Air embolus complicating transthoracic percutaneous needle biopsy

Air embolus complicating transthoracic percutaneous needle biopsy

1010 CASEREPORT WONGET AL AIR EMBOLUS COMPLICATINGLUNG BIOPSY 4. Kouchoukos NT, Davila-Roman VG, Spray TL, Murphy SF, Perrillo JB. Replacement of th...

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1010

CASEREPORT WONGET AL AIR EMBOLUS COMPLICATINGLUNG BIOPSY

4. Kouchoukos NT, Davila-Roman VG, Spray TL, Murphy SF, Perrillo JB. Replacement of the aortic root with pulmonary autograft in children and young adults with aortic root with pulmonary autograft in children and young adults with aortic valve disease. N Engl J Med 1994;330:1-6. 5. David H, Bougner DR, Vesely I, Gerosa G. The pulmonary valve: is it mechanically suitable for use as an aortic valve replacement. ASAIO J 1994;40:206-12. 6. Gorczynski A, Trenkner M, Anisimowicz L, et al. Biomechanics of the pulmonary autograft valve in the aortic position. Thorax 1982;37:535-9. 7. Elkins RC. Pulmonary autograft--the optimal substitute for the aortic valve? N Engl J Med 1994;330:59-60. 8. Matsuki O, Okita Y, Almeida RS, et aL Two decades experience with aortic valve replacement with pulmonary autograft. J Thorac Cardiovasc Surg 1988;95:705-11.

Air Embolus Complicating Transthoracic Percutaneous Needle Biopsy Rose S. Wong, MD, Loren Ketai, MD, R. Thomas Temes, MD, Fabrizio M. Follis, MD, and Robert Ashby, MD Division of Thoracic and Cardiovascular Surgery, Department of Surgery, and Department of Radiology, University of New Mexico, Albuquerque, New Mexico

Transthoracic percutaneous needle biopsy has become popular for evaluation of pulmonary nodules. However, it is a procedure with morbidity and mortality that is not negligible. In this article, we report massive air embolus complicating needle biopsy in a patient with amyloidosis. A negative biopsy does not exclude malignancy, and if surgical excision will be performed regardless of the result, preoperative assessment using this technique may not be necessary.

Ann Thorac Surg 1995;59:1010-1

A sixty-two-year-old m a n with a 50 p a c k - y e a r s m o k i n g history a n d amyloidosis refractory to c h e m o t h e r a p y was f o u n d to have a new right u p p e r lobe lesion on routine chest radiography. H e u n d e r w e n t fine-needle aspiration of the mass u n d e r c o m p u t e d t o m o g r a p h i c guidance (Medi-Tech 18-gauge needle; Boston Scientific Corp, Boston, MA). The needle r e q u i r e d repositioning b u t the stylet was m a i n t a i n e d within the h u b a n d the n e e d l e was never o p e n e d to air. Within m i n u t e s the patient comp l a i n e d of increasing back pain a n d dizziness. He became apneic, hypotensive, a n d tachycardic. The n e e d l e with stylet was r e m o v e d a n d he was i n t u b a t e d a n d resuscitated emergently. C o m p u t e d tomographic scan of the chest s h o w e d h e m o r r h a g e at the b i o p s y site a n d an air fluid level in the aortic arch (Fig 1). H e a d c o m p u t e d t o m o g r a p h i c scan s h o w e d no cerebral air or infarct. Within 4 hours of the event, he was treated in a h y p e r baric oxygen c h a m b e r for 30 minutes at 3 a t m o s p h e r e s a n d 90 minutes at 2.5 atmospheres, during which time he was agitated b u t h e m o d y n a m i c a l l y stable. Later that day he was extubated a n d a r e p e a t h e a d c o m p u t e d tomographic scan was performed, which was normal; no evidence of cortical emboli was present. He was initially confused a n d his left side was flaccid; however, over a complicated 3-month hospitalization, the e n c e p h a l o p a thy resolved a n d his left-sided m o t o r function partially returned.

