The feasibility of ultrasound-guided vacuum-assisted evacuation of large breast hematomas

Complications following therapeutic, reconstructive, or aesthetic breast surgeries as well as percutaneous procedures, both biopsies and excisions, are important considerations for women undergoing or pursuing these options. In general, the most common local complications following routine breast interventions are inherent to the surgery itself e.g. infection, pain, hematoma, delayed healing, and abnormal scarring. Risk factors for complications include smoking, obesity, larger breasts, anticoagulant treatments, and older age.1

Early clinically significant postoperative hematomas typically develop within the first 12 to 48 hours after surgery.2 Immediate reoperation is usually indicated in expanding hematomas, hemodynamic instability, and jeopardized flap viability.3 Less commonly, a hematoma appears days or weeks after surgery and may be associated with minor injury or trauma to the breast, with the majority identified within the first 14 days. Late hematomas can also occur and are thought to be related to direct trauma, clotting disorders, overactivity, and use of intraoperative corticosteroids.4, 5 Postprocedural hematomas are not uncommon, yet most of them are small and resolve spontaneously. Large, clinically more significant hematomas in the late postoperative period are infrequent. Symptomatic, painful, or infected hematomas are treated surgically since hematomas with dense contents or clots do not drain with needle aspirations or drains are blocked immediately.6

If a clinically significant hematoma does occur, an evacuation is advised. Expectant management is not favoured due to the lengthy nature of spontaneous liquefaction and discomfort that patients report, which eventually leads to fibrosis and distortion of breast tissue.7 Surgical management is aimed at the rapid decompression of the closed wound space through exploration, drainage and establishing haemostasis. After evacuation the wound is thoroughly irrigated and closed in order to preserve the cosmetic aspect of the breast.8 Percutaneous drainage of the hematoma during the first 24 hours of hematoma formation might be challenging, on the assumptions that an organized clot would have already been formed. Partial liquefaction occurs 6 to 7 days after the formation of the hematoma, which is considered as the best interval for percutaneous evacuation.9

Breast imaging-guided interventions are widely used in daily practice e.g. core biopsy and vacuum assisted breast biopsy and excision (VABB and VABE) to diagnose different types of imaging findings and remove benign or risk lesions. The larger the needle used for biopsy and the number of cores obtained, the more likely complications will appear.10 Significant vascular damage is more probable in VABB or VABE procedures.11 Recently it was reported that VABB can be used as a treatment modality for clinically significant hematoma in patients with small hematomas less than 4cm in size.6 The effectiveness of vacuum-assisted evacuation of large breast hematomas has not been previously reported.

In this study we aimed to investigate ultrasound-guided vacuum-assisted evacuation (VAE) of breast hematoma as a safe, viable, time and resource-sparing treatment modality for larger (> 5 cm) breast hematomas irrespective of aetiology. This technique could decrease the rate of multiple operations and eliminate added morbidity of surgery and anaesthesia while yielding satisfactory therapeutic results.

During the recruitment period, a total of 1208 breast operations and 358 VABB or lesion excision procedures were performed. We detected a total of 44 clinically large hematomas as complications. Of the 1208 operative patients, 33 had early postoperative bleeding and had to undergo surgical evacuation while 8 patients suffered from delayed hematoma formation. Therefore, the reoperation rate for early postoperative bleeding was 2.7% (33/1208) and the rate of late hematomas treated with VBE was 0.7% (8/1208). On the other hand, of the 358 patients that have undergone VABB and excision procedures, 3 patients were later diagnosed to have clinically relevant hematomas with an incidence rate of 0.84% (3/358).

Altogether 11 consecutive patients who have been diagnosed with breast hematoma and treated with the VAE system were included in the analysis. Patients had a mean age of 59 years (range 38-85) and their characteristics are presented in Table 1.

Of the 11 participants, 3 patients had hematomas as complications after percutaneous interventional procedures and 8 patients after surgeries, of which 5 were reduction mammoplasties. The mean number of days between the initial intervention and VAE of hematoma of 10 patients was 30 days with an outlier of 597 days due to an idiopathic late developing complicated hematoma in a mastectomy site after radiotherapy. One of these patients had a slowly progressive hematoma after VABB and refused surgical evacuation. Regarding symptoms prior to evacuation, all patients reported pain, 45.5% prolonged healing (n = 5), 45.5% mass effect (n = 5), 18.2% infection (n = 2).

Of the ultrasound imaging of the hematomas taken prior to VAE of hematoma, 7/11 were hypoechoic, 1/11 was hyperechoic and 3/11 had mixed echogenicity. All hematomas underwent unsuccessful aspiration trials with fine needles (G18–23). The mean duration of the VAE procedure was 40.5 min (range 19–62). One patient was taking aspirin alone, one aspirin and hydrocortisone, one patient was taking Warfarin, one patient taking Dabigatran and one patient taking Apixaban.

