procedures reaches 6%. Fibrinolytic therapy, antico-
agulants, large-diameter vascular sheaths, and poor
puncture or compression techniques increase the rate of
vascular complications.
2
Partial or complete thrombosis,
intimal flaps, dissection, arteriovenous fistulas (AVFs), and
pseudoaneurysms are the main vascular complications.
The neck, extremities, and abdominal organs are
anatomic sites amenable to investigation with color
Doppler duplex sonography (CDDS). Subcutaneous air,
large hematomas, casts, and large skin wounds may
impede CDDS performance. Aberrant vessels and
anatomic areas difficult to scan, such as the thoracic inlet
and the pelvis, lessen the accuracy of CDDS. Further lim-
itations are derived from operator dependence and
lengthy examinations, which may be inappropriate in the
acute care setting.
3
Despite these limitations, CDDS is
2008 by the American Institute of Ultrasound in Medicine J Ultrasound Med 2008; 27:95107 0278-4297/08/$3.50
T
Image Presentation
presently considered the first-line examination
for evaluation of vascular injuries, with
reported sensitivity of 95% to 97% and accu-
racy of 95% to 98%.
35
Magnetic resonance
angiography (MRA) and computed tomo-
graphic angiography (CTA) are useful comple-
mentary examinations. Digital subtraction
angiography (DSA) is shifting to a more thera-
peutic role for endovascular management.
Procedure-Related Vascular Injuries
Vascular injuries may follow percutaneous pro-
cedures. Puncture site vascular injuries include
perivascular hematomas, pseudoaneurysms,
and AVFs. A perivascular hematoma is the most
frequent complication at the puncture site.
Clinically, it is a nonpulsatile focal swelling with
ecchymosed skin. It appears as a complex solid
and cystic soft tissue mass adjacent to the injured
vessel, without blood flow on Doppler interroga-
tion (Figure 1). A diffuse hematoma, even obvi-
ous clinically, may be unrecognizable on CDDS
because of poorly defined infiltration of blood
into the soft tissues. An AVF is a false vascular
channel between an artery and the adjacent vein.
A palpable thrill and a bruit on auscultation are
often present. Color Doppler duplex sonography
shows a mosaic color pattern due to high turbu-
lent flow in the fistula, low-resistance arterial flow
in the feeding artery, and a high-velocity, chaotic
waveform in the draining vein. Extravascular
color signals represent perivascular tissue vibra-
tion due to transmitted pulsation of turbulent
continuous blood flow between the artery and
the vein (Figure 2). A pseudoaneurysm or false
aneurysm is a pulsatile hematoma that commu-
nicates through a channel (neck) with the injured
artery. It follows total disruption in the arterial
wall and continuous extravascular flow, con-
tained by the surrounding tissues. It complicates
0.1% to 0.2% of diagnostic and 3.5% to 5.5% of
interventional procedures, representing more
than 60% of interventional vascular complica-
tions.
6
Clinically, a pulsatile mass with a palpable
thrill and an audible to-and-fro murmur is
detected. Color Doppler duplex sonography is
the diagnostic imaging modality of choice: it can
delineate the cavity, the degree of clotting, the
communication with the artery, and the blood
flow pattern. The lumen has bidirectional,
swirling, or yin-yang color flow and turbulent or
pulsatile flow on a spectral display. The neck typi-
cally has a to-and-fro waveform due to flow enter-
ing during systole and exiting during diastole
(Figure 3). Pseudoaneurysms vary in size and may
have multiple compartments (Figure 4). A fluid-
fluid level due to hematocrit layering may be seen
in large pseudoaneurysms (Figure 5). They may
involve surgical sites, most often bypass graft
anastomosis (Figure 6). Sonographically guided
thrombin injection is the treatment of choice
for large pseudoaneurysms that do not clot
spontaneously, converting them into thrombosed
hematomas within seconds, with a 93% to 100%
success rate.
