DOI:10.2214/AJR.05.1647
AJR 2007; 189:W309-W311
© American Roentgen Ray Society
Spontaneous Thrombosis of Pseudoaneurysm of the Breast Related to Core Biopsy
Mona El Khoury1,
Benoit Mesurolle,
Ellen Kao,
Amol Mujoomdar and
Francine Tremblay2
1 Department of Radiology, McGill University Health Center, Montreal General
Hospital, 1650 Cedar Ave., Montreal, QC, Canada H3G 1A4.
2 Department of Surgery, McGill University Health Center, Montreal General
Hospital, Montreal, QC, Canada.
Received September 15, 2005;
accepted after revision December 7, 2005.
WEB This is a Web exclusive article.
Address correspondence to B. Mesurolle
(bmesurolle{at}yahoo.fr).
Keywords: biopsy • breast • Doppler sonography • sonography
Introduction
Core needle biopsy is being used increasingly for the diagnosis of
breast masses. It is considered an alternative to surgical biopsy, and the
rate of complications is relatively low. The most frequently encountered
complication is hematoma [1].
Iatrogenic pseudoaneurysm is a rare complication. We report a case of
pseudoaneurysm occurring after 14-gauge core needle biopsy. Spontaneous
thrombosis of the pseudoaneurysm occurred over a period of 3 weeks after the
biopsy.
Case Report
A 50-year-old woman with no relevant medical history underwent screening
mammography that revealed an asymmetric area of increased density at the
1-o'clock position in the left breast. Further evaluation with sonography
showed a corresponding focal ill-defined area of posterior attenuation
(Fig. 1A). This lesion was
classified as BI-RADS category 4 (suspicious, necessitating a histologic
diagnosis). Core biopsy with a 14-gauge needle was performed under sonographic
guidance.
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Fig. 1A —50-year-old woman with pseudoaneurysm after core biopsy with
14-gauge needle. Transverse sonogram obtained during 14-gauge core needle
biopsy shows ill-defined area of posterior attenuation in 1-o'clock position
in left breast.
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Slight bleeding was noticed during the procedure but resolved with focal
manual compression. Histologic analysis of the sampled core showed benign
breast tissue with prominent stromal fibrosis. This discordance between the
sonographic and pathologic findings prompted a recommendation for a second
biopsy. Three weeks after the first biopsy, the patient presented with
extensive bruising, tenderness, and a palpable throbbing mass in the biopsy
area. Sonography revealed a 2-cm well-defined hypoechoic mass with an anechoic
pulsating center. Color Doppler analysis showed swirling blood flow in the
center of the mass connected through a small track to an adjacent artery,
findings suggestive of pseudoaneurysmal flow (Figs.
1B and
1C). In view of these findings,
surgical excision of the indeterminate original lesion with concomitant
surgical repair of the iatrogenic pseudoaneurysm was recommended, but the
patient refused surgery. Three weeks later, follow-up sonography showed
complete thrombosis of the pseudoaneurysm
(Fig. 1D). Core biopsy with a
14-gauge needle was again performed with care taken to avoid the thrombosed
pseudoaneurysm and all the adjacent vessels. Five samples were obtained, and
the histologic diagnosis was fibrosis with no evidence of malignancy.
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Fig. 1B —50-year-old woman with pseudoaneurysm after core biopsy with
14-gauge needle. Transverse color Doppler sonogram 3 weeks after initial core
biopsy shows 2-cm well-defined hypoechoic mass and swirling, or yin-yang
(red, blue), flow typical of pseudoaneurysm.
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Fig. 1D —50-year-old woman with pseudoaneurysm after core biopsy with
14-gauge needle. Transverse color Doppler sonogram 6 weeks after initial core
biopsy shows complete thrombosis of pseudoaneurysm.
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Discussion
Pseudoaneurysm, also called false aneurysm or pulsatile hematoma, is most
often secondary to a traumatic injury and is a well-known complication of
vascular catheterization and percutaneous core needle biopsy of solid organs.
It is most frequent in elderly patients, persons with known atherosclerosis,
and patients undergoing coagulation therapy
[1]. Pseudoaneurysm results
from transmural disruption of an arterial wall, subsequent direct leakage of
blood, and formation of a hematoma that remains in communication with the
arterial lumen. Unlike true aneurysm, pseudoaneurysm lacks the three layers
(intima, media, and adventitia) of the vessel wall and is contained by
perivascular tissue [1].
Clotting occurs at the periphery of the hematoma, which appears hyperechoic at
sonographic examination while the center remains anechoic. During the high
intraarterial pressure of systole, blood flow is antegrade toward the
pseudoaneurysm; during diastole, the flow direction is retrograde. This
phenomenon causes a swirling, or yin-yang, flow pattern on color Doppler
images and a to-and-fro waveform on spectral Doppler sonography. These
findings lead to the diagnosis of pseudoaneurysm
[1,
2].
Pseudoaneurysm of the breast is uncommon. In a review of the literature,
Dixon and Enion [1] found eight
cases. We found one additional case
[3]. Six pseudoaneurysms
occurred after percutaneous core needle biopsy, two occurred after remote
surgery, and two were spontaneous, diagnosed in association with hypertension
and coagulation therapy for arterial disease, respectively
[4,
5].
During interventional procedures, color flow evaluation is used to map the
vessels in the vicinity of the lesion before biopsy to trace a safe path for
the needle to avoid the vessels and iatrogenic complications, including
hematoma and pseudoaneurysm [6,
7]. As with hematoma formation,
one can assume that the larger the needle, the higher is the risk of
pseudoaneurysm formation [7],
especially because most of the reported pseudoaneurysms of the breast were
encountered with a 14-gauge cutting needle
[1]. However, pseudoaneurysms
also have occurred with 18-gauge core needle biopsy
[6] and even with 20-gauge
fine-needle aspiration biopsy
[2]. These findings highlight
the importance of careful mapping of vessels before intervention.
Management options for pseudoaneurysm include surgical repair,
sonographically guided compression therapy, percutaneous thrombin or alcohol
injection, and coil embolization
[1,
2]. Although compression has
been the therapy of choice and the first line of management of
post-catheterization pseudoaneurysm, this treatment is time-consuming,
painful, and often unsuccessful
[2]. With respect to the
breast, compression failed in all of the cases reported. Alternatives include
surgical repair and percutaneous treatment with injection of microcoil,
thrombin, or alcohol [1,
3,
6].
The natural history of pseudoaneurysm is not known. However, a number of
pseudoaneurysms, such as those affecting the femoral
[8] and superior thyroid
arteries [2], undergo
spontaneous thrombosis. Spontaneous thrombosis is related to pseudoaneurysm
size, the length of the neck of the pseudoaneurysm, and the anticoagulation
status of the patient [8]. To
our knowledge, ours is the first report of pseudoaneurysm thrombosis in the
breast.
With the increased use of percutaneous diagnostic interventions in the
evaluation of breast disease, pseudoaneurysms are likely to occur more
frequently. No standard management protocol is known for this rare
complication. Although percutaneous radiologic treatments have been more
successful than sonographically guided compression therapy and should replace
invasive surgical repair, simple monitoring of the pseudoaneurysm may be an
alternative that offers a chance for spontaneous occlusion, as in our
patient.
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Introduction
Case Report
