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Hindawi Radiology Research and Practice Volume 2021, Article ID 9634938, 4 pages https://doi.org/10.1155/2021/9634938 Research Article Preprocedural Hypertension Is Not a Risk Factor for Postoperative Bleeding following Image-Guided Core Needle Breast Biopsy Ninad Salastekar , Alexis Saunders, Kushal Patel, and Katherine Willer Department of Radiology, SUNY Upstate Medical University, 750 East Adam Street, Syracuse, NY 13210, USA Correspondence should be addressed to Ninad Salastekar; firstname.lastname@example.org Received 15 April 2021; Accepted 16 August 2021; Published 7 September 2021 Academic Editor: Alfonso Fausto Copyright © 2021 Ninad Salastekar et al. 'is is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Objective. To evaluate the association between preprocedural hypertension and the risk of prolonged bleeding following image- guided core needle breast biopsy in nonpregnant/nonlactating women. Methods. A single institution-based, retrospective cohort study of 400 women who underwent image-guided core needle breast biopsy was conducted. Males and pregnant and lactating women were excluded. Preprocedural systolic or diastolic blood pressure greater than 140 or 90 mm of Hg, respectively, was deﬁned as hypertension. Prolonged bleeding was deﬁned >15 minutes of local, manual pressure required to achieve hemostasis following the biopsy. Severe bleeding complications deﬁned as clinical signiﬁcant hematoma formation, prolonged bleeding requiring an ER visit, hospitalization, or surgical intervention were also recorded. Results. 'e diﬀerence in the mean time for which manual pressure was held after biopsy for patients with and without preprocedural hypertension was not statistically signiﬁcant (13± 7 vs. 13± 8 minutes, respectively, P � 0.856). 'ere was no diﬀerence in the number of patients requiring manual postoperative pressure>15 minutes between those with preprocedural hypertension and the normotensive patients (13% vs. 12%, respectively, P � 0.765). Bivariate analysis demonstrated statistically signiﬁcant association between prolonged bleeding and current antithrombotic or antiplatelet medication use (P � 0.010), the use of stereotactic guidance (P � 0.019), and a tethered vacuum-assisted device (P � 0.045). 'e use of a tethered vacuum-assisted biopsy device was the only variable associated with prolonged bleeding in the multivariate model (P � 0.044). Conclusion. Preprocedural hypertension is not a risk factor for prolonged bleeding following image-guided core needle breast biopsies in nonpregnant/nonlactating women. complications (prolonged/severe bleeding requiring treat- 1. Introduction ment (0.7%) and postoperative hematoma formation 'e lifetime risk of developing breast cancer for an average (0.1%)), infections (0.15%), and severe pain (1.7%) were woman in the US is 12.9%, and approximately 128 new cases reported as the most common major complications fol- of breast cancer are diagnosed per 100,000 women per year lowing CNB . . Image-guided core needle breast biopsy (CNB), an While the incidence of severe bleeding complications accurate and cost-eﬀective alternative to open surgical bi- (SBC) following CNB is low, the risk factors associated with opsy, remains the investigation of choice for further eval- these complications remain poorly understood. Vacuum- uation of a majority of suspicious ﬁndings discovered on assisted biopsy device is associated with increased risk of breast imaging [2–4]. Core needle breast biopsies are as- SBC following CBC, while antithrombotic medication use is sociated with a low complication rate and are generally well not [3, 6, 7]. 'ere is insuﬃcient evidence to demonstrate the tolerated by patients [2, 3]. Overall, the rate of severe association of patient comorbidities with the risk of SBC . complications from CNB procedure is <1% . While a Particularly, systemic hypertension is a known risk factor for systematic review by Bruening et al. reported bruising, SBC following kidney biopsy [8, 9]. However, to the best of vasovagal reaction (3.0%), and pain (3.7%) as the most our knowledge, the association of systemic hypertension common minor complications, severe bleeding with severe bleeding complications following core needle 2 Radiology Research and Practice breast biopsy has not been studied. In this study, we evaluate hypertension, and 11% had a history of current or past the association between systemic hypertension and the risk smoking. About 5% patients in the study were taking of SBC following CBC in women with suspicious ﬁndings on antithrombotic/antiplatelet medications (warfarin, direct breast imaging. thrombin inhibitors, and clopidogrel). 