7,8
A flow void after injection confirms
thrombosis (Figure 7). The neck width of the pseu-
doaneurysm is of prognostic value because a wide
and short neck may carry a higher risk of failure
and embolic complications during thrombin
injection. Hypoechoic hypervascular lymph
nodes, dilated varicose veins with slow swirling
flow (Figure 8), and fluid containing femoral or
inguinal hernias, with fluid movement due to res-
piratory motion, may mimic pseudoaneurysms.
Procedures such as angioplasty, thrombolysis,
and stent placement may be complicated by
thrombosis, intimal flaps, aneurysms, arterial
ruptures, and stent stenosis. Arterial thrombosis
is the most frequent complication. Varying
degrees of thrombus echogenicity may be
96 J Ultrasound Med 2008; 27:95107
Sonographic Evaluation of Vascular Injuries
Figure 1. Image from a 70-year-old man with groin swelling
after femoral catheterization. Color Doppler sonography shows
a large hypoechoic heterogeneous mass (arrow) surrounding the
femoral artery (fa) at the proximal thigh, consistent with a
hematoma.
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Gaitini et al
Figure 2. Images from a 4-year-old child with lower limb
swelling after repeated inguinal punctures. A femoral AVF was
diagnosed by CDDS. A, On a longitudinal scan, color Doppler
sonography shows normal flow in the common femoral artery
(CFA) followed by a mosaic flow pattern representing aliasing
due to high-velocity flow in the fistula (arrow) between the
artery (FA) and vein (FV). B, A transverse scan of the fistula
shows perivascular color Doppler signals in the surrounding soft
tissue due to tissue vibration. C, A spectral display shows turbu-
lent flow in the fistula. D, Spectral Doppler sonography shows a
low-resistance, high-velocity waveform in the artery. E, Spectral
Doppler sonography shows an arterialized waveform in the
draining vein.
A B
C
E
D
detected depending on the thrombus age. A par-
tially occluding thrombus causes alteration in
the color flow pattern, waveform, and velocities
(Figure 9). A totally occluding thrombus causes
an abrupt cutoff of color flow and retrograde flow
in a collateral pathway. A vasospasm and exter-
nal compression without evidence of an intrinsic
vessel injury may be correctly diagnosed by
CDDS. Focal dissection resulting from guide
insertion may be seen in a severely atherosclerot-
ic artery (Figure 10). Color Doppler duplex
sonography, at times in combination with MRA
and CTA, can noninvasively show most arterial
injuries.
9
Vein thrombosis may complicate
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Sonographic Evaluation of Vascular Injuries
Figure 3. Images from a 55-year-old man who had a pulsatile
mass at the puncture site after coronary artery stent insertion.
Color Doppler duplex sonography showed a femoral artery
pseudoaneurysm. A, Color Doppler sonography shows bidirec-
tional yin-yang color flow in the lumen of the pseudoaneurysm
due to cyclic inflow and outflow during systole and diastole,
respectively. B, Spectral Doppler sonography shows classic to-
and-fro flow at the neck, appearing as a double trace on both
sides of the baseline.
A
B
Figure 4. Images from a 62-year-old woman with multiple com-
partment pseudoaneurysms after coronary arteriography. A, Gray
scale sonography shows a chain of false aneurysms connected to
the artery by a single neck. B, Power Doppler sonography shows
the connecting neck.
A
B
indwelling catheters, inferior vena cava filters,
and venous stents and shunts. Thrombosed
veins are typically noncompressible (Figure 11).
When a thrombus is suspected in a central vein
such as the brachiocephalic vein or the superi-
or vena cava, both sides should be examined:
bilateral dampening of the spectral waveform,
converting the normal biphasic pattern into a
nonpulsatile pattern, indicates superior vena
cava thrombosis, whereas unilateral dampening
is a sign of ipsilateral brachiocephalic thrombo-
sis.
10
Complications of transjugular intrahepatic
portosystemic shunts may occur early because
of stent dislodgement and hemorrhage or late
because of stenosis and occlusion.
