Computed-Tomography-Guided Lung Biopsy: A Practice-Oriented Document on Techniques and Principles and a Review of the Literature

Computed tomography (CT)-guided lung biopsy is one of the oldest and most widely known minimally invasive percutaneous procedures. Despite being conceptually simple, this procedure needs to be performed rapidly and can be subject to meaningful complications that need to be managed properly. Therefore, knowledge of principles and techniques is required by every general or interventional radiologist who performs the procedure. This review aims to contain all the information that the operator needs to know before performing the procedure. The paper starts with the description of indications, devices, and types of percutaneous CT-guided lung biopsies, along with their reported results in the literature. Then, pre-procedural evaluation and the practical aspects to be considered during procedure (i.e., patient positioning and breathing) are discussed. The subsequent section is dedicated to complications, with their incidence, risk factors, and the evidence-based measures necessary to both prevent or manage them; special attention is given to pneumothorax and hemorrhage. After conventional CT, this review describes other available CT modalities, including CT fluoroscopy and cone-beam CT. At the end, more advanced techniques, which are already used in clinical practice, like fusion imaging, are included.

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.

Frequency and Risk Factors for Air Embolism in Computed Tomography Fluoroscopy-Guided Biopsy of Lung Tumor With the Use of Noncoaxial Automatic Needle

PURPOSE

The aim of the study is to analyze incidence and risk factors for air embolism during computed tomography (CT) fluoroscopy-guided lung biopsies using noncoaxial automatic needle.

MATERIALS AND METHODS

Between February 2014 and December 2019, 204 CT fluoroscopy-guided lung biopsies (127 men; mean age, 70.6 years) using noncoaxial automatic needle under inspiratory breath holding were performed. We retrospectively evaluated the incidence of air embolism as presence of air in the systemic circulation on whole-chest CT images obtained immediately after biopsy. Risk factors of the patient, tumor and procedural factors (size, location and type of nodule, distance from the pleura, the level of the lesion relative to the left atrium, emphysema, patient position, penetration of a pulmonary vein, etc) were analyzed.

RESULTS

The technical success rate was 97.1%. Air embolism was radiologically identified in 8 cases (3.92%, 7 males; size, 21.6 ± 18.2 mm; distance to pleura, 11.9 ± 14.5 mm). Two patients showed overt symptoms and the others were asymptomatic. Independent risk factors were needle penetration of the pulmonary vein ( P = 0.0478) and higher location relative to left atrium ( P = 0.0353). Size, location and type of nodule, distance from the pleura, emphysema, patient position, and other variables were not significant risk factors. As other complications, pneumothorax and alveolar hemorrhage were observed in 57.4% and 77.5%, respectively.

CONCLUSIONS

In CT fluoroscopy-guided lung biopsy using the noncoaxial automatic needles, radiological incidence of air embolism was 3.92%. Given the frequency of air embolism, it is necessary to incorporate this into postprocedure imaging and clinical evaluation.

Air embolism in CT-guided transthoracic needle biopsy: emphasis on pulmonary vein injury

OBJECTIVE

To assess whether pulmonary vein injury is detectable on CT and associated with air embolism after percutaneous transthoracic needle biopsy (PTNB) in a tertiary referral hospital.

METHODS

Between January 2012 and November 2021, 11,691 consecutive CT-guided PTNBs in 10,685 patients were retrospectively evaluated. Air embolism was identified by reviewing radiologic reports. Pulmonary vein injury was defined as the presence of the pulmonary vein in the needle pathway or shooting range of the cutting needle with the presence of parenchymal hemorrhage. The association between pulmonary vein injury and air embolism was assessed using logistic regression analysis in matched patients with and without air embolism with a ratio of 1:4.

RESULTS

A total of 27 cases of air embolism (median age, 67 years; range, 48-80 years; 24 men) were found with an incidence of 0.23% (27/11,691). Pulmonary vein injury during the procedures was identifiable on CT in 24 of 27 patients (88.9%), whereas it was 1.9% (2/108) for matched patients without air embolism The veins beyond the target lesion (70.8% [17/24]) were injured more frequently than the veins in the needle pathway before the target lesion (29.2% [7/24]). In univariable and multivariable analyses, pulmonary vein injury was associated with air embolism (odds ratio, 485.19; 95% confidence interval, 68.67-3428.19, p <.001).