One patient had a massive two-sided communicating 20 x 5 and 12 x 4 cm hematoma, therefore in this analysis, we included only the largest portion. The mean maximum diameter of the evacuated hematomas was 7.9 cm and an average surface area of 32.4cm2. The gauge of the VAE probes was a choice between 7G or 10G. Most of the procedures were performed using 7G-sized needles (n = 8) owing to the larger size of the treated hematomas. Four patients underwent ultrasound-guided aspiration of the hematoma cavity due to post-evacuation seroma formation 1–7 days after VAE procedure. No complications were reported post-evacuation or aspiration procedures.

The parameters before as well as after VAE of hematoma are depicted in Table 2. All patients underwent regular follow-up after evacuation. Upon follow-up, all cases were deemed successfully treated with no major hematoma residue or seroma formation.

One of the most common complications in breast interventions is hematoma formation, which remains grossly underrated and disregarded in the literature, especially when its frequency is taken into consideration. Breast hematomas can range from small mammographically-detected hematomas to large clinically significant hematomas that can cause severe discomfort to patients. Our results suggest that Vacuum-assisted evacuation of hematoma is a time-sparing, cost-effective and successful method of evacuation for small as well as large breast hematomas regardless of aetiology.

Our patient population was comprised of both post-biopsy and post-surgical patients, thus expanding the aetiological factors to not only include biopsy-induced hematomas. In our study we included all consecutive patients treated in our institution presenting with hematomas of different sizes. This goes to prove that VAE can be implemented in clinically large significant hematomas. It is stipulated that percutaneous drainage of acute hematomas should be attempted between days 7–14 after formation of hematoma, in order to allow time for hematoma liquefaction. Moreover, delayed hematomas, i.e. hematomas developing 6 months or more post-intervention, are always evacuated surgically.7 In our study the wait time was variable, in that the procedure timing was not set on a set-point schedule, rather on different time-intervals regarding date of hematoma formation. Furthermore, one large delayed hematoma was evacuated successfully after 597 days (1.64 years), proving that even delayed hematomas can be successfully treated with VAE of hematoma irrespective of duration.

While the true incidence of large clinically significant hematomas remains unknown, findings from this study show that it is relatively uncommon. The treatment of breast hematomas in the literature is suggested as either surgical or expectant. Both treatment modalities impose certain risks and added morbidity for the patient. Patients face problems such as added costs, the ordeal of going through surgery or stress due to the aesthetic and psychological impact of the procedure. Moreover, expectant therapies may pose future diagnostic difficulties.9

Figure 2

A recent report evaluated the efficacy of the VABB system in evacuating symptomatic hematomas after VABB excision of benign breast lesions in 8 patients. Evacuation was successful in all the cases and no technique-related complications were observed.6 However, the inclusion criteria were restricted to hematomas observed post-VABB or VABE and not post-surgical complications, which limits the patient population on which this technique can be used. Moreover, 75% (6/8) of hematomas were smaller than 4 cm with a largest maximum diameter of 5.6 cm. This means that most clinically significant breast hematomas that are difficult to handle conservatively were excluded. The study failed to address whether this technique could be attempted on larger and more difficult to evacuate hematomas, which would otherwise need to be evacuated surgically.

Vacuum-assisted biopsies are also currently implemented as a treatment modality for small palpable or non-palpable benign or risk lesions, by assuring rapid and complete excision of these lesions to be better histopathologically evaluated and therefore obviating the need for therapeutic surgery or continuous follow-up.12 Minimally invasive management of many B3 lesions with VABE continues to be a suitable alternative to first-line surgical excision in most cases.13 In this study, we wanted to study the efficacy of automatic VABE system in removing symptomatic clinically significant hematomas. Not only are VABE systems faster with less implications on patients, but the endogenous vacuum capability, the large bore size as well as the slicing mechanism of the probe could be used to evacuate organized hematomas, which otherwise would be difficult to aspirate percutaneously and would need surgical drainage and evacuation.

Evacuations were performed immediately upon request and without prior scheduling as our patients presented with acute symptoms and the procedure offered immediate relief. Furthermore, most of these patients were discharged immediately after the procedure. No change in anticoagulant medications were required as the procedures were quite straightforward without any excision of fibroglandular breast tissues. The tip of the blade is very sharp and penetrates even denser tissues easily, hence special care should be applied in handling the needle inside the hematoma cavity in order not to induce any damage to the cavity walls. Due to the large size of the needles, we regularly chose the shortest insertion pathway and used a combination of local anaesthetic with adrenaline to reduce any possible bleeding consequences.

The obvious limitations of the study are the small number of patients and the retrospective nature. This study needs to be validated on a larger scale to include more patients with a more controlled inclusion and outcome criteria. Furthermore, the volume of the evacuated part of the hematoma was not measured during the procedure due to the continuous saline flush used in our practice and could not be retrospectively accurately verified.

To conclude, this study shows that VAE procedure is a successful, time-conserving, easily implemented interventional treatment modality for both small and large breast hematomas that would decrease the morbidity, costs and inconvenience of repeated surgery.