Fatal
Intrathoracic
Hemorrhage
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LEE
Because tion
of a lower
lung
biopsy
incidence is
B.
After
MILNER,1
KEVIN
of complications,
performed
in
Percutaneous RYAN,2
aspira-
preference
to
0.1%
aspiration
[2].
Four
lung
biopsy,
documented
lower
A 61-year-old
white
site. About
pulmonary
in the
nodules
posterior
basal
central
from
had multiple
pulmonary
were discovered. of the
was suggested. Coagulation count, prothrombin time,
in the posterolateral
aspect
(fig. 1). Within
of the left
one tear a small
to the five tears and obliquely
in line
nervous
system
were unremarkable. Discussion
Despite careful patient selection, aspiration needle biopsy remains a potentially fatal procedure. The usually accepted contraindications include a known bleeding diathesis or abnormal coagulation studies, emphysematous blobs or buiiae in the biopsy area, pulmonary hypertension, central on suspected vascular lesions, pulmonary function studios indicating inability to tolerate a significant pneumothorax, and inability of the patient to cooperate. This patient foil into none of these categories, and the exact reason for his death remains obscure. Slight respiratory motion may have caused the supenficial tears, resulting in laceration of the small muscular artery, and causing acute massive exsanguination. Considerable pulmonary edema, hemorrhage, and massive hemothorax compromised the patient’s cardiopuimo-
nodules.
left
The largest lower
lobe
and
were were
best seen at 4 cm by tomography. These were suspected to represent metastases from the known hypernephroma; however, more obscure causes could not be excluded, and a lung biopsy blood
3.9 cm distal
aspiration
Report
segment
tears
a 1 cm radius
with them was a 2.3 cm nodule of metastatic renal cell carcinoma. There was no gastric aspiration or blood within the tracheobronchial tree and no evidence of thrombotic or air embolism. The coronary vascuiature, cerebral vasculature, and
History included a nephrectomy for a hypernephroma about 1 ‘/2 years prior to admission. About 2 months before admission
several
GULLO3
the fatality rate was
fatalities
man
lobe within
Lung Biopsy
muscular artery appeared to have been severed. The position of all five tears was anatomically juxtaposed to the closed biopsy
lung biopsy are recorded in the literature [3-6]. This case reemphasizes the potential hazard of this increasingly common procedure.
Case
JOHN
pleural-parenchymal
other
closed-lung biopsy techniques. Norenbeng et al. [1] noted the increased risk of a cutting type or Vim-Silverman needle in performing closed-lung biopsies. This has been confirmed by Herman and Hessel [2]. The mochanisms of death after aspiration lung biopsy are tension pneumothorax, air embolism, and pulmonary hemorrhage with or without aspiration [3]. Of 1 562 patients undergoing
AND
Aspiration
studies, including partial thromboplastin
complete time,
and bleeding time, were normal. Preoperative electrocardiography was also normal. The lesion at the left base was selected for biopsy.
The technique used was that described originally by Dahigren and modified by Meyer et al. [7]. This procedure had been successfully performed in 50 patients by one of us (L. B. Mimer) either alone or with another radiologist. A 15.2 cm 20 gauge needle with a radial bevel tip was utilized, marked off to a depth of 4.5 cm. Superficial anesthesia with a 25-gauge needle was carefully placed to a depth of 1 cm. The lesion was localized
under fluoroscopy and a single pass was performed with no patient motion or respiration Fluoroscopy immediately after the procedure demonstrated no pneumothorax. About 5 mm after .
the procedure,
expectorated of some
chest tempts
the patient
about
heaviness
down
and
at cardiac
complained
20 ml bright in his
rapidly
that he had to cough
red blood.
chest.
He was
became
resuscitation
placed
unresponsive.
were
and
He also complained with
the
Extensive
unsuccessful.
left
at-
A left chest
tube was placed during the resuscitation and 500 ml bright red blood was removed. At autopsy, the posterolateral aspect of the thoracic wall demonstrated a small puncture at the percutaneous biopsy site. About 900 ml blood was present in the left thoracic cavity. The left lung weighed 850 g and was the site of acute massive intraparenchymai hemorrhage and congestion. There were five
Received
July
Department Milner. 2 Department 3 Department ,
AJR 132:280-281 © 1979 American
28, 1978;
accepted
of Radiology. of Pathology, of Medicine, ,
February Roentgen
after
Georgetown
revision
October
University
Fig.
Left lower lobe. Largest pleural-parenchymal tear with lacerartery (open arrow), smaller superficial tears (arand severe intraparenchymal hemorrhage (arrowhead). 1.
-
ated small muscular rows),
5, 1978.
Hospital,
3800
Reservoir
Road,
NW.
Georgetown University Hospital, Washington, D.C. 20007. Division of Medical Oncology, Georgetown University Hospital. 1979 Ray Society
280
,
washington, Washington,
s.c. 20007. Address
reprint
requests
to L. B.
D.C. 20007. 0361-803X/79/1322-028o
$0.00
AJR:132,
February
CASE
1979
nary status. A previous syncopal episode suggests a possible underlying cardiac abnormality. However, this
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was
not
confirmed
at autopsy.
Despite meticulous attention to detail the patient succumbed to a fatal complication. Short of standby facilities of a shock trauma unit, at present nothing can prevent similar complications. The extreme rarity of this situation mitigates against the use of such extensive precautions. In evaluating the benefit-to-risk ratio in the individual patient, the radiologist should continue to be aware
of the potential
mortality
of aspiration
lung
biopsy.
REFERENCES 1 . Norenberg
needle
A, Claxton CP Jr, Takaro T: Percutaneous biopsy of the lung: report of two fatal complications.
281
REPORTS
Chest
2. Herman
66:216-218, 1974 PG, Hessel SJ: The diagnostic
plications 1977
of closed
lung
accuracy
biopsies.
Radiology
and com125:11-14,
3. Westcott JL: Air embolism complicating percutaneous needle biopsy of the lung. Chest 63 : 108-1 10, 1973 4. Lauby VW, Burnett WE, Rosemond GP, Tyson AR: Value and risk of biopsy of pulmonary lesions by needle aspiration. J Thorac Cardiovasc Surg 49: 159-172, 1965 5. Pearce JG, Patt NL: Fatal pulmonary hemorrhage after percutaneous aspiration lung biopsy. Am Rev Respir Dis 110:346-349, 1974
6. Woolf review
CR: Applications of aspiration lung biopsy of literature. Dis Chest 25 :286-300, 1954
with
7. Meyer
JE,
PerJ
cutaneous Thorac
Gandbhir
LH,
aspiration
Cardiovasc
Milner
LB,
McLaughlin
biopsy Surg
of nodular lung 73 : 787-791 1977 ,
MM:
lesions.