CONCLUSION

Pulmonary vein injury was detected on CT and was associated with air embolism. Avoiding pulmonary vein injury with careful planning of the needle pathway on CT may reduce air embolism risk.

KEY POINTS

• Pulmonary vein injury during CT-guided biopsy was identifiable on CT in most of the patients (88.9% [24/27]). • The veins beyond the target lesion (70.8% [17/24]) were injured more frequently than the veins in the needle pathway before the target lesion (29.2% [7/24]). • Avoiding the distinguishable pulmonary vein along the pathway or shooting range of the needle on CT may reduce the air embolism risk.

Fatal left atrial air embolism as a complication of percutaneous transthoracic lung biopsy: A case report

BACKGROUND

Computed tomography (CT)-guided percutaneous lung biopsy is a common protocol in the context of diagnostic thoracic oncology, but entails a risk of complications including systematic air embolism (SAE). While SAE is often well tolerated, it can be difficult to treat and may result in rapid mortality in some cases.

CASE SUMMARY

We report a rare case of left atrial SAE in a 71-year-old woman who underwent a CT-guided lung biopsy of a pulmonary nodule in the posterior basal segment of the right lower lobe. Shortly following needle extraction, she experienced a mild cough, hemoptysis, rapid-onset unconsciousness, and cardiopulmonary arrest. Cardiopulmonary resuscitation was immediately performed, but the patient died 40 min after the procedure. A closer review of collected CT scans revealed the presence of a large volume of air within the left atrium.

CONCLUSION

Although SAE is generally well tolerated and asymptomatic, interventional radiologists must be aware of the risk of fatal outcomes and establish appropriate emergency management protocols. In this report, the characteristics, mechanisms, and treatment recommendations associated with SAE are discussed in an effort to improve the survival of affected patients.

Systemic arterial gas embolism (SAGE) as a complication of bronchoscopic lung biopsy: a case report and systematic literature review

Background

Systemic arterial gas embolism (SAGE) is a rare yet serious and underrecognized complication of bronchoscopic procedures. A recent case of presumed SAGE after transbronchial needle aspiration prompted a systematic literature review of SAGE after biopsy procedures during flexible bronchoscopy.

Methods

We performed a systematic database search for case reports and case series pertaining to SAGE after bronchoscopic lung biopsy; reports or series involving only bronchoscopic laser therapy or argon plasma coagulation (APC) were excluded. Patient data were extracted directly from published reports.

Results

A total of 29 unique patient reports were assessed for patient demographics, specifics of the procedure, clinical manifestations, diagnostic findings, and clinical outcomes. Cases of SAGE occurred after multiple types of bronchoscopic biopsy and under both positive and negative pressure ventilation. The most common clinical findings were neurologic, followed by cardiac manifestations; temporal patterns included acute onset of cardiac or neurologic emergencies immediately after biopsy, or delayed awakening post-procedure. There was a high mortality rate among cases (28%), with residual neurologic deficits also common (24%).

Discussion

SAGE is an underrecognized but severe adverse effect of bronchoscopic lung biopsy, which often presents with acute coronary or cerebral ischemia or delayed awakening from sedation. It is important for all physicians who perform bronchoscopic biopsies to be aware of the clinical manifestations and therapeutic management of SAGE in order to mitigate morbidity and mortality among patients undergoing these procedures.

Asymptomatic air collection in the left atrium after computed tomography-guided lung biopsy

Systemic air embolism is a fatal lung biopsy complication, despite its low incidence. Incidental air immigration into the pulmonary vein passing through the left heart circulation results in air embolism in percutaneous lung biopsy. Herein, we report a 73-year-old man who presented with massive air collection in the left atrium after computed tomography-guided lung biopsy which resolved without any symptom. Computed tomography fluoroscopy confirmed the gradual absorption process.

Nonintubated versus intubated “one-stage” preoperative localization and thoracoscopic lung resection

Objective

Nonintubated anesthesia, electromagnetic navigation (EMN)-guided preoperative localization, and uniportal video-assisted thoracic surgery (VATS) are recent innovations in minimally invasive thoracic surgery. This study aimed to explore the feasibility of applying nonintubated anesthesia in a “one-stage” localization and resection workflow.

Methods

Patients who underwent EMN-guided preoperative percutaneous localization with indocyanine green (ICG) and uniportal VATS were included. Perioperative data were compared between patients receiving nonintubated anesthesia and those receiving general anesthesia with endotracheal intubation.

