Volume 25
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Number 6
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June
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2014
could easily form above the filter. Sizing of the type of precurved sheath to fit the IVC caliber might make it easier to form the curve; for example, a Flexor sheath (Cook, Inc) might be useful in different-caliber vessels. Potential complications from this nontraditional procedure include migration of the filter if it disengages from the snare at any time during the retrieval process, damage to the filter, and possible IVC injury if the legs are not entirely sheathed. The described technique might not work with filters that are made of stiffer material, such as the Celect filter (Cook, Inc). Whether this technique can be applied to filters with penetrating struts is unclear. Before deployment of a filter with intent to retrieve, a potential route for retrieval should be examined with ultrasound or other modalities so that the appropriate device could be placed. Devices designed for femoral retrieval include the OptEase filter (Cordis Corpora-
Blunt Breast Trauma Treated with Endovascular Embolization From: John Yoon, MD Christopher B. Ponce, BA Sohail Contractor, MD Department of Radiology (J.Y., S.C.) Rutgers Biomedical and Health Sciences University H108 150 Bergen Street University Hospital Newark, NJ 07101; and Rutgers New Jersey Medical School (C.B.P.) Newark, New Jersey
Editor: Institutional review board approval is not required at our center for case reports such as this. A 73-year-old female restrained (seat belt) driver was involved in a head-on motor vehicle collision with airbag deployment and presented with blunt trauma to the chest. On arrival to the emergency room, her pulse was 90 beats/min and blood pressure was 130/84 mm Hg. She had bruising at the lower right breast and chest area. The secondary trauma survey was unremarkable, and she had no other injuries. Chest radiograph demonstrated bilateral rib fractures without lung parenchymal or pleural abnormalities. Computed tomography (CT; Fig 1a) showed a large right breast hematoma with an area of contrast medium extravasation in the inferior lateral right breast and axillary soft tissues. During a 5-hour observation period, her blood pressure decreased to 118/80 mm Hg and pulse to 110 beats/min. Reductions in hemoglobin and hematocrit from 13.8 g/dL and 39.3% to 8.5 g/dL and 25.0%, respectively, indicated ongoing hemorrhage. There was no coagulopathy noted. None of the authors have identified a conflict of interest. http://dx.doi.org/10.1016/j.jvir.2014.02.003
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tion, Bridgewater, New Jersey) (3) and the Crux filter (Volcano Corporation, San Diego, California) (4).
REFERENCES 1. Funaki B, Zaleski GX, Leef JA, Lorenz JN, Van Ha T, Rosenblum JD. Radiologic placement of tunneled hemodialysis catheters in occluded neck, chest, or small thyrocervical collateral veins in central venous occlusion. Radiology 2001; 18:471–476. 2. Van Ha TG, Keblinskas D, Funaki B, Lorenz J. Removal of Günther Tulip vena cava filter through femoral vein approach. J Vasc Interv Radiol 2005; 16:391–394. 3. Rimon U, Bensaid P, Golan G, et al. Optease vena cava filter optimal indwelling time and retrievability. Cardiovasc Intervent Radiol 2011; 34: 532–535. 4. Smouse HB, Mendes R, Bosiers M, Van Ha TG. The RETRIEVE trial: safety and effectiveness of the retrievable Crux vena cava filter. J Vasc Interv Radiol 2013; 24:609–621.
