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Late Hematoma following Central Venous Port Removal

Fleury, Christopher B.S.; Krishnan, Naveen M. M.D., M.Phil.; Han, Kevin D. M.D.; Nahabedian, Maurice Y. M.D.

Plastic & Reconstructive Surgery: March 2017 - Volume 139 - Issue 3 - p 814e–815e
doi: 10.1097/PRS.0000000000003078
Viewpoints

Georgetown School of Medicine, Georgetown University

Department of Plastic Surgery, Georgetown University Hospital, Washington, D.C.

Correspondence to Dr. Nahabedian, 3800 Reservoir Road, Washington, D.C. 20007, drnahabedian@aol.com

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Sir:

Intraoperative Mediport catheter (Norfolk Medical, Skokie, Ill.) removal is a common procedure for general surgeons and is occasionally performed by plastic surgeons at the time of breast reconstruction. Most studies evaluating adverse events associated with central venous catheters are focused on placement. In the largest series following central venous port placement to date, there was a 3.1 percent complication rate, which included pneumothorax, catheter tip malposition, and chest wall and mediastinal hematomas.1 No published studies have documented complications associated with central venous port removal at the time of breast reconstruction.

A 70-year-old woman with infiltrating lobular carcinoma of her right breast underwent oncoplastic reconstruction following partial mastectomy and a contralateral (left) reduction mammaplasty for symmetry. She had no documented coagulopathy or bleeding disorder. The left Mediport catheter was removed in conjunction with the reduction mammaplasty through an internal tunnel directed toward the Mediport catheter. After removal of the Mediport catheter, direct pressure was maintained for 5 minutes. No bleeding was noted throughout the remainder of the operation. The patient’s postoperative course was uncomplicated and she was discharged to home with appropriate activity restrictions. She was seen in the clinic on postoperative day 8 with a normal amount of cutaneous ecchymosis but without any evidence of hematoma. The patient reported that shortly after that appointment, she lifted a heavy bag of groceries, felt a “pop” in her left upper breast, and became lightheaded, with a rapid increase in the size of the left breast. Soon thereafter, she began to bleed from the periareolar incision. As the breast became increasingly swollen, tense, and painful, she presented to the emergency department with a hematocrit level of 22.1. A left breast hematoma was diagnosed and she was immediately taken to the operating room for exploration (Fig. 1). On opening the incisions, there was an immediate expulsion of blood, and a 500-cc hematoma was discovered (Fig. 2). Although there was no active bleeding source identified, it was determined that the clot originated superiorly from the catheter site and tracked from the subcutaneous tunnel to her left breast. The hematoma was evacuated, a drain was inserted, the incisions were closed, and she was discharged to home that day without any subsequent bleeding.

This case represents an unusual scenario of late bleeding and hematoma caused by elevated central venous pressures that resulted from a Valsalva type maneuver with subsequent disruption of the normal clotting mechanism and bleeding. Although it is not known what pressures are required to result in such an event, patients should be instructed to avoid heavy lifting and strenuous activities for at least 1 week to minimize this occurrence.

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PATIENT CONSENT

The patient provided consent for the use of her images and there are no patient identifiers in the images used.

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DISCLOSURE

Dr. Nahabedian is a consultant for LifeCell. The remaining authors have no financial interests or commercial associations to disclose. No funding was received for this study.

Christopher Fleury, B.S.

Georgetown School of Medicine

Georgetown University

Naveen M. Krishnan, M.D., M.Phil.

Kevin D. Han, M.D.

Maurice Y. Nahabedian, M.D.

Department of Plastic Surgery

Georgetown University Hospital

Washington, D.C.

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REFERENCE

1. Guth AARoutine chest X-rays after insertion of implantable long-term venous catheters: Necessary or not?Am Surg20016726–29
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