77% of all biopsies were ultrasound-guided, and the remaining were stereo- tactic biopsies. All stereotactic biopsies used a tethered 2. Materials and Methods vacuum-assisted biopsy device. Needles with≥12 gauge were 'e institutional review board approved this single insti- used in 68% of the biopsies. 31% of patients in this study had tution-based, retrospective cohort study conducted at a preprocedural hypertension, deﬁned as a systolic or diastolic university hospital. 400 consecutive women who underwent blood pressure greater than 140 or 90 mm of Hg, respec- ultrasound (US) or stereotactic-guided core needle breast tively. 'e distribution of patient characteristics grouped by biopsy from January 2016 to June 2020 were included in this presence of preprocedural hypertension is also described in study. Exclusion criteria included concurrent pregnancy or Table 1. lactation and male gender. Data were acquired through chart A total of 137 subjects were missing information re- review. garding bleeding outcomes and 68 were missing information 'e past medical history of the subjects was reviewed to regarding preprocedural blood pressure. note any hematological disorders that could aﬀect hemo- 'e distribution of the systolic and diastolic blood stasis as well as history of systemic hypertension. Medica- pressures in patients stratiﬁed by preprocedural hyperten- tions including antithrombotic and antiplatelet agents were sion and prolonged bleeding is shown in Table 2. noted. In accordance with currently accepted clinical 'e diﬀerence in the average time for which manual guidelines, antithrombotic/antiplatelet therapy was not held pressure was held after biopsy for patients with and without prior to procedures, neither was the coagulation proﬁle preprocedural hypertension was not statistically signiﬁcant (INR/PT) acquired immediately prior to the procedure. 'e (13± 7 vs. 13± 8 minutes, respectively, P � 0.856, Table 3). type of biopsy (US/Stereotactic), biopsy device (vacuum- 'ere was no diﬀerence in the number of patients requiring manual postoperative pressure >15 minutes between those assisted or not), number of biopsy sites, and number of biopsies per site were recorded. Preprocedural blood pres- with preprocedural hypertension and the normotensive sure was noted for each subject. Preprocedural systolic or patients (13% vs. 12%, respectively, P � 0.765, Table 1). diastolic blood pressure greater than 140 or 90 mm of Hg, Bivariate analysis demonstrated statistically signiﬁcant respectively, was deﬁned as hypertension. association between prolonged bleeding and current 'e main outcome of interest was prolonged bleeding as antithrombotic or antiplatelet medication use (P � 0.010), measured by the time for which manual pressure was applied the use of stereotactic guidance (P � 0.019), and a tethered to the biopsy site to achieve hemostasis. Prolonged bleeding vacuum-assisted device (P � 0.045) (Table 3). Type of biopsy, was deﬁned as greater than 15 minutes of pressure required use of tethered vacuum-assisted biopsy device, and anti- to achieve hemostasis. Severe bleeding complications de- coagulant use were further evaluated in a multivariate lo- ﬁned as clinically signiﬁcant hematoma formation, pro- gistic regression model for association with prolonged bleeding (>15 minutes). 'e use of a tethered vacuum- longed bleeding requiring an ER visit, hospitalization, or surgical intervention were also recorded. assisted biopsy device was the only variable associated with prolonged bleeding in the multivariate model (P � 0.044). A single patient required a visit to the ER for prolonged 3. Statistical Analysis bleeding but was discharged without intervention. No Analysis was conducted using R 4.0.2 and RStudio [10, 11]. clinically signiﬁcant hematomas were reported. Continuous variables (age and time to hemostasis) were described as mean± standard deviation. Categorical vari- 5. Discussion ables were described as frequency (percentage). Bivariate analysis was conducted using the independent T-test/ Prolonged bleeding in patients with preprocedural hyper- Mann–Whitney test for continuous variables and the Chi tension undergoing biopsies of the kidney has been reported Square test/Fisher’s exact test for categorical variables. [8, 9]. To the best of our knowledge, the association of Variables with P value <0.10 were included in a multivar- systemic hypertension with severe bleeding complications iable logistic regression model. A P value of 0.05 was following image-guided core needle breast biopsy has not considered as the threshold for statistical signiﬁcance. been adequately evaluated. In the current study, we found no association between preprocedural hypertension and prolonged bleeding fol- 4. Results lowing image-guided core needle breast biopsy (CNB). A 'e demographic and relevant clinical characteristics of the history of systemic hypertension was also not associated with patients are described in Table 1. 