Physical examination revealed a markedly swollen and tender right breast (Fig 1b). Selective right subclavian angiogram revealed hemorrhage arising from a branch of the lateral thoracic artery (Fig 2a). This branch vessel was selectively catheterized with a 3-F microcatheter (Progreat; Terumo, Somerset, New Jersey) and embolized by using flow-directed embolization with gelatin sponge slurry (Gelfoam; Pharmacia and Upjohn, Kalamazoo, Michigan) and a single 2-mm Nester microcoil (Cook, Bloomington, Indiana). No extravasation was seen on the subsequent angiogram (Fig 2b). She was sent to the surgical intensive care unit, where her vital signs improved (blood pressure, 136/84 mm Hg; pulse, 80 beats/min), and she required no further blood transfusions. Her hemoglobin levels remained stable after the procedure for 72 hours (range, 9.3–10.9 g/ dL). She was subsequently discharged home 5 days after her initial presentation with no further interventions or surgery being performed for the hematoma. Blunt trauma to the chest following motor vehicle accidents is commonly the result of a head-on collision at high speeds with airbag deployment. The “seat belt syndrome” is composed of injuries related to the use of three-point seatbelts (1), and includes soft-tissue and bony injuries to the chest and upper abdominal organs. Injury mechanism is related to the direct compression as well as shearing forces on the trunk. Seat belt injuries producing breast injuries are infrequently seen. In a retrospective study on female blunt breast trauma in a level I trauma center, Sanders et al (2) reported that only 108 of 5,305 women with blunt chest trauma (2%) presented with breast trauma. Of the women with blunt breast trauma, 94% of the cases were related to motor vehicle accidents. The majority of cases (n ¼ 101; 93.5%) required conservative nonoperative or noninterventional care. However, seven patients required treatment related to hemodynamic instability. Six patients were referred for angiography, of which four received embolization, and surgical ligation of the feeding vessel was performed in the seventh patient.
982
’
Letters to the Editor
Yoon et al
’
JVIR
Figure 1. (a) Contrast-enhanced CT of the patient’s thorax showing an extensive hematoma (arrow) in the right breast. (b) Image shows bruising of the right breast at time of presentation to the interventional radiology unit.
Figure 2. (a) Selective lateral thoracic artery angiogram demonstrates extravasation from its distal branches (arrow). (b) Immediate postembolization angiogram after microcoil placement (arrow) demonstrates no hemorrhage.
There is currently no established standard of management and treatment of blunt breast trauma. Majeski (3) has devised a classification system encompassing injuries from mild bruising to avulsion of the breast and included a recommended treatment plan based on the classification of injury. Patients should receive a contrast-enhanced CT examination of the thorax at presentation to identify a potential hemorrhage in the breast as well as other organ and bony injuries. Sanders et al (2) recommend that patients in hemodynamically stable condition be treated expectantly whereas those in unstable condition with bleeding be treated with additional therapeutic measures such as transarterial embolization or surgery. As a result of the loose areolar soft tissues of the breast, a hemorrhage seen on CT in these tissues may be difficult to control with local noninterventional measures. Women with bleeding in
the breast can be managed with arteriography and subsequent embolization. Surgical options including open surgical ligation of a bleeding vessel, packing of the area of hematoma, or mastectomy may be considered for severe injuries and avulsion of the breast (1,2). The arterial supply to the breast arises from several sources (Fig 3), including branches of the internal mammary artery medially, the acromiothoracic artery superiorly, the anterior intercostal arteries inferiorly, and branches of the lateral thoracic artery laterally. The inferior aspect of the breast could also receive supply from vessels originating in the abdomen such as the inferior epigastric vessels. Subselective catheterization and embolization of these vessels offers rapid control of bleeding with restoration of hemodynamic stability. Embolization with gelatin sponge slurry or coils has proven successful in treating
Volume 25
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2014
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injuries related to blunt breast trauma (4). Use of these embolic materials allows definitive and effective control of acute hemorrhage with minimal risk of tissue ischemia. Our patient presented with an area of extravasation and hemodynamic stability and was initially managed with noninterventional/operative measures; however, her hemorrhage progressed, and she required embolization. Early referral for interventional therapy may be appropriate for patients with this type of presentation.
REFERENCES
Figure 3. Image shows branches of the major feeding vessels to the breast: the subclavian artery (a), lateral thoracic artery (b), acromiothoracic artery (c), and internal mammary artery (d).
1. Paddle AM, Morrison WA. Seat belt injury to the female breast: review and discussion of its surgical management. ANZ J Surg 2010; 80:71–74. 2. Sanders C, Cipolla J, Stehly C, Hoey B. Blunt breast trauma: is there a standard of care? Am Surg 2011; 77:1066–1069. 3. Majeski J. Shoulder restraint injury of the female breast. Int Surg 2007; 92:99–102. 4. Myhre A, Pohlman T, Dee KE. Hemorrhage into the breast in a restrained driver after a motor vehicle collision. AJR Am J Roentgenol 2002; 179:690.
