Efficacy of PVCA classification in guiding management strategies for cervical vascular trauma.

PURPOSE: To evaluate the clinical efficacy of the PVCA (The degree of cervical vascular injury is defined mainly based on 4 dimensions: Penetration site, injured Vessel, Clinical manifestations, and Associated injuries.) classification in guiding management of cervical vascular trauma.

METHODS: The PVCA classification system was further developed based on various clinical classifications of carotid artery trauma, incorporating prior clinical experience in managing massive cervical hemorrhage. We retrospectively analyzed 43 patients with cervical vascular trauma treated at 4 tertiary centers between January 2022 and December 2024. Patients with confirmed cervical vascular trauma were included, while patients with incomplete clinical data, loss to follow-up, or concurrent life-threatening injuries that precluded definitive vascular management were excluded. PVCA classification was applied to guide management. Outcomes, including choice of surgical approach, hemostasis success, vascular repair integrity, neurological recovery, and complications, were assessed. Descriptive statistics were used to summarize baseline characteristics and outcome measures. Continuous variables were presented as mean ± standard deviation, and categorical variables as frequencies and percentages. Group comparisons were performed using the χ2 test or Fisher's exact test, based on expected frequencies.

RESULTS: A total of 43 patients (mean age (42.58 ± 10.77) years; 62.8% male) were classified by PVCA (P1: 14.0%, P2: 69.8%, P3: 16.3%; V1: 62.8%, V2: 23.3%, V3: 7.0%, V4: 7.0%; C0: 20.9%, C1: 69.8%, C2: 9.3%; A0: 95.3%, A1: 4.7%). All patients underwent successful intervention (open surgery: 53.5%, endovascular: 32.6%, hybrid: 14.0%), with 100% hemostasis and improved cerebral perfusion. PVCA dimensions demonstrated differential guiding value for surgical approach. Penetration site (P) was the strongest determinant (p < 0.001): 76.7% of P2 patients received open surgery, while 66.7% of P1 and 85.7% of P3 underwent endovascular repair, with hybrid procedures reserved for cases complicated by hematoma or retained foreign bodies. Injured vessel type (V) also significantly influenced strategy (p = 0.026): all V3 lesions were managed by open ligation, and 66.7% of V4 injuries required hybrid surgery. Clinical manifestations (C) and associated injuries (A) had no independent effect on surgical choice (p = 0.390 and p = 0.386). Perioperative complications occurred in 4 patients: 3 cranial nerve injuries (all in the P2 zone, 10.0% vs. 0% in other zones; p = 0.046) and 1 hyperperfusion syndrome. Nerve injuries were confined to the P2 subtype, with a significantly higher rate in A1 patients (100.0%, 2/2) than in A0 patients (2.4%, 1/41) (p = 0.048). Hyperperfusion syndrome occurred exclusively in the C2 subtype (25.0%, 1/4 vs. 0/39 in C0/C1). Overall complication rates were significantly elevated in A1 (100.0%) and C2 (25.0%) subtypes (p = 0.048 and p = 0.042, respectively). At a mean follow-up of (15.53 ± 3.90) months, asymptomatic >50% in-stent restenosis was detected in 2 patients (4.7%); no other stent or vessel complications were observed.

CONCLUSION: The PVCA classification system effectively guides surgical decision-making in cervical vascular trauma, with penetration site (P) as the strongest determinant of surgical approach and injured vessel type (V) further refining strategy. By also identifying high-risk subtypes for complications-P2 for cranial nerve injury, and A1/C2 for overall adverse events-the system enables tailored intervention and targeted complication prevention, ultimately optimizing individualized management and improving clinical outcomes.