0:00

Now let's talk about pre-procedural management.

0:04

Like any interventional procedure in radiology,

0:07

it is super important that you review all the imaging,

0:09

both the mammogram and the ultrasound to make sure that

0:13

you are biopsying what you think you're biopsying.

0:15

This may be put on the biopsy list

0:17

by a different radiologist and yourself.

0:20

Um, so make sure that the ultrasound abnormality is the same

0:24

as a mammographic abnormality, if that's

0:26

what was initially identified.

0:28

You want to see what size it is, where it is in the breast,

0:31

what it looks like, because this is going to find what kind

0:34

of equipment you use

0:35

to do the biopsy, as we'll talk about later.

0:38

You want to check the mammogram

0:39

to see if the patient has prior biopsy clips inserted

0:43

to make sure you use a different clip.

0:45

So check the shape of it

0:47

and then you're going to protocol a procedure,

0:49

including the type of device,

0:51

what local anesthetic you're going to use,

0:53

where you're going to use epinephrine,

0:54

and what sort of clip.

0:57

Don't forget to check their medical record

0:59

for allergies if they're on any anticoagulation.

1:02

If there are any contraindications to biopsy,

1:04

perhaps they had a bad vasovagal reaction to prior biopsy.

1:09

Patients who are on chemotherapy, check for low platelets.

1:12

Usually over 50 is okay to biopsy,

1:14

and then when you consent them, uh, the routine

1:17

consent elements are bleeding, infection,

1:20

need to repeat biopsy.

1:22

If it's a very posterior lesion, you might want to consent

1:25

for chest wall trauma.

1:26

AKA pneumothorax.

1:28

Uh, we've had one institution in 30 years of biopsies,

1:30

so this is a very rare event, but it does happen.

1:34

And then if they are pregnant

1:36

or lactating, I also always consent for a potential

1:40

for milk leak or a milk fistula.

1:43

If they are on some form

1:44

of anticoagulant slash antithrombotic therapy,

1:47

I do tell them they're more likely to have a bad bruise.

1:51

Just to mention a little bit more about antithrombotic

1:54

therapy, uh, it is generally safe to continue

1:58

to do a biopsy, especially for these 14 gauge biopsies.

2:01

You might be, uh, not want to do a larger gauge, uh,

2:04

vacuum biopsy in these patients.

2:06

The most recent data seems to say that these are, um, very,

2:10

say particularly the risk of having a large

2:14

hematoma is very small, a baseline INR of under 2.5.

2:19

If they're on Coumadin, um,

2:20

you can consider using a smaller needle.

2:23

You can consider using epinephrine, uh,

2:26

with your local anesthetic in these patients.

2:29

And there's always a benefit risk ratio

2:31

to stopping anticoagulants,

2:33

antithrombotic in these patients.

2:36

You know, really if you are concerned

2:39

or your clinician's concerned about the risk of stroke, uh,

2:43

generally speaking, this is much more

2:45

concerning than the risk of them having a larger hematoma.

2:49

If you do withhold these, usually three to five days

2:52

for most agents,

2:54

there are more specific guidelines you can look up.

2:56

The Society of Interventional Radiology

2:58

Has some, uh, very good guidance on this,

3:01

but I would always consult with the clinical team

3:04

and have them decide if the patient needs to have any

3:08

coverage with heparin

3:10

or if they should stay on these anticoagulants.