Results

Forty-six patients with a total of 50 nodules were included in the study. Overall, finger palpation could be avoided in 94% of the nodules, whereas fluorescent green signals with a clear border on the pleural surface were noted in 91.3% (21 of 23) of nodules in the nonintubated group and 88.9% (24 of 27) of nodules in the intubated group. Intraoperatively, the nonintubated group had a lower median pH (7.33 [interquartile range (IQR), 7.28-7.40] vs 7.41 [IQR, 7.38-7.44]; P = .003), higher median arterial CO₂ (45.5 [IQR, 41.1-58.7] mm Hg vs 38.4 [IQR, 35.3-40.6] mm Hg; P < .001), and lower arterial oxygen (322 [IQR, 211-433] mm Hg vs 426 [IQR, 355-471] mm Hg; P = .005) levels compared with the intubated group. The nonintubated group also had a shorter median registration time (2.0 [IQR, 1.0-3.0] minutes vs 3.0 [IQR, 2.0-8.0] minutes; P = .008) and total time in the operating room (150 [IQR, 130-175] minutes vs 170 [IQR, 135-203] minutes; P = .035), whereas no between-group differences were seen in localization and operative time. The duration of chest drainage, postoperative complications, pathologic diagnosis, and margins were similar in the 2 groups.

Conclusions

Nonintubated “one-stage” EMN-guided percutaneous ICG localization and uniportal VATS can be an option for selected patients undergoing treatment for small peripheral nodules.

The PEARL Approach for CT-guided Lung Biopsy: Assessment of Complication Rate

Background Percutaneous CT-guided biopsy of lung nodules is an established method with high diagnostic accuracy but a high rate of pneumothorax and chest tube insertion compared with endobronchial methods. Purpose To investigate the effect of a protocol combining patient positioning biopsy-side down, needle removal during expiration, autologous blood patch sealing, rapid rollover, and pleural patching (PEARL) on complication rate after percutaneous CT-guided lung biopsy, especially chest tube insertion. Materials and Methods In a secondary analysis of both prospectively and retrospectively acquired data from December 2019 to November 2020, consecutive participants underwent biopsy with use of the PEARL protocol (prospective data) and were compared with patients who underwent biopsy at the same tertiary cancer center according to the standard method without any additional techniques (controls, retrospective data). Patient demographics, lesion characteristics, intraprocedural data, complications, and histologic results were recorded and compared. Results One hundred patients in the control group (mean age ± standard deviation, 63 years ± 12; 61 men) and 100 participants in the PEARL group (mean age, 64 years ± 12; 48 men) were evaluated. No differences were found in patient and lesion characteristics. The emphysema rate was 47 of 100 patients (47%) in both groups. The rate of pneumothorax was 37 of 100 patients (37%) in the control group versus 16 of 100 (16%) in the PEARL group (P = .001). Of the pneumothoraxes that occurred, fewer were during the intervention in the PEARL group, with 21 of 37 onsets (57%) in the control group versus three of 16 onsets (19%) in the PEARL group (P < .001). A chest tube was inserted in 13 of 100 patients (13%) in the control group and only in one of 100 (1%) in the PEARL group (P = .002). Histologic findings were diagnostic in 94 of 100 patients (94%) in the control group and 95 of 100 (95%) in the PEARL group (P > .99). Conclusion During CT-guided percutaneous lung biopsy, a protocol of positioning biopsy-side down, needle removal during expiration, autologous blood patch sealing, rapid rollover, and pleural patching, or PEARL, reduced rates of pneumothorax and chest tube insertion. © RSNA, 2021.

Coronary artery air embolism complicating a CT-guided percutaneous lung biopsy

Coronary arterial air embolism is an extremely rare but readily recognizable condition on computed tomography (CT) that may complicate a lung biopsy. We present an incidence of symptomatic air embolism into the right coronary artery during a percutaneous CT-guided lung biopsy that was successfully recognized during the procedure and managed accordingly. An active search for this complication should be made when the patient deteriorates on table and the usual complications (pneumothorax, vasovagal shock, etc.) are ruled out, as immediate resuscitative measures could be life-saving.

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.

Dependent lesion positioning at CT-guided lung biopsy to reduce risk of pneumothorax

OBJECTIVES

To evaluate the impact of patient positioning during CT-guided lung biopsy on patients' outcomes.

