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

Abstract

The air embolism in this case was likely to have been caused by positioning the patient in a prone position, which was associated with the lesion to be biopsied being at a maximum height over the left atrium. Due to the resulting negative pressure, air entered through a fistula that formed between the airspace and the pulmonary vein. The air could have been trapped in the left atrium by positioning the patient in left lateral position. The event itself could have been prevented by positioning the patient in an ipsilateral dependent position during the biopsy. In addition to hyperbaric oxygen therapy, the preferred treatment options are positioning maneuvers, administration of pure oxygen, and heparinization.

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

“…Third, air may be sucked into the pulmonary arterial system and may reach the pulmonary venous circulation by traversing the pulmonary microvasculature. Evidence from case reports suggests that certain factors can increase the risk of SAE, including the use of a larger biopsy needle, smaller lesions, procedures performed for a cystic or cavitary lesion, and patients with vasculitis, inflammation, or coagulopathy, although the relevance of these risk factors remains controversial[ 11 - 13 ].…”

Systemic air embolism as a complication of percutaneous computed tomography guided transthoracic lung biopsy

“…As pulmonary vein pressure is low, and may be even negative in case of biopted lesions located above the level of the left atrium, it is easy to suppose that patient position may increase the risk of air embolism in cases of accidental pulmonary vein injury, although this supposition is not confirmed in the literature. 3 Similarly, other conditions prolonging the exposure of the vessel lumen to the airway can increase the risk of embolism, such as chronic obstructive pulmonary disease and air trapping, cavitary or cystic lesions, pathological states that interfere with the normal haemostatic mechanism or circumstances decreasing pulmonary vein pressure, such as cough and inspiration.…”

Left ventricle and systemic air embolism after percutaneous lung biopsy

“…Systemic arterial air embolism, while rare, is an event that can be associated with potentially fatal complications resulting from migration of air into the cerebral and cardiac vascularization leading to arrhythmias, myocardial ischemia, and ischemic strokes. The proposed mechanism for developing a systemic arterial air embolism during a percutaneous chest procedure is the direct introduction of air into the pulmonary vein through a hollow biopsy needle or the formation of a tract between the airway and pulmonary vein [1] , [4] , [5] . Several studies have analyzed risk factors associated with the development of systemic arterial air embolism, and common factors include prone positioning, needle biopsy technique, and location of lesions (mainly lower lobe lesions) among relevant factors [1] , [4] , [5] .…”

“…The proposed mechanism for developing a systemic arterial air embolism during a percutaneous chest procedure is the direct introduction of air into the pulmonary vein through a hollow biopsy needle or the formation of a tract between the airway and pulmonary vein [1] , [4] , [5] . Several studies have analyzed risk factors associated with the development of systemic arterial air embolism, and common factors include prone positioning, needle biopsy technique, and location of lesions (mainly lower lobe lesions) among relevant factors [1] , [4] , [5] . In this case, although prone positioning was chosen for lesion selection, this position may have predisposed the patient to air entry through an iatrogenic bronchopulmonary venous fistula as a result of pressure conditions that occur as a result of positioning the lesion above the level of the left atrium, where the pulmonary arterial pressure and alveolar pressures are greater than then pulmonary venous pressure [9] .…”