Comment Transthoracic needle biopsy's major role is to diagnose b e n i g n disease, to avoid exploratory thoracotomy, to direct t r e a t m e n t of infectious conditions, a n d to establish a m a l i g n a n t diagnosis in patients who will receive nonsurgical treatment. The sensitivity of the technique in obtaining a cytologic

(Ann Thorac Surg 1995;59:1010-I)

ith the refinement of interventional techniques in chest radiology, m a n y patients are u n d e r g o i n g p e r c u t a n e o u s n e e d l e b i o p s y of p u l m o n a r y nodules. This procedure, however, is not without risk. The most comm o n complications, p n e u m o t h o r a x and hemoptysis, are mild, self-limiting, a n d treatable. Less frequent complications such as severe h e m o r r h a g e a n d air e m b o l i s m m a y be fatal [1]. W e describe in this article a patient with amyloidosis who u n d e r w e n t p e r c u t a n e o u s transthoracic n e e d l e bio p s y (TTNB) of a lesion f o u n d on routine chest radiography. P e r m a n e n t neurologic sequelae d e v e l o p e d from a massive air e m b o l u s sustained during the b i o p s y despite expeditious t r e a t m e n t with h y p e r b a r i c oxygen. Accepted for publication Aug 15, 1994. Address reprint requests to Dr Temes, Division of Thoracic and Cardiovascular Surgery, University of New Mexico, 2211 Lomas Blvd NE, Albuquerque, NM 87131. © 1995 by The Society of Thoracic Surgeons

Fig 1. Chest computed tomographic scan with air fluid level in aortic arch. 0003-4975/95/$9.50

0003-4975(94)00742-P

Ann Thorac Surg 1995;59:1011-3

CASE REPORT VICTORINOET AL THORACOTOMY FOR REPAIROF VENTRICULARRUPTURE

1011

Table 1. Air Embolism Complicating Needle Biopsy of the Lung Age (y)

Sex

Westcott (1973) [7]

62

M

Infection

Aberle (1987) [3] Cianci (1987) [5] Tolly (1987) [6] Baker (1988) [4] Worth (1990) [8l

60 63 32 39 80

M F M F F

Possible malignancy Possible malignancy Possible malignancy Infection Possible malignancy

Author (Year)

Indication

Technique

Outcome

Documentation

Percutaneous 18-gauge

Death

Percutaneous 19-gauge Percutaneous 22-gauge Percutaneous 22-gauge Percutaneous 22-gauge Thoracotomy, 18-gauge TruCut

