Systemic air embolism following computed-tomography-guided transthoracic needle biopsy of lung lesion – a systematic search of case reports and case series

Abstract

Background Systemic air embolism is a rare, however potentially fatal, low incidence, complication to CT-guided transthoracic needle biopsy of lung lesions. Purpose The purpose of this review of case reports and series was to pool data about this rare complication and glance for a pattern or similarities in the patients’ initial symptoms and course, as well as the management of the patients in relation to current guidelines. Material and methods PubMed was searched for case reports and case series about systemic air embolisms following CT-guided transthoracic needle biopsy of lung lesions from inception to November 2021. A reviewer screened the results for eligibility and included studies which reported at least two outcomes of interest. Data was extracted by one author and a descriptive analysis was conducted. Results Of 1,136 studies screened, 83 were eligible for inclusion involving 97 patients. The mean age was 64.8±11.7 years and ≈60% of the patients were men. In 15 cases the outcome was fatal, and most of the fatal cases ( n = 12) had cardiac arrest as the primary initial symptom. In addition to conventional oxygen therapy, 34 patients received hyperbaric oxygen therapy, and in 30 cases the physician in charge chose to change the patient from standard supine position to – most often – Trendelenburg position. Conclusion No similarities were found that could lead to more rapid diagnosis or more correct management. The staff should keep systemic air embolisms in mind, when more common complications are ruled out, and consider hyperbaric oxygen therapy in case of suspicion.

Acute Coronary Artery Air Embolism Complicating a CT-guided percutaneous lung biopsy: A case report

“…Subsequently, the patient was placed in the Trendelenburg position. Previous research has shown that the Trendelenburg position has no significant effect on preventing bubbles in arteries from reaching the brain [ [14] , [15] , [16] ]; however, many physicians still place the patient in this position empirically in clinical practice [ [17] , [18] , [19] , [20] , [21] , [22] , [23] , [24] ], and a recent analysis seems to indicate a good prognosis of patients in the Trendelenburg position in the treatment of symptomatic air embolism. This approach is controversial but still worth considering; complications, including airway edema and cerebral edema, need to be controlled [ 3 , 4 , 25 , 26 ].…”

Review of Air Embolism for the Interventional Radiologist

“…38 Pietersen et al's review of air embolism complicating lung biopsy had 15.5% mortality, the majority of which were due to cardiac arrest. 17 However, 63% had no sequela and 9% had only minor sequela. Besseraeu et al reported outcomes in 119 patients with air embolism treated with HBO.…”

“…15,16 In Pietersen's literature review, air was mostly found in the aorta or left heart (>50% of cases) with the coronary arteries (34%) and cerebral arteries (30%) less commonly affected. 17 Performing the biopsy with suspended respiration and occluding the hub with a finger or a few drops of saline to create a water seal are unverified techniques which may minimize the likelihood of air embolus.…”

“…Cerebral air emboli result in altered mental status or neurological defects such as stroke or transient ischemic attacks, whereas coronary emboli can cause chest pain and arrhythmias. Emboli to the spinal cord and arteries were described in 3% of all air emboli occurring in lung biopsy patients 17 (►Figs. 6 and 7).…”

“…A review of 97 patients suffering air embolism during percutaneous lung biopsy highlights variability in management. 17 Only the minority of patients had their position changed, mostly to Trendelenburg position. One patient was placed in right lateral decubitus with head down after CT showed air in the left ventricle and one was placed left lateral decubitus with head down after air was seen in the left ventricle.…”