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.

Fatal intrathoracic hemorrhage after percutaneous aspiration lung biopsy.

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