Transcutaneous Management of Bleeding after Solid Organ Biopsy
proper procedure planning, familiarity with potential complications, and appropriate interventional and clinical management are necessities.
Percutaneous biopsy in high-risk patients is made safer and easier by employing a co-axial system.10
This enables acquisition of multiple
biopsies using a single puncture site as well as percutaneous deployment of embolization devices and blood products accurately along the tract (see Figure 2). Obtaining a diagnostic sample in peripherally located lesions, as well as those situated in technically challenging positions, is made easier.7
Fine-needle aspirations are easily obtainable through the same access site. In addition, use of a co-axial system minimizes the theoretical incidence of malignant tract seeding.2,7
Bleeding may be confined to an organ or space, making sonographic evaluation feasible. However, hemoperitoneum often remains less conspicuous and is more strongly associated with death, particularly in those with malignancy or liver cirrhosis.9
Therefore,
in some instances, dynamic CT may be effective in obtaining accurate diagnosis and localizing the site of active bleeding. With ultrasound guidance and realtime Doppler, the bleeding site could be re-accessed using a new needle or co-axial system. This technique may be used at a later time when active bleeding has been detected.
If a bleeding-related complication is identified before removal of the co-axial system, percutaneous deployment of embolic material may be performed directly into the co-axial tract. If the co-axial system has been discontinued, Doppler ultrasound can provide valuable realtime information to localize the site of active bleeding. With ultrasound guidance and realtime Doppler, the bleeding site could be re-accessed using a new needle or co-axial system. This technique could also be used at a later time when active bleeding has been detected.
The two most commonly used embolizing materials are Gelfoam® (Pfizer) and metallic coils. Gelfoam is a hemostatic compressed gelatin sponge derived from purified porcine skin gelatin. It is water-insoluble and porous, capable of absorbing up to 45 times its weight of whole blood, and is typically absorbed completely within four to six weeks.11
for quick and accurate deployment, makes percutaneous biopsy safer and easier in higher-risk patients, and is relatively inexpensive. It can be used for hypervascular or necrotic lesions and reduces the observation time required following outpatient biopsy to three hours. In addition, its use reduces complication rates, necessitating fewer subsequent transfusions and hospital admissions. The minimal risks involved with Gelfoam use include possible embolization into biliary or vascular systems and increased risk of infection in immunocompromised and/or transplant patients.1
In evaluating hematoma following percutaneous biopsy, it is important to bear in mind that approximately 89–96 % of instances of bleeding present within the first 24 hours and that close monitoring during this period is essential.10
Ultrasound-guided liver biopsy performed using 17-gauge co-axial needle and 18-gauge core biopsy needle. Gelfoam® was prophylactically inserted to prevent bleeding. Diagnosis: moderately differentiated adenocarcinoma.
Figure 4: Status Post-computed Tomography-guided Liver Biopsy with Fiducial Placement
Figure 3: 76-year-old Female with Newly Diagnosed Colon Cancer and Positron Emission Tomography Avid Liver Lesions
Gelfoam allows
Also,
deployment into active bleeding sites may be difficult. In these situations, the Gelfoam pledget may be advanced using sterile saline injection.
Metallic coils offer a viable alternative for the management of larger amounts of hemorrhage than is possible with Gelfoam. They are composed of a thrombogenic material, typically platinum or stainless steel. A pre-loaded coil system makes deployment quick and precise and enables the use of either ultrasound or dynamic CT guidance to monitor accurate deployment.
US RADIOLOGY
Follow-up imaging demonstrated active bleeding and coils were deployed locally to achieve hemostasis.
Obvious limitations include beam-hardening artifacts, which restrict follow-up radiographic evaluation of bleeding, and a potential risk of embolization into the biliary or vascular systems.6,12
The potential risk of remote embolization
is lower in cases of coil deployment compared with Gelfoam. Finally, the permanent nature of these devices within subcutaneous tissues serves as a potential nidus for future infection; therefore, if possible, they should be avoided in immunocompromised patients.
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