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Number 6
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June
’
2014
could easily form above the filter. Sizing of the type of precurved sheath to fit the IVC caliber might make it easier to form the curve; for example, a Flexor sheath (Cook, Inc) might be useful in different-caliber vessels. Potential complications from this nontraditional procedure include migration of the filter if it disengages from the snare at any time during the retrieval process, damage to the filter, and possible IVC injury if the legs are not entirely sheathed. The described technique might not work with filters that are made of stiffer material, such as the Celect filter (Cook, Inc). Whether this technique can be applied to filters with penetrating struts is unclear. Before deployment of a filter with intent to retrieve, a potential route for retrieval should be examined with ultrasound or other modalities so that the appropriate device could be placed. Devices designed for femoral retrieval include the OptEase filter (Cordis Corpora-
Blunt Breast Trauma Treated with Endovascular Embolization From: John Yoon, MD Christopher B. Ponce, BA Sohail Contractor, MD Department of Radiology (J.Y., S.C.) Rutgers Biomedical and Health Sciences University H108 150 Bergen Street University Hospital Newark, NJ 07101; and Rutgers New Jersey Medical School (C.B.P.) Newark, New Jersey
Editor: Institutional review board approval is not required at our center for case reports such as this. A 73-year-old female restrained (seat belt) driver was involved in a head-on motor vehicle collision with airbag deployment and presented with blunt trauma to the chest. On arrival to the emergency room, her pulse was 90 beats/min and blood pressure was 130/84 mm Hg. She had bruising at the lower right breast and chest area. The secondary trauma survey was unremarkable, and she had no other injuries. Chest radiograph demonstrated bilateral rib fractures without lung parenchymal or pleural abnormalities. Computed tomography (CT; Fig 1a) showed a large right breast hematoma with an area of contrast medium extravasation in the inferior lateral right breast and axillary soft tissues. During a 5-hour observation period, her blood pressure decreased to 118/80 mm Hg and pulse to 110 beats/min. Reductions in hemoglobin and hematocrit from 13.8 g/dL and 39.3% to 8.5 g/dL and 25.0%, respectively, indicated ongoing hemorrhage. There was no coagulopathy noted. None of the authors have identified a conflict of interest. http://dx.doi.org/10.1016/j.jvir.2014.02.003
981
tion, Bridgewater, New Jersey) (3) and the Crux filter (Volcano Corporation, San Diego, California) (4).
REFERENCES 1. Funaki B, Zaleski GX, Leef JA, Lorenz JN, Van Ha T, Rosenblum JD. Radiologic placement of tunneled hemodialysis catheters in occluded neck, chest, or small thyrocervical collateral veins in central venous occlusion. Radiology 2001; 18:471–476. 2. Van Ha TG, Keblinskas D, Funaki B, Lorenz J. Removal of Günther Tulip vena cava filter through femoral vein approach. J Vasc Interv Radiol 2005; 16:391–394. 3. Rimon U, Bensaid P, Golan G, et al. Optease vena cava filter optimal indwelling time and retrievability. Cardiovasc Intervent Radiol 2011; 34: 532–535. 4. Smouse HB, Mendes R, Bosiers M, Van Ha TG. The RETRIEVE trial: safety and effectiveness of the retrievable Crux vena cava filter. J Vasc Interv Radiol 2013; 24:609–621.
