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% [3]. 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 [3] 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
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