Death Permanent hemiplegia Transient hemiplegia Death Cardiac arrest

Skull roentgenogram, autopsy Head CT Head CT Chest CT Head CT Crepitus in heart

CT = computed tomographic scan. diagnosis of cancer is greater than 90% in the h a n d s of a skilled radiologist a n d pathologist [1, 2]. A false-positive rate up to 1% can result from misinterpretation of inflamm a t o r y processes [1]. Negative results do not rule out malignancy [2]. For these reasons, m a n y surgeons advocate w e d g e excision in lieu of TTNB to ascertain the true nature of an i n d e t e r m i n a n t lesion. In addition, potential complications m u s t be acknowledged. Patients with b l e e d i n g disorders, s u s p e c t e d vascular malformations or h y d a t i d cysts, p u l m o n a r y h y p e r tension, or bullous a n d e m p h y s e m a t o u s lung disease, a n d those who are unable to cooperate are at higher risk for p n e u m o t h o r a x (25% to 30%), h e m o p t y s i s (5% to 10%), a n d local h e m o r r h a g e (11%) [1]. Rare complications include air embolism, t u m o r implantation, e m p y e m a , a n d b r o n c h o p l e u r a l fistula. Only 6 d o c u m e n t e d cases of air e m b o l i s m complicating TTNB of the lung have b e e n described in the literature over the past 20 years [3-8]. Table 1 s u m m a r i z e s the previous cases a n d their catastrophic outcomes. Air e m b o l i s m can result from a communication between the p u l m o n a r y vein and either the a t m o s p h e r e or bronchus. Biopsy t h r o u g h air-space disease is the most widely recognized risk factor in formation of a b r o n c h o venous fistula. However, u n d e r l y i n g vascular p a t h o l o g y within the lung has been associated with previous cases of air e m b o l i s m d u r i n g lung b i o p s y [3]. In this case, a m y l o i d vasculopathy m a y have inhibited vessel contraction, allowing b r o n c h o v e n o u s fistula formation. Air e m b o l i s m is treated by placing the patient h e a d down, administering 100% oxygen, a n d p r o m p t l y transferring to a h y p e r b a r i c o x y g e n c h a m b e r . Steroids, antiplatelet agents, a n d anticonvulsants should be cons i d e r e d [3]. Transthoracic needle b i o p s y is not risk-free, a n d the rare complication can be devastating. A p u l m o n a r y lesion should be considered for excision if the patient can tolerate general anesthesia. With advances in videoassisted thoracoscopy, surgical removal often can be p e r f o r m e d without thoracotomy. The choice b e t w e e n TTNB a n d w e d g e excision as the initial diagnostic m e t h o d for p e r i p h e r a l lung masses m u s t take into account the patient's clinical condition a n d s u b s e q u e n t t r e a t m e n t plan if the TTNB b i o p s y is negative. © 1995 by The Society of Thoracic Surgeons

References 1. Salazar AM, Westcott JL. The role of transthoracic needle biopsy for the diagnosis and staging of lung cancer. Clin Chest Med 1993;14:99-110. 2. Calhoun P, Feldman PS, Armstrong P, et al. The clinical outcome of needle aspirations of the lung when cancer is not diagnosed. Ann Thorac Surg 1986;41:592-6. 3. Aberle DR, Gamsu G, Golden JA. Fatal systemic arterial air embolism following lung needle aspiration. Radiology 1987; 165:351-3. 4. Baker BK, Awwad EE. Computed tomography of fatal cerebral air embolism following percutaneous aspiration biopsy of the lung. J Comput Assist Tomogr 1988;12:1082-3. 5. Cianci P, Posin JP, Shimshak RR, Singzon J. Air embolism complicating percutaneous thin needle biopsy of lung. Chest 1987;92:749-50. 6. Tolly TL, Feldmeier JE, Czarnecki D. Air embolism complicating percutaneous lung biopsy. AJR 1988;150:555-6. 7. Westcott JL. Air embolism complicating percutaneous needle biopsy of the lung. Chest 1973;63:108-10. 8. Worth ER, Burton RJ Jr., Landreneau RJ, Eggers GWN Jr., Curtis JJ. Left atrial air embolism during intraoperative needle biopsy of a deep pulmonary lesion. Anesthesiology 1990; 73:342-5.

Left Thoracotomy for Emergent Repair of Ventricular Rupture During Mitral Valve Replacement G r e g o r y Victorino, MD, J. Nilas Young, MD, William M. DeCampli, MD, a n d Coyness L. Ennix, Jr, MD Department of Surgery, University of California, Davis-East Bay, and Department of Cardiac Surgery, Alta Bates Medical Center, Berkeley, California Ventricular rupture is a dreaded complication of mitral valve replacement. We present a case of ventricular

rupture that occurred during mitral valve replacement and was successfully repaired through a left thoracotomy approach.

(Ann Thorac Surg 1995;59:1011-3) Accepted for publication Aug 13, 1994. Address reprint request to Dr Young, Center for Cardiac Surgery, 2500 Milvia St, Suite 224, Berkeley,CA 94704. 0003-4975/95/$9.50 0003-4975(94)00741 -O