Systemic Air Embolism following Percutaneous Lung Biopsy

Cone-beam computed tomography image-guided percutaneous microwave ablation for lung nodules in a hybrid operating room: an initial experience

OBJECTIVES

The experience of thermal ablation of lung lesions is limited, especially performing the procedure under localisation by cone-beam CT in the hybrid operation room (HOR). Here, we present the experience of microwave ablation (MWA) of lung nodules in the HOR.

METHODS

We reviewed patients who underwent image-guide percutaneous MWA for lung nodules in the HOR under general anaesthesia between July 2020 and July 2022. The workflow in the HOR including the pre-procedure preparation, anaesthesia consideration, operation methods, and postoperative care was clearly described.

RESULTS

Forty lesions in 33 patients who underwent MWA under general anaesthesia (GA) in the HOR were analysed. Twenty-seven patients had a single pulmonary nodule, and the remaining six patients had multiple nodules. The median procedure time was 41.0 min, and the median ablation time per lesion was 6.75 min. The median global operation room time was 115.0 min. The median total dose area product was 14881 μGym2. The median ablation volume was 111.6 cm3. All patients were discharged from the hospital with a median postoperative stay of 1 day. Four patients had pneumothorax, two patients had pleural effusion during the first month of outpatient follow-up, and one patient reported intercostal neuralgia during the 3-month follow-up.

CONCLUSIONS

Thermal ablation of pulmonary nodules under GA in the HOR can be performed safely and efficiently if we follow the workflow provided. The procedure provides an alternative to managing pulmonary nodules in patients.

CLINICAL RELEVANCE STATEMENT

Thermal ablation of pulmonary nodules under GA in the HOR can be performed safely and efficiently if the provided workflow is followed.

KEY POINTS

• We tested the feasibility of microwave ablation of lung lesions performed in a hybrid operating room. • To this end, we provide a description of microwave ablation of the lung under cone-beam CT localisation. • We describe a workflow by which ablation of the pulmonary nodule can be performed safely under general anaesthesia.

Coronary Air Embolism Secondary to Percutaneous Lung Biopsy: A Systematic Review

To determine mortality and morbidity associated with coronary air embolism (CAE) secondary to complications of percutaneous lung biopsy (PLB) and illicit-specific risk factor associated with this complication and overall mortality, we searched PubMed to identify reported cases of CAE secondary to PLB. After assessing inclusion eligibility, a total of 31 cases from 26 publications were included in our study. Data were analyzed using Fisher's exact test. In 31 reported cases, cardiac arrest was more common after left lower lobe (LLL) biopsies (n=4, 80%, p=0.001). Of these patients who suffered from cardiac arrest, CAE was found more frequently in the right coronary artery (RCA) than other locations but did not reach statistical significance (n=5, 62%, p=0.39). At the same time, intervention in the LLL was significantly associated with patient mortality (n=3, 60%, p=0.010). Of the patients who died, CAE was more likely to have occurred in the RCA, but this association was not statistically significant (n=4, 57%, p=0.33). LLL biopsies have a statistically significant correlation with cardiac arrest and patient death. More research is needed to examine the effect of the air location in the RCA on patient morbidity and mortality.

Risk factors for air embolism following computed tomography-guided percutaneous transthoracic needle biopsy: a systematic review and meta-analysis

To quantitatively analyze the risk factors for air embolism following computed tomography (CT)-guided percutaneous transthoracic needle biopsy (PTNB) and qualitatively review their characteristics. The databases of PubMed, Embase, Web of Science, Wanfang Data, VIP information, and China National Knowledge Infrastructure were searched on January 4, 2021, for studies reporting the occurrence of air embolisms following CT-guided PTNB. After study selection, data extraction, and quality assessment, the characteristics of the included cases were qualitatively and quantitatively analyzed. A total of 154 cases of air embolism following CT-guided PTNB were reported. The reported incidence was 0.06% to 4.80%, and 35 (22.73%) patients were asymptomatic. An unconscious or unresponsive state was the most common symptom (29.87%). Air was most commonly found in the left ventricle (44.81%), and 104 (67.53%) patients recovered without sequelae. Air location (P < 0.001), emphysema (P = 0.061), and cough (P = 0.076) were associated with clinical symptoms. Air location (P = 0.015) and symptoms (P < 0.001) were significantly associated with prognosis. Lesion location [odds ratio (OR): 1.85, P = 0.017], lesion subtype (OR: 3.78, P = 0.01), pneumothorax (OR: 2.16, P = 0.003), hemorrhage (OR: 3.20, P < 0.001), and lesions located above the left atrium (OR: 4.35, P = 0.042) were significant risk factors for air embolism. Based on the current evidence, a subsolid lesion, being located in the lower lobe, the presence of pneumothorax or hemorrhage, and lesions located above the left atrium were significant risk factors for air embolism.

