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.
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