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Ann Thorac Surg 1995;59:1010-1011
© 1995 The Society of Thoracic Surgeons

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Case Reports

Air Embolus Complicating Transthoracic Percutaneous Needle Biopsy

Division of Thoracic and Cardiovascular Surgery, Department of Surgery, and Department of Radiology, University of New Mexico, Albuquerque, New Mexico

Accepted for publication August 15, 1994.

	Abstract

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Transthoracic percutaneous needle biopsy has become popular for evaluation of pulmonary nodules. However, it is a procedure with morbidity and mortality that is not negligible. In this article, we report massive air embolus complicating needle biopsy in a patient with amyloidosis. A negative biopsy does not exclude malignancy, and if surgical excision will be performed regardless of the result, preoperative assessment using this technique may not be necessary.

	Introduction

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With the refinement of interventional techniques in chest radiology, many patients are undergoing percutaneous needle biopsy of pulmonary nodules. This procedure, however, is not without risk. The most common complications, pneumothorax and hemoptysis, are mild, self-limiting, and treatable. Less frequent complications such as severe hemorrhage and air embolism may be fatal [1].

We describe in this article a patient with amyloidosis who underwent percutaneous transthoracic needle biopsy (TTNB) of a lesion found on routine chest radiography. Permanent neurologic sequelae developed from a massive air embolus sustained during the biopsy despite expeditious treatment with hyperbaric oxygen.

A sixty-two-year-old man with a 50 pack-year smoking history and amyloidosis refractory to chemotherapy was found to have a new right upper lobe lesion on routine chest radiography. He underwent fine-needle aspiration of the mass under computed tomographic guidance (Medi-Tech 18-gauge needle; Boston Scientific Corp, Boston, MA). The needle required repositioning but the stylet was maintained within the hub and the needle was never opened to air. Within minutes the patient complained of increasing back pain and dizziness. He became apneic, hypotensive, and tachycardic. The needle with stylet was removed and he was intubated and resuscitated emergently. Computed tomographic scan of the chest showed hemorrhage at the biopsy site and an air fluid level in the aortic arch (Fig 1). Head computed tomographic scan showed no cerebral air or infarct. Within 4 hours of the event, he was treated in a hyperbaric oxygen chamber for 30 minutes at 3 atmospheres and 90 minutes at 2.5 atmospheres, during which time he was agitated but hemodynamically stable. Later that day he was extubated and a repeat head computed tomographic scan was performed, which was normal; no evidence of cortical emboli was present. He was initially confused and his left side was flaccid; however, over a complicated 3-month hospitalization, the encephalopathy resolved and his left-sided motor function partially returned.

View larger version (93K): [in this window] [in a new window]   Fig 1. . Chest computed tomographic scan with air fluid level in aortic arch.

	Comment

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The sensitivity of the technique in obtaining a cytologic diagnosis of cancer is greater than 90% in the hands of a skilled radiologist and pathologist [1, 2]. A false-positive rate up to 1% can result from misinterpretation of inflammatory processes [1]. Negative results do not rule out malignancy [2]. For these reasons, many surgeons advocate wedge excision in lieu of TTNB to ascertain the true nature of an indeterminant lesion.

In addition, potential complications must be acknowledged. Patients with bleeding disorders, suspected vascular malformations or hydatid cysts, pulmonary hypertension, or bullous and emphysematous lung disease, and those who are unable to cooperate are at higher risk for pneumothorax (25% to 30%), hemoptysis (5% to 10%), and local hemorrhage (11%) [1]. Rare complications include air embolism, tumor implantation, empyema, and bronchopleural fistula.

Only 6 documented cases of air embolism complicating TTNB of the lung have been described in the literature over the past 20 years [3–8]. Table 1 summarizes the previous cases and their catastrophic outcomes.

Air embolism is treated by placing the patient head-down, administering 100% oxygen, and promptly transferring to a hyperbaric oxygen chamber. Steroids, antiplatelet agents, and anticonvulsants should be considered [3].

Transthoracic needle biopsy is not risk-free, and the rare complication can be devastating. A pulmonary lesion should be considered for excision if the patient can tolerate general anesthesia. With advances in video-assisted thoracoscopy, surgical removal often can be performed without thoracotomy. The choice between TTNB and wedge excision as the initial diagnostic method for peripheral lung masses must take into account the patient's clinical condition and subsequent treatment plan if the TTNB biopsy is negative.

	Footnotes

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Address reprint requests to Dr Temes, Division of Thoracic and Cardiovascular Surgery, University of New Mexico, 2211 Lomas Blvd NE, Albuquerque, NM 87131.

	References

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1. Salazar AM, Westcott JL. The role of transthoracic needle biopsy for the diagnosis and staging of lung cancer. Clin Chest Med 1993;14:99–110.[Medline]
2. Calhoun P, Feldman PS, Armstrong P, et al. The clinical outcome of needle aspirations of the lung when cancer is not diagnosed. Ann Thorac Surg 1986;41:592–6.[Abstract]
3. Aberle DR, Gamsu G, Golden JA. Fatal systemic arterial air embolism following lung needle aspiration. Radiology 1987;165:351–3.[Abstract/Free Full Text]
4. Baker BK, Awwad EE. Computed tomography of fatal cerebral air embolism following percutaneous aspiration biopsy of the lung. J Comput Assist Tomogr 1988;12:1082–3.[Medline]
5. Cianci P, Posin JP, Shimshak RR, Singzon J. Air embolism complicating percutaneous thin needle biopsy of lung. Chest 1987;92:749–50.[Abstract/Free Full Text]
6. Tolly TL, Feldmeier JE, Czarnecki D. Air embolism complicating percutaneous lung biopsy. AJR 1988;150:555–6.[Free Full Text]
7. Westcott JL. Air embolism complicating percutaneous needle biopsy of the lung. Chest 1973;63:108–10.[Abstract/Free Full Text]
8. Worth ER, Burton RJ Jr., Landreneau RJ, Eggers GWN Jr., Curtis JJ. Left atrial air embolism during intraoperative needle biopsy of a deep pulmonary lesion. Anesthesiology 1990;73:342–5.[Medline]

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Rose S. Wong R. Thomas Temes Fabrizio M. Follis Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Wong, R. S. Articles by Ashby, R. Search for Related Content PubMed PubMed Citation Articles by Wong, R. S. Articles by Ashby, R.