Elsevier

Clinical Imaging

Volume 48, March–April 2018, Pages 127-130
Clinical Imaging

Case Report
Nonfatal air embolism complicating percutaneous CT-guided lung biopsy and VATS marking: Four cases from a single institution☆,☆☆

https://doi.org/10.1016/j.clinimag.2017.10.010Get rights and content

Highlights

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    To know systemic air emboli occur as a rare complication of CT guided lung biopsy and VATS marking.

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    To present four cases of air emboli from a single institution and the imaging findings.

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    To show the embolism' kinetics using contrast-enhanced media during VATS color marking with indocyanine green.

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    Early detection using routine whole-lung CT is required for asymptomatic patients with abnormal air.

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    To present the management of the abnormal air, including the patient's posture in order to prevent moving the air.

Abstract

Systemic air emboli occur as a rare complication of percutaneous needle biopsy of the lung and video-assisted thoracoscopic surgery (VATS) marking.

Here we present four cases of systemic air emboli from single institution and the imaging findings and embolism' kinetics using contrast-enhanced media during VATS color marking with indocyanine green. We suggest that early detection using routine whole-lung CT is required for asymptomatic patients with abnormal air. If abnormal air is found, we should keep the patient to the appropriate posture in order to prevent moving the air until it dissipates. Early detection of abnormal air can prevent severe complications.

Introduction

Percutaneous computed tomography (CT)-guided lung biopsy and the CT-guided preoperative pulmonary marking for video-assisted thoracoscopic surgery (VATS marking) have become a widely accepted diagnostic procedure for evaluating lung lesions including lung adenocarcinomas in the form of ground glass nodule and have been performed at many institutions [1], [2], [3], [4], [5]. The VATS marking has been performed in an attempt to identify small tumors easily during VATS. In preoperative VATS marking, hook wire, color (methylene blue and indocyanine green etc.), and barium are used [6], [7]. These procedures have the CT-guided pleural puncture.

Such procedures have several major and well-known complications, such as pneumothorax and pulmonary bleeding, neither of which usually require further treatment [8]. Although the incidence of systemic air emboli is very low, at 0.001%–3.8%, these emboli are occasionally fatal [1], [2], [3], [4], [8]. Hence, the incidence of air emboli may be underestimated in patients without cardiac or cerebral symptoms in whom the air quickly disappears.

Here we report four cases of systemic air emboli and demonstrate their imaging findings, time-dependent changes, kinetics using contrast-enhanced media during VATS color marking with indocyanine green, and treatment.

Section snippets

Case 1

A 58-year-old female presented with a ground-glass nodule. Cardiopulmonary arrest due to ventricular fibrillation occurred immediately after VATS marking with a hook wire in the supine position in which the VATS marker needle was passed through the minor fissure (Table 1, Fig. 1a). This caused a large volume of air to fill the right coronary arteries (Fig. 1b, arrow). Abnormal air was observed in the ascending aorta, coronary artery, and left ventricle. Risk factors of this case included a long

Discussion

The four cases presented here did not lead to severe residual complications. We believe that the early detection of air emboli leads to earlier treatment and absence of severe complications. It is critically important to prevent residual air from moving to avoid severe complications.

Risk factors for systemic air emboli include the use of a coaxial biopsy system, the number of biopsies, a long needle pathway through the ventilated lung, the patient coughing during the procedure, positive

Declaration of conflicting interests

The authors declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Ethical approval

All procedures performed in the studies involving human participants were in accordance with the ethical standards of the institutional and national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

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    Funding: None.

    ☆☆

    Conflict of interest: All authors have no conflict of interest to declare.

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