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Journal of Blood Disorders Symptoms and Treatments

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Short Communication

Thrombocytopenia and Coagulopathy Following Hepatic Cryoablation

Woldie Indryas, Littrup Peter, Aoun Hussein, Bankuru Satish, Andersen Judith, Schiffer Charles

Correspondence Address :

Indryas Woldie
4100 John R, Detroit, MI 48201, USA
Tel: 3135768720
Email: woldiei@karmanos.org

Received on: March 05, 2018, Accepted on: March 15, 2018, Published on: March 21, 2018

Citation: Woldie Indryas, Littrup Peter, Aoun Hussein, Bankuru Satish, Andersen Judith, Schiffer Charles (2018) Thrombocytopenia and Coagulopathy Following Hepatic Cryoablation

Copyright: 2018 Woldie Indryas et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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Abstract

Fulltext
Background
Cryoablation for primary or metastatic liver lesions is performed with increasing frequency [1]. There are several hematologic and biochemical derangements following hepatic cryoablation some of which are fatal. Thrombocytopenia and coagulopathy are prominent hematologic abnormalities described in literature [2].

Methods

We conducted a retrospective record review of hepatic cryoablation procedures at the Karmanos cancer center (KCC), Interventional Radiology unit. For those patients who had severe thrombocytopenia and coagulopathy, more detailed information on laboratory data and outcome was collected and summarized.

Results

A total of 194 hepatic cryoablation procedures were performed on 127 patients. Indications for cryoablation were colorectal cancer in 47 (37%) and hepatocellular carcinoma 23 (18%) non-colon metastasis in 57 (45%), around 90% of the patients had platelet count of ≥100,000/mm3 at baseline. Platelet count dropped by more than 50% from baseline in 20% of the cryoablation procedures. Six patients had severe thrombocytopenia with platelet count of ≤20,000/mm3 following cryoablation (Table 1). All six patients required care in the intensive care unit and had clinical feature consistent with disseminated intravascular coagulation (DIC) like picture with thrombocytopenia, low fibrinogen, elevated D-dimer, prolonged partial thromboplastin time (aPTT) and prolonged prothrombin time (PT). Two of the six patients died of multi-organ failure.

Discussion


The observations in this retrospective study showed thrombocytopenia as a common complication following hepatic cryoablation with significant drop in platelet count (by >50% from baseline) occurring in 20% of the procedures. The study also showed severe thrombocytopenia with platelet drop to ≤ 20,000/mm3 in six patients (0.04%) which is less common compared to previous studies. However, all of the studies were retrospective with wide range of observations [3].
A unique complication of hepatic cryoablation is multi-organ failure, severe coagulopathy and DIC termed as cryo-shock phenomena [4]. Similar complication was seen in six patients in this retrospective review with fatal outcome in two. Possible pathophysiology of such systemic catastrophe following hepatic cryoablation is thought to be the result of pro-inflammatory cytokine release including phospolipase A2, IL-6 and TNF-alpha from cryoablation induced tissue injury [5,6].

Conclusion

Thrombocytopenia is a common complication following hepatic cryoablation. Although unusual, DIC with fatal outcome is occasionally seen. We recommend prospective study to understand the mechanism and explore interventions that can help prevent adverse outcome.

References
1. Erinjeri JP, Clark TW. Cryoablation: mechanism of action and devices. J Vasc Interv Radiol. 2010;21(8):S187-S191.
2. Jansen MC, van Hillegersberg R, Schoots IG, et al. Cryoablation induces greater inflammatory and coagulative responses than radiofrequency ablation or laser induced thermotherapy in a rat liver model. Surgery. 2010;147(5):686-695.
3. Joachim K, Seifert, David L. Morris. World Survey on the Complications of Hepatic and Prostate Cryotherapy. World J Surg. 1999;23(2):109-113.
4. Nair RT, Silverman SG, Tuncali K, et al. Biochemical and Hematologic Alterations Following Percutaneous Cryoablation of Liver Tumors: Experience in 48 Procedures. Radiology. 2008;248(1):303-311.
5. Hamad G, Neifeld J. Biochemical, Hematologic, and Immunologic Alterations Following Hepatic Cytotherapy. Seminars in Surgical Oncology. 1998;14:122-128.
6. Seifert JK, Stewart GJ, Hewitt PM, et al. Interleukin-6 and tumor necrosis factor-alpha levels following hepatic cryotherapy: association with volume and duration of freezing. World J Surg. 1999;23(10):1019-1026.
Tables & Figures


NA: Not available.
Normal laboratory reference values:
PT (prothrombin time): 9.1-11.9 sec; PTT (partial thromboplastin time): 23-34 sec; Fibrinogen: 180-462 mg/dl; D-dimer: < 2.78 mg/dl.

Table 1: Laboratory values and outcome for 6 patients with post cryoablation platelet drop of 20,000/mm3 or less.

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