Combined autologous blood patch-immediate patient rollover does not reduce the pneumothorax or chest drain rate following CT-guided lung biopsy compared to immediate patient rollover alone

PUPROSE

The purpose of this study was to evaluate a combined autologous blood-patch (ABP)-immediate patient rollover (IPR) technique compared with the IPR technique alone on the incidence of pneumothorax and chest drainage following CT-guided lung biopsy.

METHODS

In this interventional cohort study of both prospectively and retrospectively acquired data, 652 patients underwent CT-guided lung biopsy. Patient demographics, lesion characteristics and technical biopsy variables including the combined ABP-IPR versus IPR alone were evaluated as predictors of pneumothorax and chest drain rates using regression analysis.

RESULTS

The combined ABP-IPR technique was performed in 259 (39.7 %) patients whilst 393 (60.3 %) underwent IPR alone. There was no significant difference in pneumothorax rate or chest drains required between the combined ABP-IPR vs IPR groups (p =.08, p =.60 respectively). Predictors of pneumothorax adjusted for the combined ABP-IPR and IPR alone groups included age (p =.02), lesion size (p =.01), location (p =.005), patient position (p =.008), emphysema along the needle track (p =.005) and lesion distance from the pleura (p =.02). Adjusted predictors of chest drain insertion included lesion location (p =.09), patient position (p =.002), bullae crossed (p =.02) and lesion distance from the pleura (p =.02).

CONCLUSION

The combined ABP-IPR technique does not reduce the pneumothorax or chest drain rate compared to the IPR technique alone. Utilising IPR without an ABP following CT-guided lung biopsy results in similar pneumothorax and chest drain rates while minimising the potential risk of systemic air embolism.

Acute decompensation of patient following an outpatient CT-guided needle biopsy: A case report

A 74-year-old female with history of type 2 diabetes, hypertension, and uterine adenocarcinoma presented for CT-guided lung biopsy that was ultimately complicated by an arterial air embolus requiring intensive care. Systemic air embolism is a very rare event but can be devastating. Prompt recognition can be difficult due to an often-vague presentation but is essential and should be considered upon rapid deterioration of a patient's status following high risk procedures. Hyperbaric oxygen therapy is preferred; however, if this is unavailable, additional treatments are predominately supportive care with 100% supplemental oxygen, rapid volume expansion, and ionotropic medications as needed.

Computed Tomography-guided Lung Biopsy: A Review of Techniques for Reducing the Incidence of Complications

Computed tomography-guided lung biopsy is a well-established method for the histological diagnosis of pulmonary lesions. There is abundant literature regarding the diagnostic yield of and complications associated with computed tomography-guided lung biopsy. Many studies have investigated the risk factors influencing pneumothorax. Conversely, there are a limited number of reports detailing techniques for reducing the incidence of pneumothorax or other complications. This study reviews the indications, diagnostic accuracy, and complications of computed tomography-guided lung biopsy. In addition, techniques for reducing the incidence of these complications were reviewed.

Systemic vascular air embolus following CT-guided transthoracic needle biopsy: a potentially fatal complication

Following an uncomplicated CT-guided transthoracic biopsy, a patient becomes unconscious and subsequently dies despite immediate cardiac resuscitation. The patient felt well during the procedure but started complaining about dizziness and chest pain when he sat up. When he again was put in a supine position, cardiac arrest was noted. A CT scan performed when the symptoms initiated was afterwards rigorously reviewed by the team and revealed air located in the left ventricle, aorta and right coronary artery.We present a rare but potentially lethal complication following CT-guided transthoracic needle biopsy-systemic vascular air embolus. Knowledge and evidence about the complication are sparse because of low incidence and varying presentation. However, immediate initiation of treatment can save a life, and awareness of the complication is therefore crucial.

Incidence, risk factors, and prognostic indicators of symptomatic air embolism after percutaneous transthoracic lung biopsy: a systematic review and pooled analysis

Objectives

To determine the incidence, risk factors, and prognostic indicators of symptomatic air embolism after percutaneous transthoracic lung biopsy (PTLB) by conducting a systematic review and pooled analysis.

Methods

We searched the EMBASE and OVID-MEDLINE databases to identify studies that dealt with air embolism after PTLB and had extractable outcomes. The incidence of air embolism was pooled using a random effects model, and the causes of heterogeneity were investigated. To analyze risk factors for symptomatic embolism and unfavorable outcomes, multivariate logistic regression analysis was performed.

