SYSTEMIC AIR EMBOLISM AFTER PERCUTANEOUS CT-GUIDED LUNG BIOPSY

Abstract

SESSION TITLE: Global Case Report Posters SESSION TYPE: Global Case Reports PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Computed-tomography (CT) guided transthoracic needle biopsy (TTNB) is widely performed to establish a histological diagnosis of peripheral lung tumors. Systemic air embolism is described as a rare complication. CASE PRESENTATION: In a 70-year-old man with systemic arterial hypertension and benign prostatic hypertrophy a peripheral pulmonary consolidation in the left upper lobe and multiple brain nodules were detected after an acute episode of epilepsy. As a primary lung tumor was suspected, he underwent a total body positron emission tomography-CT scan, showing pathological glucose uptake in the left lung lesion (Figure 1) and metastatic involvement of mediastinal lymph nodes, adrenal glands and vertebral bodies. His coagulation profile, hemoglobin and platelets levels were normal, so a bronchoscopy with transbronchial lung biopsy under fluoroscopy was set. The histological analysis showed bronchial inflammatory cells, so the patient underwent a CT-guided TTNB. Under local anesthesia, two bioptic samples were collected using the 18-gauge outer coaxial needle by an expert interventional radiologist (Figure 2A). During the procedure the onset of air embolism in both heart ventricles, main pulmonary artery and ascending aorta was immediately detected on CT scans (Figure 2B). A layer of ipsilateral pneumothorax (maximum thickness 12 mm) together with chest wall subcutaneous emphysema were present. The patient complained about general malaise with signs of hypotension and desaturation. No electrocardiographic alterations were recorded. After he was administered 100% oxygen through a mask and hydrated, his clinical conditions rapidly improved. Two hours later a chest and brain CT scans were repeated. While cardiac, aortic and pulmonary artery air embolisms were solved, the pneumothorax layer increased (20 mm) (Figure 3). No ischemic lesions were detected in brain CT scans. The patient was maintained on close monitoring and after four days the pneumothorax was no longer radiologically detectable. An invasive lung adenocarcinoma was diagnosed and the patient was referred to the Oncology Department. DISCUSSION: Systemic air embolism is described in 0.02-0.07% of TTNB (1). Direct exposure of pulmonary vein to air through the needle, bronchovenus fistula formation and air penetration from the pulmonary arterial circulation to the pulmonary vein are all possible pathogenic mechanisms (2). Possible prevention strategies include avoiding coughing and straining during the procedure and ventilation with positive pressure (3). No specific treatment has established yet other than supplying 100% oxygen and hyperbaric chamber. The patient has to be strictly monitored because potential life-threatening complications may rise and the repetition of a chest-brain CT scan may be urgently needed (3). CONCLUSIONS: Even if uncommon, systemic air embolism after TTBN must be always considered and rapidly handled. Reference #1: Sinner WN. Complications of percutaneous transthoracic needle aspiration biopsy. Acta Radiol. 1976;17:813-28 Reference #2: Mokhlesi B, Ansaarie I et al. Coronary artery air embolism complicating CT.guided transthoracic needle biopsy of the lung. Chest. 2002;121:993-996 Reference #3: Hare SS, Gupta ATC et al. Systemic arterial air embolism after percutaneous lung biopsy. Clin Radiol. 2011;66:589-596. DISCLOSURES: No relevant relationships by Paolo Ceruti, source=Web Response No relevant relationships by SARA ALESSANDRA LONNI, source=Web Response