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A Rare Cause of Air Embolism
October 2013, Vol 144, No. 4_MeetingAbstracts
Signs and Symptoms of Chest Diseases | October 2013
A Rare Cause of Air Embolism Phoebe King, MD; David Ferraro, MD; Sergio Burguete, MD; A. Anzueto, MD University of Texas Health Science Center at San Antonio, San Antonio, TX Chest. 2013;144(4_MeetingAbstracts):903A. doi:10.1378/chest.1704381
Abstract SESSION TITLE: Miscellaneous Case Report Posters I SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM INTRODUCTION: This case illustrates a rare but serious complication after a percutaneous lung biopsy. CASE PRESENTATION: A 60 year old man with a history of rectal carcinoma, diabetes, and hypertension presented for a percutaneous biopsy of a 1.5 cm cavitary pulmonary nodule in the right lower lobe. The patient was placed in the prone position and using CT guidance, three passes were made into the lung nodule using a 20G needle. Immediately after, the patient had an episode of hemoptysis (50cc) and a CT scan immediately post-procedure revealed a small right pneumothorax and the presence of air in the aorta and the left ventricle suggestive of an air embolism (Figure 1). Subsequently, the patient suffered a PEA arrest and received CPR for a total of 20 minutes. A repeat CT scan performed after stabilization showed resolution of the air in the aorta and left ventricle (Figure 2). The patient was admitted to the MICU and had a complicated hospital course. Unfortunately his mental status did not recover significantly, therefore the patient underwent trachesotomy and percutaneous gastrostomy tube placement. The biopsy revealed metastatic carcinoma of colonic origin however due to his neurologic status he is not currently a candidate for treatment. He remains hospitalized awaiting transfer to a longterm care facility. DISCUSSION: The most common complications of percutaneous lung biopsy are pneumothorax and hemoptysis, both of which are usually minor and self-limited. The more rare complications include air embolism, pulmonary hemorrhage, tension pneumothorax, and seeding of the biopsy track. The incidence of air embolism has historically been reported to be 0.07 - 0.2% (1, 2), however a recent review found a radiographic incidence of 3.8% and a clinically apparent incidence of 0.49% (3). Possible mechanisms include: placement of the needle into a pulmonary vein resulting in aspirated air, formation of a bronchialvenous or alveolar-venous fistula as the needle passes through the lung parenchyma, or passage of air from the pulmonary capillary bed into the pulmonary venous system (3). Treatment varies depending the severity and symptoms, ranging from supportive care, 100% oxygen supplementation, hyperbaric oxygen therapy, and positional therapy, to the need for endotracheal intubation. CONCLUSIONS: While air emboli are rare, early recognition during or immediately after the biopsy can allow for urgent treatment measures and potential avoidance of severe consequences. Reference #1: Ibukuro, K, et.al. Air Embolism and Needle Track Implantation Complicating CT-Guided Percutaneous Thoracic Biopsy: Single-Institution Experience. AJR 2009;193: 430-436. Reference #2: Regge, D, et.al. Systemic arterial air embolism and tension pneumothorax: two complications of transthoracic percutaneous thin-needle biopsy in the same patient. Eur Radiol 1997;7: 173-175. Reference #3: Freund, M.C, et.al. Systemic air embolism during percutaneous core needle biopsy of the lung: frequency and risk factors. BMC Pulm Med 2012;12: DISCLOSURE: The following authors have nothing to disclose: Phoebe King, David Ferraro, Sergio Burguete, A. Anzueto
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Signs and Symptoms of Chest Diseases | October 2013
A Rare Cause of Air Embolism Phoebe King, MD; David Ferraro, MD; Sergio Burguete, MD; A. Anzueto, MD University of Texas Health Science Center at San Antonio, San Antonio, TX Chest. 2013;144(4_MeetingAbstracts):903A. doi:10.1378/chest.1704381
Abstract SESSION TITLE: Miscellaneous Case Report Posters I SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM INTRODUCTION: This case illustrates a rare but serious complication after a percutaneous lung biopsy. CASE PRESENTATION: A 60 year old man with a history of rectal carcinoma, diabetes, and hypertension presented for a percutaneous biopsy of a 1.5 cm cavitary pulmonary nodule in the right lower lobe. The patient was placed in the prone position and using CT guidance, three passes were made into the lung nodule using a 20G needle. Immediately after, the patient had an episode of hemoptysis (50cc) and a CT scan immediately post-procedure revealed a small right pneumothorax and the presence of air in the aorta and the left ventricle suggestive of an air embolism (Figure 1). Subsequently, the patient suffered a PEA arrest and received CPR for a total of 20 minutes. A repeat CT scan performed after stabilization showed resolution of the air in the aorta and left ventricle (Figure 2). The patient was admitted to the MICU and had a complicated hospital course. Unfortunately his mental status did not recover significantly, therefore the patient underwent trachesotomy and percutaneous gastrostomy tube placement. The biopsy revealed metastatic carcinoma of colonic origin however due to his neurologic status he is not currently a candidate for treatment. He remains hospitalized awaiting transfer to a longterm care facility. DISCUSSION: The most common complications of percutaneous lung biopsy are pneumothorax and hemoptysis, both of which are usually minor and self-limited. The more rare complications include air embolism, pulmonary hemorrhage, tension pneumothorax, and seeding of the biopsy track. The incidence of air embolism has historically been reported to be 0.07 - 0.2% (1, 2), however a recent review found a radiographic incidence of 3.8% and a clinically apparent incidence of 0.49% (3). Possible mechanisms include: placement of the needle into a pulmonary vein resulting in aspirated air, formation of a bronchialvenous or alveolar-venous fistula as the needle passes through the lung parenchyma, or passage of air from the pulmonary capillary bed into the pulmonary venous system (3). Treatment varies depending the severity and symptoms, ranging from supportive care, 100% oxygen supplementation, hyperbaric oxygen therapy, and positional therapy, to the need for endotracheal intubation. CONCLUSIONS: While air emboli are rare, early recognition during or immediately after the biopsy can allow for urgent treatment measures and potential avoidance of severe consequences. Reference #1: Ibukuro, K, et.al. Air Embolism and Needle Track Implantation Complicating CT-Guided Percutaneous Thoracic Biopsy: Single-Institution Experience. AJR 2009;193: 430-436. Reference #2: Regge, D, et.al. Systemic arterial air embolism and tension pneumothorax: two complications of transthoracic percutaneous thin-needle biopsy in the same patient. Eur Radiol 1997;7: 173-175. Reference #3: Freund, M.C, et.al. Systemic air embolism during percutaneous core needle biopsy of the lung: frequency and risk factors. BMC Pulm Med 2012;12: DISCLOSURE: The following authors have nothing to disclose: Phoebe King, David Ferraro, Sergio Burguete, A. Anzueto
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