METHODS

In this retrospective, IRB-approved, HIPAA-compliant study, consecutive CT-guided lung biopsies performed on 5/1/2015-12/26/2017 were included. Correlation between incidence of pneumothorax, chest tube placement, pulmonary bleeding with patient, and procedure characteristics was evaluated. Lesion-trachea-table angle (LTTA) was defined as an angle between the lesion, trachea, and horizontal line parallel to the table. Lesion above trachea has a positive LTTA. Univariate and multivariate logistic regression analysis was performed.

RESULTS

A total of 423 biopsies in 409 patients (68 ± 11 years, 231/409, 56% female) were included in the study. Pneumothorax occurred in 83/423 (20%) biopsies with chest tube placed in 11/423 (3%) biopsies. Perilesional bleeding occurred in 194/423 (46%) biopsies and hemoptysis in 20/423 (5%) biopsies. Univariate analysis showed an association of pneumothorax with smaller lesions (p = 0.05), positive LTTA (p = 0.002), and lesions not attached to pleura (p = 0.026) with multivariate analysis showing lesion size and LTTA to be independent risk factors. Univariate analysis showed an association of increased pulmonary bleeding with smaller lesions (p < 0.001), no attachment to the pleura (p < 0.001), needle throw < 16 mm (p = 0.05), and a longer needle path (p < 0.001). Multivariate analysis showed lesion size, a longer needle path, and lesions not attached to the pleura to be independently associated with perilesional bleeding. Risk factors for hemoptysis were longer needle path (p = 0.002), no attachment to the pleura (p = 0.03), and female sex (p = 0.04).

CONCLUSIONS

Interventional radiologists can reduce the pneumothorax risk during the CT-guided biopsy by positioning the biopsy site below the trachea.

KEY POINTS

• Positioning patient with lesion to be below the trachea for the CT-guided lung biopsy results in lower rate of pneumothorax, as compared with the lesion above the trachea. • Positioning patient with lesion to be below the trachea for the CT-guided lung biopsy does not affect rate of procedure-associated pulmonary hemorrhage or hemoptysis.

Systemic air embolism depicted on systematic whole thoracic CT acquisition after percutaneous lung biopsy: Incidence and risk factors

OBJECTIVES

To evaluate the incidence and risk factors of systemic air embolism (SAE) depicted on systematic whole thoracic CT performed after percutaneous lung biopsy.

METHODS

A total of 559 CT-guided lung biopsies performed between April 2014 and May 2016 were retrospectively evaluated. SAE was defined by the presence of air in the aorta or left cardiac cavities seen on whole thorax CT images acquired after needle withdrawal. Analyzed data focused on patient (age, sex, spirometry data, emphysema on CT, therapeutics received), target lesion (location, depth, size and feature) and procedure (patient position, length of intrapulmonary needle path, number of pleural passes and of biopsy samples, operator's experience). A regression logistic model was used to identify risk factors of SAE.

RESULTS

SAE was observed after 27 of the 559 lung biopsies, corresponding to a radiological incidence of 4.8% (95%CI: 3.3-7.0). Clinical incidence was 0.17% (n = 1). For 21/27 patients (78%), a targeted acquisition in the nodule area would not have included the cardiac cavities meaning SAE would have been missed. On multivariate analysis, the independent risk factors were needle path length through ventilated lung (OR: 1.13, 95%CI: 1.02-1.25, p = 0.024), number of samples (OR: 1.48, 95%CI: 1.01-2.17, p = 0.046) and prone position (OR: 3.12, 95%CI: 1.11-8.31, p = 0.031) or right-sided lateral decubitus (OR: 6.15, 95%CI: 1.66-22.85, p = 0.005).

CONCLUSIONS

Asymptomatic systemic air embolism can be depicted in almost 5% of post biopsy CT examinations, when they are not limited to the targeted nodule area but include the entire thorax.

Does Ipsilateral-Dependent Positioning During Percutaneous Lung Biopsy Decrease the Risk of Pneumothorax?

OBJECTIVE

The purpose of this study is to determine whether placing patients in an ipsilateral-dependent position during percutaneous CT-guided transthoracic biopsy reduces the pneumothorax rate.