'e average age of patients prolonged bleeding following CNB. Factors associated with in this study was 59± 13 years. Approximately 2% patients prolonged bleeding, deﬁned as >15 minutes of manual and had a history of hematological disorders that could po- postoperative pressure required to achieve hemostasis, were tentially aﬀect hemostasis (for example, antiphospholipid the current use of antithrombotic/antiplatelet medications, syndrome and protein C/S deﬁciency), 39% had a history of stereotactic-guided biopsies, and the use of a tethered Radiology Research and Practice 3 Table 1: Demographic and clinical characteristic of subjects by preprocedural hypertension. All patients Preprocedural hypertension Normotensive P value^ (n � 332) (n � 104) (n � 228) Age (in years) 59 (13) 63 (13) 57 (12) <0.001 ^ ∗∗ History of smoking (current or past) 37 (11%) 4 (4%) 33 (15%) 0.004^ ∗∗ History of hypertension 131 (39%) 55 (53%) 76 (33%) <0.001 ^ History of hematological disorders aﬀecting 6 (2%) 1 (1%) 5 (2%) 0.435 ∗∗ hemostasis ∗∗ Antithrombotic/antiplatelet medications 17 (5%) 8 (8%) 9 (4%) 0.151 ∗∗ Type of biopsy Ultrasound-guided 251 (77%) 79 (77%) 172 (77%) 0.895 Stereotactic 81 (24%) 24 (23%) 57 (25%) 0.690 ∗∗ Tethered vacuum-assisted device 76 (23%) 25 (24%) 51 (23%) 0.768 ∗∗ Needle gauge ≥12 180 (68%) 59 (71%) 121 (67%) 0.531 Bleeding after biopsy (in minutes) 13 (8) 13 (7) 13 (8) 0.856 ∗∗ Prolonged postbiopsy bleeding (>15 minutes) 32 (12%) 11 (13%) 21 (12%) 0.765 ∗ ∗∗ ^ Mean (standard deviation). Frequency (percentage). Statistically signiﬁcant P value (<0.05). Table 2: 'e distribution of the systolic and diastolic blood pressures stratiﬁed by preprocedural hypertension. Preprocedural hypertension Normotensive Prolonged bleeding Normal hemostasis P value P value (n � 104) (n � 228) (n � 32) (n � 231) Systolic blood 152 (14) 121 (11) <0.001 ^ 131 (17) 131 (18) 0.944 pressure (mm of Hg) Diastolic blood 87 (8) 77 (7) <0.001 ^ 81 (9) 80 (9) 0.461 pressure (mm of Hg) ∗ Mean (standard deviation). Statistically signiﬁcant P value (<0.05). Table 3: Bivariate analysis of factors aﬀecting postbiopsy bleeding time. Prolonged bleeding (n � 32) Normal hemostasis (n � 231) P value^ Age (in years) 59 (11) 58 (14) 0.895 ∗∗ History of smoking (current or past) 2 (6%) 26 (12%) 0.356 ∗∗ History of hypertension 11 (34%) 87 (38%) 0.719 ∗∗ History of hematological disorders aﬀecting hemostasis 1 (3%) 5 (2%) 0.733 ∗∗ Antithrombotic/antiplatelet medications 5 (16%) 10 (4%) 0.010^ ∗∗ Type of biopsy Ultrasound-guided 22 (71%) 191 (84%) 0.070^ Stereotactic 11 (34%) 39 (17%) 0.019^ ∗∗ Tethered vacuum-assisted device 10 (31%) 38 (17%) 0.045^ ∗∗ Needle gauge ≥12 16 (59%) 139 (77%) 0.051 Preprocedural hypertension 11 (34%) 73 (32%) 0.765 ∗ ∗∗ Mean (standard deviation). Frequency (percentage). Statistically signiﬁcant Pvalue (<0.05). vacuum-assisted device. A single patient with preproce- required for hemostasis, in patients taking antith- dural hypertension (207/70 mm Hg), not anticoagulated, rombotic/antiplatelet medications. However, none of the undergoing ultrasound-guided breast biopsy was trans- patients reported clinically signiﬁcant postoperative ferred to the ER for prolonged bleeding, but was even- hematomas or bleeding requiring intervention/hospi- tually discharged without the need for surgical talization. Previous studies have used diﬀerent criteria for deﬁning bleeding complications but have also not re- intervention or hospitalization. 'ere were no other reported severe bleeding complications in the study cohort (including ported clinically signiﬁcant hematomas or severe clinically signiﬁcant hematoma, ER visit/hospitalization, or bleeding complications in patients using antithrombotic surgical intervention). medications . Multivariate analysis demonstrated a 'e ﬁndings of prolonged postoperative bleeding in signiﬁcant association between prolonged bleeding and patients undergoing stereotactic biopsies/using tethered the use of a tethered vacuum-assisted device, a ﬁnding vacuum-assisted devices are similar to those reported consistent with previous reports . previously [3, 5]. We report increased incidence of 'is study has several limitations. Findings from this prolonged bleeding, deﬁned as >15 minutes of pressure single institution study have not been externally validated. 