Results

The pooled incidence of symptomatic air embolism after PTLB was 0.08% (95% confidence interval [CI], 0.048–0.128%; I² = 45%). In the subgroup analysis and meta-regression, guidance modality and study size were found to explain the heterogeneity. Of the patients with symptomatic air embolism, 32.7% had unfavorable outcomes. The presence of an underlying disease (odds ratio [OR], 5.939; 95% CI, 1.029–34.279; p = 0.046), the use of a ≥ 19-gauge needle (OR, 10.046; 95% CI, 1.103–91.469; p = 0.041), and coronary or intracranial air embolism (OR, 19.871; 95% CI, 2.725–14.925; p = 0.003) were independent risk factors for symptomatic embolism. Unfavorable outcomes were independently associated with the use of aspiration biopsy rather than core biopsy (OR, 3.302; 95% CI, 1.149–9.492; p = 0.027) and location of the air embolism in the coronary arteries or intracranial spaces (OR = 5.173; 95% CI = 1.309–20.447; p = 0.019).

Conclusion

The pooled incidence of symptomatic air embolism after PTLB was 0.08%, and one-third of cases had sequelae or died. Identifying whether coronary or intracranial emboli exist is crucial in suspected cases of air embolism after PTLB.

Key Points

• The pooled incidence of symptomatic air embolism after percutaneous transthoracic lung biopsy was 0.08%, and one-third of patients with symptomatic air embolism had sequelae or died.

• The risk factors for symptomatic air embolism were the presence of an underlying disease, the use of a ≥ 19-gauge needle, and coronary or intracranial air embolism.

• Sequelae and death in patients with symptomatic air embolism were associated with the use of aspiration biopsy and coronary or intracranial locations of the air embolism.

Systemic Air Embolism Following Computed Tomography-Guided Lung Biopsy

A 61-year-old male with a history of poorly differentiated squamous cell carcinoma of tongue who completed chemo-radiation was found to have bilateral lung nodules on follow-up positron emission tomography (PET) scan. He underwent computed tomography (CT)-guided lung biopsy. Sequential chest scans done during the procedure showed air-fluid level in the left ventricle, suggestive of air embolism. He was hemodynamically stable during the procedure, however at the end of the procedure he developed right-sided face and arm weakness with aphasia. Emergent CT scans including angiography of head and neck were done which did not show any bleed and was also negative for any air in intracranial vasculature. Patient was treated with 100% oxygen. His neurological symptoms resolved in 30 minutes and he was subsequently admitted to intensive care unit (ICU) for further management. Six hours later, repeat CT of chest was done which showed resolution of air embolism.

Systemic Air Embolism following CT-Guided Percutaneous Core Needle Biopsy of the Lung: Case Report and Review of the Literature

Systemic air embolism (SAE) is a rare but serious complication of percutaneous core needle biopsy (PCNB) of the lung. Incidence of clinically apparent SAE is estimated at 0.061%, while clinically silent SAE may be as high as 3.8%. We present the complication of a small SAE during PCNB of the lung in a 78-year-old patient, which resulted in a transient myocardial ischemic event. This case highlights the importance of understanding the mechanism, frequency, and management of rare complications of PCNB of the lung; these complications should be considered in preoperative risk stratification. Regarding evaluation of postbiopsy computed tomography, operators should utilize a systematic search pattern to assess for complications. Level of Evidence:  Level 4, Case Report.

[Analysis of Percutaneous Biopsy of 41 Small Lung Lesions]

BACKGROUND

When lung cancer screening work extensively developed in recent years, more and more small lung lesions were found in clinic. The aim of this study is to analysis computed tomography (CT) guided percutaneous biopsy for lung small lesions (diameter<2 cm) on results, complications and prognosis.

METHODS

Choose CT guided percutaneous lung biopsy were performed in 41 cases of pulmonary peripheral lesions, single lesion in 39 cases, multiple lesions in 2 cases, 5-20 (13.1±5.2) mm in maximum diameter, depth from lung surface 1-45 (16.5±13.7) mm, ground-glass opacity (GGO) components 0%-100% (66.8%±35.2%).

RESULTS

41 patients and 43 biopsies successfully obtained pathological tissue. Atypical adenomatous hyperplasia in 3 cases, squamous carcinoma in 1 case, adenocarcinoma in 37 cases( carcinoma in situ in 7 cases, micro-invasive carcinoma in 5 cases, invasive adenocarcinoma in 25 cases, double primary lung cancer in 2 cases), inflammatory lesions in 2 cases. Except 2 cases of inflammatory lesions are in follow-up, biopsy and surgical pathology alignment (specificity) was 100%. 41 patients occurred complications related to percutaneous biopsy. Pneumothorax were in 22 cases, drainage required in 2 cases. There were 17 cases with hemoptysis, accounting for 39.5% incidence are self-limited. Intracranial air embolism occurred in 2 cases by 4.6% incidence. They were fully recovered.

CONCLUSIONS

For small lung lesions, CT guided percutaneous biopsy is technically feasible. However, for small lung lesions especially pure GGO biopsy, it is still need to be cautious.