Percutaneous nonvascular procedures such as
kidney and liver biopsies may cause vascular
injuries. Active hemorrhage may be detected dur-
ing real-time examination as a jet from the biopsy
tract to the organ capsule. Pseudoaneurysms and
AVFs (Figure 12), more common complications,
may be detected in up to 10% to 15% of trans-
plant kidney biopsies, and large AVFs may cause
renal dysfunction.
11
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Gaitini et al
Figure 6. Images from a 67-year-old man with limb swelling
after aortobifemoral and left femoropopliteal bypass graft
surgery. Deep vein thrombosis was not seen on compression
sonography. A surgical site pseudoaneurysm in the left groin
was shown on CDDS (A) and DSA (B). A, Color Doppler sonog-
raphy shows the pseudoaneurysm; surgical clips are shown pos-
teriorly. A yin-yang pattern in the pseudoaneurysm cavity is
shown. B, On DSA, both the pseudoaneurysm and an AVF are
shown, with early venous filling. Because the clinical suspicion
was deep venous thrombosis, pulsed Doppler imaging was not
performed in the accompanying artery, thus missing the AVF.
A
B
Figure 5. Image from a 78-year-old man with a large pulsatile
inguinal mass after diagnostic coronary arteriography. Gray scale
sonography shows a large pseudoaneurysm with hematocrit lay-
ering. The central echogenic line (arrows) is due to inflow of
blood from the artery into the pseudoaneurysm through its neck.
Trauma-Related Vascular Injuries
Vascular injuries following blunt or penetrating
trauma are illustrated according to different body
levels accessible to CDDS: the neck, extremities,
and abdomen. Penetrating neck trauma leads to
vascular injuries in 25% of casualties. Carotid
artery injuries constitute 80% of penetrating
trauma incidents, whereas vertebral artery
injuries are more common in blunt trauma.
12,13
Thrombosis is the most common injury. Other
injuries include mild intimal irregularities, inti-
mal flaps, pseudoaneurysms, and AVFs (Figure
13).
1416
Although CDDS was sensitive in evalua-
tion of stable patients with neck zone II penetrat-
ing injuries (Figure 14)
17,18
and accurately
showed arterial injuries in 86% of examina-
tions,
16
CTA with multiplanar reformation is the
first-line examination.
19
Magnetic resonance
angiography in the acute setting is restricted
because of limited availability and lack of com-
patibility with life support devices.
20,21
In limb
artery injuries, CDDS is less sensitive than arteri-
ography for detection of small intimal defects or
small-vessel occlusions but is successful in
detecting more substantial lesions such as pseu-
doaneurysms, AVFs, and major vessel occlusions
(Figure 15), with reported specificity of 99%, sen-
sitivity of 50%, and accuracy of 96% compared
with arteriography.
3,22,23
Blunt or penetrating
abdominal trauma may result in visceral pseu-
doaneurysms and AVFs, which are increasingly
detected because of the widespread use of diag-
nostic computed tomography for blunt trauma
(Figures 16 and 17).
24,25
In conclusion, CDDS is considered the imaging
technique of choice for most vascular injuries.
Computed tomographic angiography, MRA and
DSA are reserved for selected cases or directed
therapy.
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Sonographic Evaluation of Vascular Injuries
Figure 7. Sonographically guided thrombin injection for treat-
ment of an anastomotic pseudoaneurysm. A, Power Doppler
sonography shows the needle tip in the lumen (arrow) and par-
tial thrombosis during thrombin injection. B, A completely
thrombosed pseudoaneurysm is shown. Flow is shown in the
femoral artery. Low-resistance flow is due to the presence of an
AVF, as shown on DSA. Thrombin allowed rapid and successful
therapy without complications despite the short and wide neck
and without femoral artery circulation impairment.
A
B
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Gaitini et al
Figure 8. Images from a 37-year-old woman with a sudden
appearance of an inguinal mass after weight lifting. An inguinal
hernia containing a large varicose vein was diagnosed by CDDS.
