Abstract

Air embolism is an extremely rare complication of image guided trans-thoracic percutaneous lung biopsy whatever the modality or technique employed. Air embolism in the coronary arteries is an even rarer form and is scarcely reported in British medical literature. We present a case of coronary artery embolism following percutaneous trans-thoracic lung biopsy in a 70 years old female and highlight the need for both the interventional radiologist and the referring physician to be aware of this potentially risky complication. An immediate post-biopsy CT is usually adequate to make the diagnosis and is therefore recommended for patients manifesting vaso-vagal syncope and those with a previous history of myocardial infarction.

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INTRODUCTION

Air embolism is an extremely rare complication of image guided trans-thoracic percutaneous lung biopsy whatever the modality or technique employed. Air embolism in the coronary arteries is an even rarer form and is scarcely reported in British medical literature. Percutaneous image-guided procedures such as lung biopsy are frequently performed in the radiology departments. Several modalities are available for this purpose such MRI, ultrasound and CT. Among these, Percutaneous CT guided lung biopsy is the mainstay of image-guided lung biopsy today (Gohari and Haramati, 2004; Tomiyama et al., 2006). There are possible complications for this procedure which the interventional radiologist must be aware and fully prepared to deal with (Gohari and Haramati, 2004; Anderson et al., 2003; Oikonomou et al., 2004; Manhire et al., 2003). Coronary artery air embolism is hardly a common complication and is therefore under-reported. This case study aims at highlighting its possibility and need for adequate preparation to deal with such a potential medical emergency.

MATERIALS AND METHODS

A 72 years old lady, a smoker for over 50 years presented in the A/E department with dry cough and haemoptysis. She admitted a previous exposure to tuberculosis. Plain chest radiograph of the same day showed 4.5 cm cavitating mass in the left upper lobe (Fig. 1). A contrast enhanced (100 mL Omnipaque 300, GE Healthcare AS Norway) CT examination of the thorax carried out subsequently (40 slice Brilliance MDCT, Philips Medical Systems, Nederland B.V) confirmed the solid lung mass suspicious of cancer (Fig. 2).

Fig. 1:	Plane chest radiograph

PET CT confirmed the presence of a solitary lesion without distant metastases (Fig. 3 and 4).

Following the regular study up the patient underwent a routine CT-guided core biopsy of the mass using an 18 g, 15 cm long quick core cutting needle (William Cook Europe ApS, Denmark).

Access to the lesion proved difficult due to overlying bony structures but eventual success on hitting target was immediately followed by about of coughing with haemoptysis (Fig. 5). She then lapsed into shock rapidly and required resuscitation within the CT room.

Fig. 2:	Solid lung mass suspicious of cancer

 

Fig. 3:	PET presence of solitary lesions without distant metastases

 

She had had 2 previous episodes of myocardial infarction and later described the symptoms, she experienced as similar.

To exclude a major pulmonary haemorrhage or haemothorax or pneumothorax we proceeded to perform a contrast enhanced CT thorax immediately she was haemodynamically stable.

This showed the presence of air bubbles in the left ventricle adjacent to the interventricular septum as well as air in the root of the aorta and in both coronary arteries (Fig. 5-9). There was also a mild left sided pneumothorax.

Fig. 4:	CT presence of solitary lesions without distant metastases

 

Fig. 5:	Bout of coughing with haemoptysis

 

 

Fig. 6:	Gas left ventricle

 

She was transferred to A/E resuscitation room and subsequently to the medical admissions unit. Her ECG did not show evidence of Myocardial infarction and Troponin T<0.010 ug L^-1 (undetectable Troponin T indicates no myocardial injury assuming at least 12 h post event).

Fig. 7:	Gas in aorta

 

Fig. 8:	Right coronary artery

 

 

Fig. 9:	Gas in LCA

 

She made a complete recovery. She was back in the Day Case ward next morning and a check chest radiograph showed resolution of the left pneumothorax. She was discharged without further incident. Consent was obtained from the Ethics committee to reproduce patients CT images and history.

RESULTS AND DISCUSSION

Percutaneous CT guided lung biopsy is the mainstay of image-guided lung biopsy today (Gohari and Haramati, 2004; Tomiyama et al., 2006). Combined with bronchoscopic biopsy it makes up over 90% of diagnostic procedures for tissue diagnosis of intrapul-monary masses (Manhire et al., 2003; Golfieri et al., 1998). The most common documented complications of needle biopsy of the lung whether CT or other image guided are pneumothorax and pulmonary haemorrhage (Gohari and Haramati, 2004; Anderson et al., 2003; Oikonomou et al., 2004; Manhire et al., 2003).

Infection has also been reported as well as haemothorax, seeding along the biopsy needle tract and cardiac tamponade (Manhire et al., 2003; Yoshikawa et al., 2000).

The incidence of air embolism in the coronary arterial system complicating percutaneous transthoracic lung biopsy has been reported only in a handful of cases often associated with myocardial infarction (Mokhlesi et al., 2002; Mansour et al., 2005) although post lung biopsy air embolism has been reported in the systemic circulation (Aberle et al., 1987; Mahyar and Peyman, 2008) including the cerebral arterial tree (Timpert et al., 2006). When it occurs it is potentially life-threatening (Arnold and Zwiebel, 2002).

Vascular air embolism is thus a rare complication of lung biopsy and coronary air embolism is rarer still (Aberle et al., 1987) there has not been even a single case reported in British medical literature.

The physical theory concerning aetiology is evidently the establishment of an abnormal communcation between an airway and pulmonary veins leading to introduction of gas emboli which subsequently flow in usual direction into the left atrium and ventricle and thus to the systemic circulation (Arnold and Zwiebel, 2002). With a cavitating lesion the likelihood rises because of the pressure differences with normal lung. Since pulmonary venous pressure is usually about 10 cm H₂O, Arnold and Zwiebel (2002) have postulated that coughing may have contributed to the introduction of air into the pulmonary veins as a result of the sudden increase in pulmonary airway pressure. Aberle et al. (1987) has suggested in a case of fatal air embolism resulting from needle aspiration in Wergener’s disease that biopsy of abnormal veins in which transmural inflammation prevented the normal vasoconstrictive responses to injury is the causative factor (Arnold and Zwiebel, 2002). In view of the above findings demonstrated by the case report, the question is whether patients should be routinely informed of the remote but documented risk of air embolism, myocardial infarction or stroke consequent to routine image-guided lung biopsy. Also should we routinely perform a full thorax CT following lung/pleural biopsies whenever a patient suffers what may appear to be fainting spell or vaso-vagal syncope?

RECOMMENDATIONS

We recommend that both should be included in the guidelines for percutaneous transthoracic CT-guided lung biopsy.

How to cite this article:

Erondu Okechukwu Felix and Obi C. Iwuagwu Obi Cosmos. Left Ventricular and Coronary Air Embolism Complicating a Routine CT-Guided Cavitating Lung Mass Biopsy: A Case Report.
DOI: https://doi.org/10.36478/rjmsci.2010.248.251
URL: https://www.makhillpublications.co/view-article/1815-9346/rjmsci.2010.248.251