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J Thorac Cardiovasc Surg 2003;126:1207-1209
© 2003 The American Association for Thoracic Surgery

Brief communication

Fatal air embolism during computed tomography–guided pulmonary marking with a hook-type marker

^a Department of Oncological and Regenerative Surgery School of Medicine, The University of Tokushima, Tokushima, Japan
^b Department of Radiology, School of Medicine, The University of Tokushima, Tokushima, Japan

Received for publication March 21, 2003; accepted for publication April 24, 2003.

^* Address for reprints: Shoji Sakiyama, MD, PhD, Department of Oncological and Regenerative Surgery, School of Medicine, The University of Tokushima, Kuramoto-cho 3, Tokushima 770-8503, Japan
sakiyama{at}clin.med.tokushima-u.ac.jp

Pulmonary marking with a hook wire, guided by computed tomography (CT), is often used to assist in the resection of small lung tumors that are difficult to identify by means of thoracoscopic surgical techniques or digital palpation. The most common complications accompanying this procedure are pneumothorax, intrapulmonary hemorrhage, and hemoptysis. These complications are usually mild, self-limiting, and curable. Air embolism is a widely recognized complication of transthoracic percutaneous needle biopsy, but in the case of CT-guided pulmonary marking, few complications have been reported. We report a case of fatal arterial gas embolism during hook wire localization of a pulmonary lesion. The patient mortality was mainly attributed to ischemic heart injury caused by air embolism. Physicians should be aware of this possible complication when a hook wire–type marker is used to avoid further fatalities.

Clinical summary

A 79-year-old woman visited our hospital for an examination of a 2.0-cm abnormal shadow in the left upper lung field revealed by a mass chest radiographic survey. A chest CT demonstrated a 1.5-cm tumor shadow with a faint density and ground-glass opacity in S⁸ of the right lung in addition to a 2.0-cm tumor in S¹⁺² of the left lung (Figure 1).

View larger version (83K): [in this window] [in a new window]   Figure 1. Thin-section CT images: Top, left lung cancer in S1+2; bottom, faint density-type tumor with ground-glass opacity in S8.

On the day of the operation, CT-guided marking for the right pulmonary tumor was performed before the patient was sent to the operating room. The procedure was performed in the left-sided semilateral position with a hook-type marking needle (Guiding Marker System; Hakko Medical Co, Nagano, Japan).

The patient was stable during the procedure. However, she had sudden cardiovascular collapse with unconsciousness, bradycardia, and hypotension as soon as she was returned to the supine position from the left-sided semilateral position after the procedure. Electrocardiography showed a remarkable ST-segment increase in leads II, III, aV_F, and V_1-3. One hundred percent oxygen was administered with a facemask. A hypertensor was administered, and spontaneous breathing was maintained. Chest CT scanning was performed promptly. The CT scan showed an air-fluid level in the ascending aorta and air density in the right coronary artery (Figure 2).

View larger version (111K): [in this window] [in a new window]   Figure 2. Chest CT scan showing air density in ascending aorta and right coronary artery.

Discussion

Gas embolism is a largely iatrogenic clinical problem that can result in serious morbidity and death.¹ Most reported cases of arterial gas embolism in relation to a lung procedure occur during percutaneous lung biopsy.² A reported case such as ours is rare. Recently, opportunities of locating small lesions in the lung and of performing video-assisted thoracoscopic surgery procedures have increased. Accordingly, some preoperative marking for small lesions are considered. Horan and colleagues³ reported a case of arterial air embolism during hook wire localization for a pulmonary nodule. The structure of the hook wire used in that case was similar to the one used on our patient. Both hook apparatuses open into a V shape with spring force after releasing from an introducer (a covering needle).

The possible mechanisms for air embolism during lung procedures are (1) communication between the bronchus, bronchiole, or air space and pulmonary vein and (2) communication between the pulmonary vein and the atmosphere. The first reason listed above is the most likely explanation for the outcome in our case. Although increase of airway pressure caused by a cough, the Valsalva maneuver, or positive pressure ventilation increases the risk,⁴ such circumstances were not found in our case. The second explanation seems less likely to apply to our case because it is doubtful that a large volume of air was sucked into the pulmonary vein through the needle. We measured the relationship between pressure gradient and airflow through the needle that we used. Under 6, 11, and 19 cm H₂O of pressure gradient between the needle tip and its tail, 0, 0.14, and 0.39 mL/10 seconds of air passed through the needle, respectively.

Horan and colleagues³ described a probable mechanism of hook wire gas embolism. In that case the wire penetrated both the venule and the bronchiole, and as a result, the springing open hook wire introduced a connection between the two and caused an air embolism. In contrast to their case, in which the marking procedure was performed during positive pressure ventilation, our case was performed during spontaneous breathing. We could not find the cause of the increase in airway pressure. The lesion was located in the periphery of the right lower lobe and became the highest position in the chest under the left-sided semilateral position. Hence, the pulmonary vein blood pressure around where the hook wire was placed might become lower than the pressure of the airway. This situation might facilitate airflow into the pulmonary vein.

The mortality and morbidity associated with transthoracic needle biopsy cannot be precisely determined but has been estimated at 0.02%⁵ and 0.07%,⁶ respectively. Recently, the use of CT-guided pulmonary marking for small pulmonary lesions before video-assisted thoracoscopic surgery became more frequently used. Three cases of air embolism caused by CT-guided pulmonary marking were reported (Table 1). ^3,7,8 A hook-type marker was used in all cases. In 4 cases the lesions were present in the lower lobe of the lung. The positions in marking procedure of the 4 cases were the lateral or prone position.

References

1. Murphy BP, Harford FJ, Cramer FS. Cerebral air embolism resulting from invasive medical procedures. Treatment with hyperbaric oxygen. Ann Surg. 1985;201:242–245[Medline]
   
2. Wong RS, Ketai L, Temes RT, Follis FM, Ashby R. Air embolus complicating transthoracic percutaneous needle biopsy. Ann Thorac Surg. 1995;59:1010–1011[Abstract/Free Full Text]
   
3. Horan TA, Pinheiro PM, Araujo LM, Santiago FF, Rodrigues MR. Massive gas embolism during pulmonary nodule hook wire localization. Ann Thorac Surg. 2002;73:1647–1649[Abstract/Free Full Text]
   
4. Lalli AF, McCormack LJ, Zelch M, Reich NE, Belovich D. Aspiration biopsies of chest lesions. Radiology. 1978;127:35–40[Abstract]
   
5. Greene RE. Transthoracic needle aspiration biopsy. Athanasoulis CA, Pfister RC, Greene RE, Robertson GH. Interventional radiology. Philadelphia: WB Saunders; 1982. p. 587–634
   
6. Tolly TL, Feldmeier JE, Czarnecki D. Air embolism complicating percutaneous lung biopsy. AJR Am J Roentgenol. 1988;150:555–556[Free Full Text]
   
7. Satake A, Kasugai T, Mizuno K, Saito Y, Urakami T. Japanese abstract. Jpn J Chest Surg. 2002;16:390
   
8. Kamiyoshihara M, Sakata K, Ishikawa S, Morishita Y. Cerebral arterial air embolism following CT-guided lung needle marking. Report of a case. J Cardiovasc Surg (Torino). 2001;42:699–700[Medline]
   

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This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Kazuya Kondo Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Sakiyama, S. Articles by Monden, Y. Search for Related Content PubMed PubMed Citation Articles by Sakiyama, S. Articles by Monden, Y. Related Collections Lung - other