Physical examination revealed a markedly swollen and tender right breast (Fig 1b). Selective right subclavian angiogram revealed hemorrhage arising from a branch of the lateral thoracic artery (Fig 2a). This branch vessel was selectively catheterized with a 3-F microcatheter (Progreat; Terumo, Somerset, New Jersey) and embolized by using flow-directed embolization with gelatin sponge slurry (Gelfoam; Pharmacia and Upjohn, Kalamazoo, Michigan) and a single 2-mm Nester microcoil (Cook, Bloomington, Indiana). No extravasation was seen on the subsequent angiogram (Fig 2b). She was sent to the surgical intensive care unit, where her vital signs improved (blood pressure, 136/84 mm Hg; pulse, 80 beats/min), and she required no further blood transfusions. Her hemoglobin levels remained stable after the procedure for 72 hours (range, 9.3–10.9 g/ dL). She was subsequently discharged home 5 days after her initial presentation with no further interventions or surgery being performed for the hematoma. Blunt trauma to the chest following motor vehicle accidents is commonly the result of a head-on collision at high speeds with airbag deployment. The “seat belt syndrome” is composed of injuries related to the use of three-point seatbelts (1), and includes soft-tissue and bony injuries to the chest and upper abdominal organs. Injury mechanism is related to the direct compression as well as shearing forces on the trunk. Seat belt injuries producing breast injuries are infrequently seen. In a retrospective study on female blunt breast trauma in a level I trauma center, Sanders et al (2) reported that only 108 of 5,305 women with blunt chest trauma (2%) presented with breast trauma. Of the women with blunt breast trauma, 94% of the cases were related to motor vehicle accidents. The majority of cases (n ¼ 101; 93.5%) required conservative nonoperative or noninterventional care. However, seven patients required treatment related to hemodynamic instability. Six patients were referred for angiography, of which four received embolization, and surgical ligation of the feeding vessel was performed in the seventh patient.
982
’
Letters to the Editor
Yoon et al
’
JVIR
Figure 1. (a) Contrast-enhanced CT of the patient’s thorax showing an extensive hematoma (arrow) in the right breast. (b) Image shows bruising of the right breast at time of presentation to the interventional radiology unit.
Figure 2. (a) Selective lateral thoracic artery angiogram demonstrates extravasation from its distal branches (arrow). (b) Immediate postembolization angiogram after microcoil placement (arrow) demonstrates no hemorrhage.
There is currently no established standard of management and treatment of blunt breast trauma. Majeski (3) has devised a classification system encompassing injuries from mild bruising to avulsion of the breast and included a recommended treatment plan based on the classification of injury. Patients should receive a contrast-enhanced CT examination of the thorax at presentation to identify a potential hemorrhage in the breast as well as other organ and bony injuries. Sanders et al (2) recommend that patients in hemodynamically stable condition be treated expectantly whereas those in unstable condition with bleeding be treated with additional therapeutic measures such as transarterial embolization or surgery. As a result of the loose areolar soft tissues of the breast, a hemorrhage seen on CT in these tissues may be difficult to control with local noninterventional measures. Women with bleeding in
the breast can be managed with arteriography and subsequent embolization. Surgical options including open surgical ligation of a bleeding vessel, packing of the area of hematoma, or mastectomy may be considered for severe injuries and avulsion of the breast (1,2). The arterial supply to the breast arises from several sources (Fig 3), including branches of the internal mammary artery medially, the acromiothoracic artery superiorly, the anterior intercostal arteries inferiorly, and branches of the lateral thoracic artery laterally. The inferior aspect of the breast could also receive supply from vessels originating in the abdomen such as the inferior epigastric vessels. Subselective catheterization and embolization of these vessels offers rapid control of bleeding with restoration of hemodynamic stability. Embolization with gelatin sponge slurry or coils has proven successful in treating
Volume 25
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Number 6
’
June
’
2014
983
injuries related to blunt breast trauma (4). Use of these embolic materials allows definitive and effective control of acute hemorrhage with minimal risk of tissue ischemia. Our patient presented with an area of extravasation and hemodynamic stability and was initially managed with noninterventional/operative measures; however, her hemorrhage progressed, and she required embolization. Early referral for interventional therapy may be appropriate for patients with this type of presentation.
REFERENCES
Figure 3. Image shows branches of the major feeding vessels to the breast: the subclavian artery (a), lateral thoracic artery (b), acromiothoracic artery (c), and internal mammary artery (d).
1. Paddle AM, Morrison WA. Seat belt injury to the female breast: review and discussion of its surgical management. ANZ J Surg 2010; 80:71–74. 2. Sanders C, Cipolla J, Stehly C, Hoey B. Blunt breast trauma: is there a standard of care? Am Surg 2011; 77:1066–1069. 3. Majeski J. Shoulder restraint injury of the female breast. Int Surg 2007; 92:99–102. 4. Myhre A, Pohlman T, Dee KE. Hemorrhage into the breast in a restrained driver after a motor vehicle collision. AJR Am J Roentgenol 2002; 179:690.