4 Radiology Research and Practice  S. L. Versaggi and A. De Leucio, Breast Biopsy, StatPearls MRI-guided biopsies were not included. Factors that could Publishing, Treasure Island, FL, USA, 2020, http://www.ncbi. aﬀect bleeding such as platelet count and INR were not nlm.nih.gov/books/NBK559147. recorded for a majority of patients on the day of the biopsy  W. Bruening, J. Fontanarosa, K. Tipton, J. R. Treadwell, due to absence of such a requirement in the clinical J. Launders, and K. Schoelles, “Systematic review: Compar- guidelines for image-guided core needle breast biopsy. Al- ative eﬀectiveness of core-needle and open surgical biopsy to cohol intake on the day of the procedure was not recorded diagnose breast lesions,” Annals of Internal Medicine, vol. 152, may confound the bleeding time. 'e study could not no. 4, pp. 238–246, 2010. evaluate the eﬀect of operator experience or skill since all the  S. Pettine, R. Place, S. Babu, W. Williard, D. Kim, and biopsies were performed by attending radiologists without P. Carter, “Stereotactic breast biopsy is accurate, minimally the involvement of residents or fellows. 'e type of lesion/ invasive, and cost eﬀective,” -e American Journal of Surgery, pathology was not accounted for. However, there is no vol. 171, no. 5, pp. 474–476, 1996.  I. J. Dahabreh, L. S. Wieland, G. P. Adam, C. Halladay, J. Lau, evidence in the literature that postoperative bleeding is and T. A. Trikalinos, Core Needle and Open Surgical Biopsy for reliably aﬀected by the type of pathology. Data regarding the Diagnosis of Breast Lesions: An Update to the 2009 Report, number of biopsy sites and/or the number of biopsies per Agency for Healthcare Research and Quality (US), Rockville. site were not consistently recorded in the original reports MD, USA, 2014, http://www.ncbi.nlm.nih.gov/books/ and thus could not be included in the analysis. However, NBK246878. there is no evidence to suggest a diﬀerential distribution of  A. L. Chetlen, C. Kasales, J. Mack, S. Schetter, and J. Zhu, the number of biopsies in patients with/without preproce- “Hematoma formation during breast core needle biopsy in dural hypertension, and as such, this is unlikely to aﬀect the women taking antithrombotic therapy,” American Journal of results. 'is study did not consider the eﬀect of patient Roentgenology, vol. 201, no. 1, pp. 215–222, 201321. positioning which may aﬀect postbiopsy bleeding rates. We  P. Somerville, P. J. Seifert, S. V. Destounis, P. F. Murphy, and may have missed any severe bleeding complications that W. Young, “Anticoagulation and bleeding risk after core needle biopsy,” American Journal of Roentgenology, vol. 191, were not reported to our hospital and in cases where the no. 4, pp. 1194–1197, 2008. patients sought care elsewhere.  M. Eiro, T. Katoh, and T. Watanabe, “Risk factors for bleeding complications in percutaneous renal biopsy,” Clinical and 6. Conclusion Experimental Nephrology, vol. 9, no. 1, pp. 40–45, 2005.  J. S. Kriegshauser, M. D. Patel, S. W. Young, F. Chen, A history of systemic hypertension and/or preprocedural W. G. Eversman, and Y.-H. H. Chang, “Risk of bleeding after hypertension is not a risk factor for prolonged bleeding native renal biopsy as a function of preprocedural systolic and diastolic blood pressure,” Journal of Vascular and Interven- following image-guided core needle breast biopsies in tional Radiology, vol. 26, no. 2, pp. 206–212, 2015. nonpregnant/nonlactating women. Despite the described  R Studio Team, RStudio: Integrated Development Environment limitations, the ﬁndings of this study should help guide for R, R Studio, PBC, Boston, MA, USA, 2020, http://www. clinical management of hypertensive patients on the day of rstudio.com. the breast biopsy, speciﬁcally avoiding unnecessary delay or  R Core Team, R: A Language and Environment for Statistical postponement of the biopsy due to perceived risk of pro- Computing, R Foundation for Statistical Computing, Vienna, longed bleeding in patients with preprocedural hyperten- Austria, 2020, https://www.R-project.org. sion. 'e ﬁndings also inform the relatively unclear literature on the patient-related risk factors for prolonged bleeding following breast biopsies. Data Availability 'e clinical data used to support the ﬁndings of this study are restricted by the institutional review board in order to protect patient privacy. Data are available from Ninad Salastekar (email@example.com) for researchers who meet the criteria for access to conﬁdential data. Conflicts of Interest 'e authors declare that there are no conﬂicts of interest regarding the publication of this paper. References  N. Howlader, A. Noone, M. Krapcho et al., SEER Cancer Statistics Review, National Cancer Institute, Bethesda, MD, USA, 2017, https://seer.cancer.gov/csr/1975_2017.
Radiology Research and Practice – Hindawi Publishing Corporation
Published: Sep 7, 2021
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