Influenceable and Avoidable Risk Factors for Systemic Air Embolism due to Percutaneous CT-Guided Lung Biopsy: Patient Positioning and Coaxial Biopsy Technique—Case Report, Systematic Literature Review, and a Technical Note

Abstract

Following the first case of a systemic air embolism due to percutaneous CT-guided lung biopsy in our clinic we analysed the literature regarding this matter in view of influenceable or avoidable risk factors. A systematic review of literature reporting cases of systemic air embolism due to CT-guided lung biopsy was performed to find out whether prone positioning might be a risk factor regarding this issue. In addition, a technical note concerning coaxial biopsy practice is presented. Prone position seems to have relevance for the development and/or clinical manifestation of air embolism due to CT-guided lung biopsy and should be considered a risk factor, at least as far as lesions in the lower parts of the lung are concerned. Biopsies of small or cavitary lesions in coaxial technique should be performed using a hemostatic valve.

Complications of CT-guided transthoracic lung biopsy

“…The pathogenesis of air embolism may be complex; however, what several explanatory models have in common is the access of air into the pulmonary vasculature following a pressure gradient. This is usually created by an additional factor, leading to either higher intrabronchial pressure, or to decreased endovascular pressure [ 13 – 15 ]. In line with these theoretical physical approaches, risk factors for systemic air embolism identified in various studies include a lesion level above the left atrium, prone patient position and positive pressure ventilation.…”

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

“…analysis yielded simplified approach with recommendations for flat, supine positioning for all SAE [6]. Additional treatment options to consider include hyperbaric oxygen by increasing dissolved O 2 deliver to tissues, pharmacologic coronary vasodilatation, direct percutaneous and/or endovascular aspiration of air from the aorta, or coronaries, or emergent cardiac bypass [1], [2], [3], [4], [5], [6], [7], [8], [9], [10], [11], [12], [13], [14], [15].…”

Systemic air embolism causing acute stroke and myocardial infarction after percutaneous transthoracic lung biopsy – a case report

“…Figure 1 illustrates how the “position of the lesion above or below the level of the left atrium” should be understood. If the patient had been positioned in “ipsilateral dependent position” [ 3 ] i.e. in a supine position with the right side elevated somewhat, this complication may not have occurred.…”