What is the management for a hematoma or mass in the pericardium related to pigtail (percutaneous drainage) catheter insertion?

Management of Pericardial Hematoma or Mass Following Pigtail Catheter Insertion

For a hematoma or mass in the pericardium related to pigtail catheter drainage, the catheter should remain in place while obtaining urgent vascular surgery or interventional radiology consultation, as premature removal may worsen bleeding and lead to cardiac tamponade.

Initial Assessment and Management

When a hematoma or mass is identified in the pericardium following pigtail catheter insertion:

1. Leave the catheter in place

   • The catheter may be partially occluding the site of injury 1
   • Premature removal could worsen bleeding and lead to hemodynamic compromise

2. Immediate consultation

   • Obtain urgent vascular surgical or interventional radiology consultation 1
   • These specialists should guide the management and potential removal of the catheter

3. Hemodynamic monitoring

   • Monitor for signs of cardiac tamponade:
     • Hypotension
     • Tachycardia
     • Pulsus paradoxus
     • Jugular venous distention
     • Muffled heart sounds
   • Continuous ECG monitoring for arrhythmias that may be precipitated by pericardial irritation 1

Diagnostic Evaluation

1. Imaging

   • Echocardiography to:
     • Confirm presence and size of hematoma/mass
     • Assess for tamponade physiology
     • Guide potential drainage procedures 1
   • Consider CT imaging if echocardiography is inadequate or to better characterize the hematoma

2. Laboratory studies

   • Complete blood count to assess for anemia
   • Coagulation studies (PT/INR, PTT)
   • Type and cross-match for potential blood transfusion

Therapeutic Options

Conservative Management

For stable patients with small hematomas:

• Continue monitoring with serial echocardiography
• Correct any coagulopathy
• Maintain the catheter for controlled drainage 2

Drainage Procedures

For significant hematomas causing or threatening tamponade:

1. Extended catheter drainage

   • If the existing pigtail catheter is functional, it can be used for drainage
   • Consider continuous flush with heparinized saline (3 ml/hr) to maintain patency 3
   • Continue drainage until output is <25 ml per day 1

2. Additional pericardiocentesis

   • If the existing catheter is inadequate, a second pericardiocentesis may be required
   • Should be performed under echocardiographic or fluoroscopic guidance 1
   • Success rate is 93% for anterior effusions >10 mm 1

Surgical Intervention

Indications for surgical management:

• Failed catheter removal
• Large or loculated hematomas
• Recurrent accumulation despite drainage
• Hemodynamic instability despite drainage 4

Surgical options include:

• Subxiphoid pericardial window
• Limited thoracotomy
• Video-assisted thoracoscopic surgery (VATS)

Prevention of Recurrence

1. Extended catheter drainage

   • Mean duration of 3.5-3.6 days reported in studies 3, 5
   • May extend up to 7 days for complete drainage 3

2. For malignant effusions (if applicable):

   • Consider sclerosing agents
   • Pericardial window creation may be necessary for recurrent effusions 6, 7

Complications to Monitor

• Pneumothorax (0.6%)
• Infection (0.3%)
• Arrhythmias (0.6%)
• Arterial bleeding (1.1%)
• Cardiac perforation (0.9%) 1
• Catheter occlusion (more common with continuous drainage) 5

Special Considerations

• If the catheter becomes stuck or coiled, surgical removal may be necessary 4
• For patients with coagulopathy, correction should precede any intervention
• If the hematoma is due to myocardial perforation, surgical intervention may be required 1

Follow-up

• Echocardiographic follow-up based on effusion size:
  • Moderate effusions (10-20mm): every 6 months
  • Large effusions (>20mm): every 3-6 months 6
• Monitor for recurrence, which occurs in approximately 7% of cases within 30 days 2