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
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. 1. Introduction Percutaneous computed tomography- (CT-) guided lung biopsy, an everyday practice in many institutions, has well-known potential complications, in numbers, mainly occurring as pneumothorax and pulmonary bleeding with both of them normally requiring little or no further treatment. Systemic air embolism is a feared and potentially fatal complication but with very low reported incidences ranging from 0,001% to 0,003% according to publications dealing with greater series of biopsies [1, 2]. Statistically, most radiologists performing percutaneous lung biopsies will never have to deal with this complication. On the other hand one study with a smaller patient population recently reported an incidence of 3,8% . Risk factors for systemic air embolism have been speculated, postulated, and reported; these include use of a coaxial biopsy system, number of biopsies, needle path through a longer distance of ventilated lung, coughing during the procedure, positive pressure ventilation, location of lesion in the lower lobes or lower parts of the lung, location of the lesion above the level of the left atrium, vasculitis, and small or cavitary lesions with some of these being influenceable or even avoidable and others not [2–9]. Prone positioning as a truly influenceable factor has been considered a risk factor  but to our knowledge has never been evaluated systematically in a literature review. Our very first case of systemic air embolism after CT-guided lung biopsy occurred at our institution after performing the procedure for much more than 10 years with a frequency of at least 50 cases per year. We are presenting this case, as we strongly believe that, in the light of the very low incidence of this complication, every
N. Tomiyama, Y. Yasuhara, Y. Nakajima et al., “CT-guided needle biopsy of lung lesions: a survey of severe complication based on 9783 biopsies in Japan,” European Journal of Radiology, vol. 59, no. 1, pp. 60–64, 2006.
S. S. Hare, A. Gupta, A. T. C. Goncalves, C. A. Souza, F. Matzinger, and J. M. Seely, “Systemic arterial air embolism after percutaneous lung biopsy,” Clinical Radiology, vol. 66, no. 7, pp. 589–596, 2011.
M. C. Freund, J. Petersen, K. C. Goder, T. Bunse, F. Wiedermann, and B. Glodny, “Systemic air embolism during percutaneous core needle biopsy of the lung: frequency and risk factors,” BMC Pulmonary Medicine, vol. 12, article 2, 2012.
H. Ishii, T. Hiraki, H. Gobara, et al., “Risk factors for systemic air embolism as a complication of percutaneous CT-guided lung biopsy: multicenter case-control study,” CardioVascular and Interventional Radiology, vol. 37, no. 5, pp. 1312–1320, 2014.
R. Thomas, B. Thangakunam, R. A. Cherian, R. Gupta, and D. J. Christopher, “Cerebral air embolism complicating CT-guided trans-thoracic needle biopsy of the lung,” Clinical Respiratory Journal, vol. 5, no. 2, pp. e1–e3, 2011.
W. M. Al-Ali, T. Browne, and R. Jones, “A case of cranial air embolism after transthoracic lung biopsy,” American Journal of Respiratory and Critical Care Medicine, vol. 186, no. 11, pp. 1193–1195, 2012.
T. Hiraki, H. Fujiwara, J. Sakurai et al., “Nonfatal systemic air embolism complicating percutaneous CT-guided transthoracic needle biopsy: four cases from a single institution,” Chest, vol. 132, no. 2, pp. 684–690, 2007.
H. K. Kok, S. Leong, U. Salati, W. C. Torreggiani, and P. Govender, “Left atrial and systemic air embolism after lung biopsy: Importance of treatment positioning,” Journal of Vascular and Interventional Radiology, vol. 24, no. 10, pp. 1587–1588, 2013.
D. R. Smit, S. A. Kleijn, and W. G. de Voogt, “Coronary and cerebral air embolism: a rare complication of computed tomography-guided transthoracic lung biopsy,” Netherlands Heart Journal, vol. 21, no. 10, pp. 464–466, 2013.
K. Suzuki, M. Ueda, K. Muraga et al., “An unusual cerebral air embolism developing within the posterior circulation territory after a needle lung biopsy,” Internal Medicine, vol. 52, no. 1, pp. 115–117, 2013.
