Reading the signs in penetrating cervical vascular injuries: Analysis of hard/soft signs and initial management from a nationwide vascular trauma database.

作者信息

Marrotte Alexander, Calvo Richard Y, Badiee Jayraan, Rooney Alexandra S, Krzyzaniak Andrea, Sise Michael, Bansal Vishal, DuBose Joseph, Martin Matthew J

机构信息

From the Trauma Service, Department of Surgery (A.M., R.Y.C., J.B., A.S.R., A.K., M.S., V.B.), Scripps Mercy Hospital, San Diego, California; Department of Surgery and Perioperative Care (J.D.), University of Texas-Austin, Dell Medical School, Austin, Texas; and Division of Trauma and Acute Care Surgery, Department of Surgery (M.J.M.), Los Angeles County + USC Medical Center, Los Angeles, California.

出版信息

J Trauma Acute Care Surg. 2022 Nov 1;93(5):632-638. doi: 10.1097/TA.0000000000003678. Epub 2022 May 12.

BACKGROUND

Algorithms for management of penetrating cervical vascular injuries (PCVIs) commonly call for immediate surgery with "hard signs" and imaging before intervention with "soft signs." We sought to analyze the association between initial examination and subsequent evaluation and management approaches.

METHODS

Analysis of PCVIs from the American Association for the Surgery of Trauma Prospective Observational Vascular Injury Treatment vascular injury registry from 25 US trauma centers was performed. Patients were categorized by initial examination findings of hard signs or soft signs, and subsequent imaging and surgical exploration/repair rates were compared.

RESULTS

Of 232 PCVI patients, 110 (47%) had hard signs (hemorrhage, expanding hematoma, or ischemia) and 122 (53%) had soft signs. With hard signs, 61 (56%) had immediate operative exploration and 44% underwent computed tomography (CT) imaging. After CT, 20 (18%) required open surgical repair, and 7% had endovascular intervention. Of note, 21 (19%) required no operative intervention. A total of 122 patients (53%) had soft signs on initial examination; 37 (30%) had immediate surgery, and 85 (70%) underwent CT imaging. After CT, 9% had endovascular repair, 7% had open surgery, and 65 (53%) were observed. No difference in mortality was observed for hard signs patients undergoing operative management versus observation alone (23% vs. 17%, p = 0.6). Those with hemorrhage as the primary hard signs most often required surgery (76%), but no interventions were required in 19% of hemorrhage, 20% of ischemia, and 24% of expanding hematoma.

CONCLUSION

Although hard signs in PCVIs are associated with the need for operative intervention, initial CT imaging can facilitate endovascular options or nonoperative management in a significant subgroup. Hard signs should not be considered an absolute indication for immediate surgical exploration.

LEVEL OF EVIDENCE

Prognostic/Epidemiological; Level IV.