Beware of positive pressure: coronary artery air embolism following percutaneous lung biopsy

Abstract

Patients undergoing percutaneous lung biopsy are at risk of developing a systemic air embolism. Air embolism may manifest as a catastrophic iatrogenic event with ischemic insult to the end organs, with sites of least resistance such as coronary and cerebral circulation the most susceptible. We review the available literature and present a case of iatrogenic air embolism during computed tomography guided percutaenous lung biopsy under general anesthesia. Management, outcome, and periprocedural factors that may have contributed to the complication are discussed.

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

“…In the evaluation of risk factors, 81 of 90 articles were judged as high quality, as they satisfied all four items. However, seven case reports did not establish a causality between air embolism and PTLB because the air embolism occurred after repositioning of the biopsy needle to target the lung lesions before firing the biopsy needle [ 16 , 24 , 39 , 53 , 61 , 89 , 106 ]. Another case report was judged to have insufficient establishment of causality because it described a patient with air embolism just after removal of the coaxial needle stylet [ 75 ].…”

“…As was described above, the organ involved in air embolism is a critical factor for patients' symptoms and outcomes, and it is therefore natural for location of the air embolism in the coronary arteries and intracranial spaces to be a significant predictor of unfavorable outcomes. There has been controversy about application of the Trendelenburg position for patients with air embolism [61,90,111,[113][114][115]. According to some authorities, the Trendelenburg position is only appropriate for cases of venous air embolism, as it keeps the air bolus in the right ventricular cavity [114,115].…”

“…To explain the association found in our study, it is speculated that once an air embolism occurs, the use of a large needle results in higher chance of a sufficiently large air bolus entering the bloodstream and causing symptoms [ 9 ]. Finally, the presence of an air embolism in the coronary or cerebral arteries was linked to a severely deteriorated prognosis, with outcomes including myocardial infarction and permanent neurological deficits [ 6 , 61 , 85 , 111 ]. Concordant with prior studies, location of the air embolism in the coronary arteries or intracranial spaces was a significant predictor of symptomatic air embolism.…”

“…There has been controversy about application of the Trendelenburg position for patients with air embolism [ 61 , 90 , 111 , 113 – 115 ]. According to some authorities, the Trendelenburg position is only appropriate for cases of venous air embolism, as it keeps the air bolus in the right ventricular cavity [ 114 , 115 ].…”

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

“…Indeed moderate-tosevere bleeding is commonly reported in cases of SAGE following bronchoscopic biopsy, though direct confirmation of damaged pulmonary venous structures on pathology is rare (6,38). Positive pressure ventilation may create a pressure gradient for airflow into the pulmonary venous circulation and appears to be a risk factor for SAGE in the case literature of percutaneous lung biopsy (35,39) and penetrating thoracic trauma (40). Our case describes an instance of SAGE occurring during a recruitment manuever and an episode of SAGE included in our series occurred directly after oxygen insufflation into a collapsed airway, both demonstrating the potentially-deleterious effect of increased positive airway pressure (9).…”