G. R. Shroff, M. Sarraf, M. D. Sprenkle, and R. M. Karim, “Air embolism involving the coronary and pulmonary circulation: an unusual cause of sudden cardiac death,” Circulation, vol. 124, no. 25, pp. 2949–2950, 2011.
A. Singh, A. Ramanakumar, and J. Hannan, “Simultaneous left ventricular and cerebral artery air embolism after computed tomographic-guided transthoracic needle biopsy of the lung,” Texas Heart Institute Journal, vol. 38, no. 4, pp. 424–426, 2011.
W. Bou-Assaly, P. Pernicano, E. Hoeffner, et al., “Systemic air embolism after transthoracic lung biopsy: a case report and review of literature,” World Journal of Radiology, vol. 2, no. 5, pp. 193–196, 2010.
H.-M. Cheng, K.-H. Chiang, P.-Y. Chang, et al., “Coronary artery air embolism: a potentially fatal complication of CT-guided percutaneous lung biopsy,” The British Journal of Radiology, vol. 83, no. 988, pp. e83–e85, 2010.
H. L. Kuo, L. Cheng, T. J. Chung, and et al, “Systemic air embolism detected during percutaneous transthoracic needle biopsy: report of two cases and a proposal for a routine postprocedure computed tomography scan of the aorto-cardiac region,” Clinical Imaging, vol. 34, no. 1, pp. 53–56, 2010.
K. Ibukuro, R. Tanaka, T. Takeguchi, H. Fukuda, S. Abe, and K. Tobe, “Air embolism and needle track implantation complicating CT-guided percutaneous thoracic biopsy: single-institution experience,” American Journal of Roentgenology, vol. 193, no. 5, pp. W430–W436, 2009.
Y. Ishikawa, H. Matsuguma, R. Nakahara, A. Ui, H. Suzuki, and K. Yokoi, “Arterial air embolism: a rare but life-threatening complication of percutaneous needle biopsy of the lung,” Annals of Thoracic Surgery, vol. 87, no. 5, p. 1622, 2009.
S. Hirasawa, H. Hirasawa, A. Taketomi-Takahashi et al., “Air embolism detected during computed tomography fluoroscopically guided transthoracic needle biopsy,” CardioVascular and Interventional Radiology, vol. 31, no. 1, pp. 219–221, 2008.
D. H. Hsi, T. N. Thompson, A. Fruchter, M. S. Collins, O. U. Lieberg, and H. Boepple, “Simultaneous coronary and cerebral air embolism after CT-guided core needle biopsy of the lung,” Texas Heart Institute Journal, vol. 35, no. 4, pp. 472–474, 2008.
M. Tomabechi, K. Kato, M. Sone et al., “Cerebral air embolism treated with hyperbaric oxygen therapy following percutaneous transthoracic computed tomography-guided needle biopsy of the lung,” Radiation Medicine, vol. 26, no. 6, pp. 379–383, 2008.
T. Kau, E. Rabitsch, S. Celedin, S. M. Habernig, J. R. Weber, and K. A. Hausegger, “When coughing can cause stroke - A case-based update on cerebral air embolism complicating biopsy of the lung,” CardioVascular and Interventional Radiology, vol. 31, no. 5, pp. 848–853, 2008.
A. Khalil, H. Prigent, A. Parrot, and M.-F. Carette, “Systemic air embolism complicating percutaneous transthoracic needle biopsy,” The American Journal of Roentgenology, vol. 187, no. 2, pp. W242–W243, 2006.
G. Lattin Jr., W. O'Brien, B. McCrary, P. Kearney, and D. Gover, “Massive systemic air embolism treated with hyperbaric oxygen therapy following CT-guided transthoracic needle biopsy of a pulmonary nodule,” Journal of Vascular and Interventional Radiology, vol. 17, no. 8, pp. 1355–1358, 2006.