MATERIALS AND METHODS

Between July 2013 and August 2017, a total of 516 patients (317 men and 199 women; mean age, 66.4 years) underwent core needle biopsies performed using 17- and 18-gauge needles. The overall pneumothorax rate and the rate of pneumothorax requiring drainage catheter insertion were compared between group A (patients placed in an ipsilateral-dependent position) and group B (patients placed in a position other than the ipsilateral-dependent position), with use of a chi-square test or Fisher exact test, as appropriate. Linear regression analysis and multiple regression analysis were performed for risk factors of pneumothorax, including patient characteristics (e.g., emphysema along the needle track), lesion characteristics (e.g., size and position), and biopsy technique characteristics (e.g., needle path length, needle-pleura angle, and fissure crossing).

RESULTS

For patients in group A and group B, the overall pneumothorax rate (21/94 [22.3%] and 95/422 [22.5%], respectively; p = 0.97) and the rate of pneumothorax requiring drainage catheter insertion (6/94 [6.4%] and 28/422 [6.6%], respectively; p = 0.90) were not statistically different. After multiple regression analysis, the only independent risk factors for pneumothorax and insertion of a drainage catheter were needle path length (p < 0.001 and p = 0.02, respectively), emphysema along the needle track (p = 0.01 and p < 0.001, respectively), and fissure crossing (p = 0.04 and p < 0.001, respectively).

CONCLUSION

Even though the pneumothorax rate does not appear to be reduced, with the limits of a retrospective evaluation considered, other advantages of the ipsilateral decubitus position exist, including protection of the contralateral lung in patients with severe hemoptysis.

Diagnosing filamentous fungal infections in immunocompromised patients applying computed tomography-guided percutaneous lung biopsies: a 12-year experience

Background

Invasive fungal diseases (IFD) are an important cause of morbidity and mortality in immunocompromised patients, and early diagnosis and management are a challenge. We evaluated the clinical utility of computed tomography (CT)-guided percutaneous lung biopsies in diagnosing IFD.

Methods

Between 2003 and 2014, we analyzed 2671 CT-guided lung biopsies, from which 157 were IFD associated; we aimed to determine microbiological-based diagnostic accuracy of calcofluor white staining (CFWS), culture, Aspergillus antigen detection (GM), broad-range fungal PCR, and Aspergillus PCR per sample.

Results

127 (81%) specimens were microscopically positive for any fungal elements, 30 (19%) negative. Aspergillus and non-Aspergillus like hyphae were obtained in 85 (67%) and 42 (33%) specimens, respectively. CFWS positivity was defined as proof of infection. Sensitivity, specificity, and positive (PPV) and negative predictive (NPV) values for CT scan were 100, 44, 80, and 100%, for Aspergillus PCR 89, 58, 88, and 58%, for broad-range fungal PCR 90, 83, 95, and 90%, and for GM 94, 83, 95, and 90%. The most common CT features were patchy opacifications with central necrosis (78%) or cavern defects (50%), less common were air bronchograms (39%) or ground glass halos (39%), and all other features were rare. The overall pneumothorax rate subsequent to biopsy was 19%, but in only 2% of all cases the placement of a chest tube was indicated. One case of fatal air embolism occurred.

Conclusions

CT-guided lung biopsies have high diagnostic accuracy in terms of microscopic examination, and complication rates are low. Molecular-based and antigen tests applied on fungal hyphae-positive specimens showed comparable results.

Left ventricle and systemic air embolism after percutaneous lung biopsy

Background

Systemic arterial air embolism following a percutaneous transthoracic lung biopsy is a rare but known complication, with current literature reporting an incidence of 0.01–0.45%. A prompt diagnosis of arterial air embolism is important as complications resulting from migration of air to the systemic circulation with correspondent complications.

Case report

A 60-year-old female who presented for an elective percutaneous lung biopsy of an incidentally found pulmonary nodule. The procedure was performed, following the completion of the procedure the patient experiment syncopal symptoms and was diagnosed by CT scan with Left ventricular air embolism, subsequently transferred to Intensive care unit for medical attention, she was placed on right lateral decubitus Trendelenburg for 24 hours and administer 100% oxygen via a nonrebreather mask. Repeat chest CT the following day revealed complete resolution of her intracardiac free air.

Conclusion

Although systemic arterial air embolism remains a rare complication of percutaneous lung biopsies, recognition prevents potential mortality which can develop due to neurological and cardiac complications. Close vigilance in the intensive care unit is recommended and hyperbaric chamber when appropriate.