Surgery confirmed the findings. A, On color Doppler sonogra-
phy, a lesion with weak internal echoes is shown lateral to the
femoral vessels. B, Bidirectional color Doppler flow is shown
within the lesion, mimicking a pseudoaneurysm. C, On pulsed
Doppler sonography, performed with the patient erect, flow
with the venous pattern is shown inside the cavity.
A B
C
Figure 9. Images from a 78-year-old man with a partially
occluding thrombus after an angioplasty attempt. A, Gray scale
sonography shows a hypoechoic thrombus on the anterior wall
with substantial lumen stenosis (arrows). B, Color Doppler
sonography shows a mosaic pattern due to a very high velocity
in the narrowed residual lumen.
A B
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Sonographic Evaluation of Vascular Injuries
Figure 10. Images from a 76-year-old man with severe
atherosclerotic disease who had focal dissection in the femoral
artery after guide wire insertion. A, Longitudinal color Doppler
sonography shows a filiform canal parallel to the main lumen of
the artery with a mosaic flow pattern (arrow). B, Transverse color
Doppler imaging shows the dissecting lumen (arrow).
A
B
Figure 11. Images from a 34-year-old woman with arm
swelling after receiving a peripherally inserted central catheter. A
thrombotic basilic vein and tributaries were found. A, On a
transverse scan, the vein is noncompressible (right, without
compression; left, with compression). B, On gray scale imaging,
the catheter is clearly visible in the thrombotic lumen.
Thrombotic tributaries of the main vein are also shown.
A
B
Figure 12. Arteriovenous fistulas in 2 patients after biopsy of kid-
ney transplants. A, Color and spectral Doppler sonography shows
turbulent high-velocity flow at the fistula in the renal parenchyma
(first patient). B, Color and Doppler sonography shows an arteri-
ovenous fistula at the renal hilum (second patient).
A B
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Gaitini et al
A
B
C
E
D
Figure 13. Images from a 23-year-old woman with an AVF and
a pseudoaneurysm of the vertebral artery after a knife stab to the
neck. A, Color Doppler sonography shows high-velocity turbu-
lent flow in the fistula (arrow). B, The turbulent flow is shown on
a spectral display. C, Bidirectional color flow in the lumen of
the pseudoaneurysm is shown (arrow). D, Digital subtraction
angiography shows the pseudoaneurysm and the fistula with
early venous filling. E, Both the fistula and the pseudoaneurysm
were closed by endovascular treatment with coils.
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Sonographic Evaluation of Vascular Injuries
Figure 14. Anatomic division of the neck for classifying pene-
trating injuries. Zone I is from the sternal notch to the cricoid car-
tilage; Zone II, from the cricoid cartilage to the mandibular
angle; and Zone III, from the mandibular angle to the skull base.
Reproduced with permission from Radiographics.
18
Figure 15. Images from a 14-year-old boy with multiple calf frac-
tures and a large pulsating hematoma. A posterior tibial artery
pseudoaneurysm was found. A, Power Doppler sonography
shows the pseudoaneurysm (calipers on neck) surrounded by a
large hematoma. B, Digital subtraction angiography shows the
pseudoaneurysm and the displaced arteries by the large soft tis-
sue hematoma. C, Digital subtraction angiography shows pos-
tendovascular treatment with coils. Retrograde arterial filling is
shown (arrows).
B C
A
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Figure 16. Images from a 4-year-old child with a liver pseudoaneurysm after blunt trauma from a motor vehicle collision. A, Gray
scale sonography shows several liver lacerations (arrows). B, Yin-yang flow is shown in the pseudoaneurysm at segment 8. A second
pseudoaneurysm was seen in segment 1 (not shown). C, Computed tomographic angiography with coronal reformation shows the
pseudoaneurysms (arrows). D, Follow-up CDDS shows complete thrombosis of both pseudoaneurysms at 6 weeks. The thrombotic
pseudoaneurysm in segment 8 is shown.
A B
C D
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