K. I. Timpert, J. Schmutz, and K. Steinke, “Massive zerebrale Luftembolie nach Computertomographie-gesteuerter Lungenbiopsie,” Fortschritte auf dem Gebiet der R？ntgenstrahlen, vol. 178, no. 4, pp. 441–443, 2006.
A. Mansour, S. AbdelRaouf, M. Qandeel, and M. Swaidan, “Acute coronary artery air embolism following CT-guided lung biopsy,” CardioVascular and Interventional Radiology, vol. 28, no. 1, pp. 131–134, 2005.
K. Ashizawa, H. Watanabe, H. Morooka, and K. Hayashi, “Hyperbaric oxygen therapy for air embolism complicating CT-guided needle biopsy of the lung,” The American Journal of Roentgenology, vol. 182, no. 6, pp. 1606–1607, 2004.
S. Ohashi, H. Endoh, T. Honda, N. Komura, and K. Satoh, “Cerebral air embolism complicating percutaneous thin-needle biopsy of the lung: complete neurological recovery after hyperbaric oxygen therapy,” Journal of Anesthesia, vol. 15, no. 4, pp. 233–236, 2001.
B. Mokhlesi, I. Ansaarie, M. Bader, M. Tareen, and J. Boatman, “Coronary artery air embolism complicating a CT-guided transthoracic needle biopsy of the lung,” Chest, vol. 121, no. 3, pp. 993–996, 2002.
F. Kodama, T. Ogawa, M. Hashimoto, Y. Tanabe, Y. Suto, and T. Kato, “Fatal air embolism as a complication of CT-guided needle biopsy of the lung,” Journal of Computer Assisted Tomography, vol. 23, no. 6, pp. 949–951, 1999.
D. Regge, T. Gallo, J. Galli, A. Bertinetti, C. Gallino, and E. Scappaticci, “Systemic arterial air embolism and tension pneumothorax: two complications of transthoracic percutaneous thin-needle biopsy in the same patient,” European Radiology, vol. 7, no. 2, pp. 173–175, 1997.
B. K. Baker and E. E. Awwad, “Computed tomography of fatal cerebral air embolism following percutaneous aspiration biopsy of the lung,” Journal of Computer Assisted Tomography, vol. 12, no. 6, pp. 1082–1083, 1988.
C. C. Wu, M. M. Maher, and J.-A. O. Shepard, “Complications of CT-guided percutaneous needle biopsy of the chest: prevention and management,” American Journal of Roentgenology, vol. 196, no. 6, pp. W678–W682, 2011.
The Royal College of Radiologists, Protocol for Prevention of and Management of Vascular Air Embolism during Interventional Radiological Procedures, The Royal College of Radiologists, London, UK, 2011, BFCR(11)7.
B. M. P. Rademaker, F. A. Groenman, P. A. van der Wouw, and E. A. Bakkum, “Paradoxical gas embolism by transpulmonary passage of venous emboli during hysteroscopic surgery: a case report and discussion,” The British Journal of Anaesthesia, vol. 101, no. 2, pp. 230–233, 2008.
S. Donepudi, D. Chavalitdhamrong, L. Pu, and P. V. Draganov, “Air embolism complicating gastrointestinal endoscopy: a systematic review,” World Journal of Gastrointestinal Endoscopy, vol. 5, no. 8, pp. 359–365, 2013.
M. M. Maher, M. K. Kalra, R. L. Titton, et al., “Percutaneous lung biopsy in a patient with a cavitating lung mass: indications, technique, and complications,” American Journal of Roentgenology, vol. 185, no. 4, pp. 989–994, 2005.
A. M. Rozenblit, J. Tuvia, G. N. Rozenblit, and A. Klink, “CT-guided transthoracic needle biopsy using an ipsilateral dependent position,” The American Journal of Roentgenology, vol. 174, no. 6, pp. 1759–1764, 2000.
B. C. Odisio, A. L. Tam, R. Avritscher, S. Gupta, and M. J. Wallace, “CT-guided adrenal biopsy: comparison of ipsilateral decubitus versus prone patient positioning for biopsy approach,” European Radiology, vol. 22, no. 6, pp. 1233–1239, 2012.