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Case Report |
1 Department of Radiology, Breast Imaging and Intervention Section, MetroHealth
Medical Center, 2500 MetroHealth Dr., Cleveland, OH 44109-1998.
2 Department of Radiology, Uniformed Services University of the Health Sciences,
4310 Jones Bridge Rd., Bethesda, MD 20814.
Received January 10, 2002;
accepted after revision March 22, 2002.
The opinions and assertions contained herein are the private views of the
authors and are not to be construed as official or reflecting the views of the
Uniformed Services University of the Health Sciences or the Department of
Defense.
Introduction
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Evaluation with color Doppler imaging, performed 17 days before biopsy, showed no obvious flow in the mass.
The lesion, a hypoechoic solid mass, measured approximately 5 x 6 x 3 mm and was located in the left breast at the 10:30-o'clock position 6 cm from the nipple. Local anesthesic of the skin and parenchyma about the lesion was achieved with 1% lidocaine without epinephrine. An 18-gauge cutting needle with a "throw" of 22 mm (Magnum; Bard, Covington, GA) was chosen for the biopsy.
Our usual approach is to take several cores and to vary the location of tissue acquisition to ensure adequate sampling. However, after a single pass through the center of the target (Figs. 1A and 1B), immediate swelling of the breast over the lesion site and mild to moderate nonpulsatile bleeding from the needle tract were noted. Pressure was applied for approximately 1 min until bleeding from the tract ceased. Further sampling was deferred because rescanning revealed a 1-cm pseudoaneurysm just distal to the lesion, along the path the needle had traversed (Fig. 1C).
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The patient was informed of the occurrence and nature of the complication, and sonographically guided compression therapy was performed. Partial thrombosis was achieved after 10 min of compression (Fig. 1D). A subsequent 15-min attempt did not show any significant change, so compression was applied for an additional 15 min. After this effort, no flow was detected and a fluid—debris (hematocrit) level was noted. However, after a short period of observation, reestablishment of flow in the pseudoaneurysm occurred.
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Further compression attempts were abandoned, and thrombin therapy was pursued. An initial attempt to inject the thrombin through a 25-gauge needle was unsuccessful. Thrombin had been advanced into the needle, and it is likely that thrombus formation occurred in the tip of the needle as it was advanced through the tissues. On withdrawal of the needle, blood exiting the pseudoaneurysm at the site of the 25-gauge-needle tract was noted.
Thrombin was injected through a 20-gauge needle without difficulty. Initially, 1 mL (1000 U) was placed into the center of the cavity with some immediate thrombus formation (Fig. 1E). After a short wait, flow could still be seen. Complete coagulation occurred after a repeated 1 mL of thrombin was injected.
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Rescanning at 4 hr after thrombin injection confirmed no flow, and the patient was sent home. Because flow in pseudoaneurysms can wax and wane [5], we studied the patient with color Doppler imaging at 24 hr and 5 days after the procedure (Fig. 1F). Again, absence of flow was confirmed.
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In our patient, preprocedure color-flow evaluation had focused on the mass itself, and no attention had been directed to the environment of the lesion. At the time of a sonographically guided biopsy, we usually study the anticipated needle path with color-flow imaging to identify vessels to be avoided [6]. Inexplicably, we failed to do so in this case. We believe that use of color-flow imaging to study the needle path—both the portion from the skin surface to the lesion as well as the path of the throw beyond the lesion—would have alerted us to the presence of the vessel and would have prompted a modification of the needle path to allow the vessel to be avoided.
As a result of this experience, we have modified our approach to core biopsy to include a procedural checklist, like the pilot's list before takeoff and landing, to ensure that critical steps in the process, from informed consent to home-going instructions, are not omitted. Additionally, in patients who do not have a contraindication, we have begun to use 1% lidocaine with epinephrine (1:100,000) for the skin and subcutaneous tissues to provide a "cone" of anesthesia, done with a "fanning" technique that extends from the skin entry point to beyond the lesion. Injection is made with a 25-gauge, 2-inch-long (5.08-cm) Monoject hypodermic needle (Sherwood Medical, St. Louis, MO). The needle is kept in motion during the injection to avoid inadvertent intravascular injection. When we have scanned the anticipated needle path with color-flow Doppler imaging before and then after the use of the lidocaine with epinephrine, we have noted that the area becomes hypovascularized. We believe that the constriction of the vessels in response to the presence of epinephrine makes them more difficult to inadvertently hit and diminishes blood-flow volume, allowing easier control of potential bleeding.
Topical bovine thrombin injection of an iatrogenic femoral artery pseudoaneurysm under sonographic guidance has been shown to be an effective treatment [7]. However this is an "off-label" use of thrombin, which is specifically Food and Drug Administration—approved for topical use only. Food and Drug Administration investigators have reported that several deaths and at least one severe injury have resulted when thrombin has been injected intravascularly directly into the spleen or placed into the nasogastric tube of a patient with gastric bleeding [8]. Injection of thrombin into a pseudoaneurysm appears to be well tolerated probably because the pseudoaneurysm is largely isolated from the systemic circulation. Nevertheless, one case of downstream arterial thrombus with temporary clinical symptoms has occurred [7].
Given the small size of the arteries in the breast, we believe it is theoretically possible to cause occlusion of the small feeding artery when ablating a pseudoaneurysm with thrombin. In our patient, however, the amount of thrombin injected likely overdistended the pseudoaneurysm, but the vessel that gave rise to it could be clearly seen to be patent on follow-up. If this potential complication occurs, it is not likely to be clinically symptomatic because surgeons routinely clamp or cauterize small arteries in the breast. Nevertheless, the region of the tract should be avoided, and thrombin should be injected slowly into the portion of the pseudoaneurysm containing flow away from the artery.
The product literature from the manufacturer also cites the potential for antibody formation to bovine thrombin and factor V, which may cross-react with human factor V, the likelihood of which is thought to increase with repeated clinical use of bovine thrombin.
Although the true incidence of breast pseudoaneurysm is unknown, in this case as well as the ones reported by Chorny et al. [2] and Beres et al. [3], pseudoaneurysm formation was accompanied by an immediate hematoma and excessive bleeding from the tract. Hence, a high index of suspicion for pseudoaneurysm formation and scanning of the area with color Doppler imaging should occur if similar symptoms are encountered.
Our experience shows that a clinically apparent pseudoaneurysm can occur with cutting needles that are smaller than the 14-gauge devices commonly used. Given that 11- and 8-gauge Mammotome devices (Ethicon Endo-Surgery, Cincinnati, OH) are now available for clinical use, we believe that this complication may be encountered more frequently in the future and that this off-label use of thrombin can provide a quick and effective therapy for a breast pseudoaneurysm. Off-label use of thrombin should be considered if an attempt at compression therapy is unsuccessful.
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