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Ann Thorac Surg 2002;73:1647-1649
© 2002 The Society of Thoracic Surgeons

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Case report

Massive gas embolism during pulmonary nodule hook wire localization

^a Divisions of Thoracic Surgery, Hospital SARAH, Brasília, Brazil
^b Oncology, Hospital SARAH, Brasília, Brazil
^c Anesthesia, Hospital SARAH, Brasília, Brazil

Accepted for publication September 25, 2001.

* Address reprint requests to Dr Horan, Hospital SARAH, SMHS, Quadra 501, Conjunto "A," Brasília, Distrito Federal, 70330-150, Brazil
e-mail: thoran{at}bsb.sarah.br

	Abstract

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The locaization of pulmonary nodules by the hook wire technique has allowed accurate resection of small and nonsuperficial pulmonary nodules by video-assisted thoracoscopic surgery. Hook wire localization has been shown efficacious and safe with principal complications limited to pneumothorax, wire dislocation, and localized intrapulmonary hemorrhage. We report a case of massive gas embolism complicating this procedure. The probable causative mechanisms and possible methods for avoidance are discussed.

	Introduction

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Since its introduction [1], preoperative localization of pulmonary nodules has facilitated VAT (video-assisted thoracoscopic) resection of small and nonsuperficial lesions [2]. The commonly used hook wire technique has been accompanied by a low rate of complications [3]. Recent evidence has confirmed its safety and efficacy [4]. The principal complications have been pneumothorax, localized intrapulmonary hemorrhage, and hook wire dislocation.

In February 2000, a 32-year-old white man presented with a giant cell tumor of the distal right femur 10.5 cm in extent, invading the knee and suprapatellar soft tissues. Clinical evaluation including chest computed tomography (CT) was otherwise normal. Ample tumor-free margins were obtained by en bloc segmental resection of the distal femur, knee joint, and tibial plateau, followed by bone graft arthrodesis. Chest CT follow-up in March 2001, revealed two nodules of 10-mm diameter in close proximity to one another in the left lower lobe. The nodules were judged to be too distant to be palpable to an examining finger. Preoperative hook wire localization and VAT resection was scheduled.

Double lumen tube general anesthesia with the patient in the right lateral recumbent position was accomplished in the CT suite adjacent to the operating theater. A standard hook wire delivered via 20 gauge needle (U.S. Biopsy, Franklin, IN) was positioned between the two tumors during sustained lung inflation. As the first CT image following placement of the hook wire was being obtained, the patient experienced sudden cardiovascular collapse. Bradycardia progressed rapidly to asystole. Immediate resuscitation with external cardiac massage was commenced. Airway difficulties were excluded, manual ventilation with 100% oxygen was begun, and a left-sided chest tube was placed, but no evidence of pneumothorax was encountered. The last CT image was reviewed identifying a large quantity of gas in the descending aorta (Fig 1). The patient was placed in Trendelenburg’s position and vigorous resuscitation continued until spontaneous cardiac output resumed 15 minutes later. Ultrasound exam at 30 minutes demonstrated absence of residual air in the heart and great vessels. The patient recovered from anesthesia within an hour without evidence of altered sensorium or other neurological dysfunction.

View larger version (124K): [in this window] [in a new window]   Fig 1. Aorta with air fluid level just prior to cardiac arrest.

	Comment

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Although gas embolism has been described during cutting and fine-needle biopsies of lung nodules [5, 6], this complication in patients undergoing hook wire localization of pulmonary nodules is rare. This may be simply due to chance and a lower frequency of the hook wire procedure. Air embolism during biopsy techniques may be due to gas entry through induced defects of the pulmonary vasculature. This has been associated with Valsalva maneuver, cough, and mechanical ventilation. Aspiration of air into the pulmonary veins via the open lumen of a needle or along its tract may also be possible [5, 6]. These mechanisms would seem less probable during hook wire placement, because the wire fills the needle during insertion reducing the possibility of cutting action or air aspiration. Following removal of the needle, any disruption caused by its passage through the lung is similarly reduced by the presence of the hook wire within the needle tract. This, however, may not be true of the acutely angled hook, which springs opens as the covering needle is removed (Fig 2). The hook apparatus is 9 mm in length with a spring opening up to 3 mm in width. This may permit passage of air between a bronchiole and adjacent pulmonary vasculature, especially under conditions of positive pressure ventilation. In our case, at resection 2 days after the episode of massive gas embolism, the wire was seen to pass through a sub-segmental bronchus within the surgical specimen, suggesting this possibility. The risk may be higher with the longer trajectories necessary for deeper or more medially placed lesions.

View larger version (31K): [in this window] [in a new window]   Fig 2. Probable mechanism hook wire gas embolism.

Massive gas embolism from hook wire insertion in the lung for localization of pulmonary nodules must be added to the list of possible complications of this procedure. The choice of a short trajectory for the hook wire and avoidance of sustained lung inflation may reduce the likelihood of air embolism. Shortening of the hook’s spring arm might also be beneficial, but would have to be balanced against a likely rise in the already substantial dislocation rate [3, 4]. There may be need to reevaluate the risk of hook wire insertion in light of the other techniques available for nodule localization [7].

	References

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1. Mack M.J., Gordon M.J., Postuma T.W., et al. Percutaneous localization of pulmonary nodules for thoracoscopic lung resection. Ann Thorac Surg 1992;53:1123-1124.[Abstract]
2. Gossot D., Miaux Y., Guermazi A., Celerier M., Friga J. The hook wire technique for localization of pulmonary nodules during thoracoscopic resection. Chest 1994;105:1467-1469.[Abstract/Free Full Text]
3. Sheppard J.A., Mathisen D.J., Muse V.V., Bhalla M., McLoud T.C. Needle localization of peripheral lung nodules for video assisted thoracoscopic surgery. Chest 1994;105:1559-1563.[Abstract/Free Full Text]
4. Thaete F.L., Peterson M.S., Plunkett M.B., Ferson P.F., Keenan R.J., Landreneau R.J. Computed tomography-guided wire localization of pulmonary lesions before thoracoscopic resection: results in 101 cases. J Thorac Imaging 1999;14:90-98.[Medline]
5. Worth E.R., Burton R.J., Landreneau R.J., Eggers G.W., Curtis J.J. Left atrial air embolism during biopsy of a deep pulmonary lesion. Anesthesiology 1990;73:342-345.[Medline]
6. Cianci P., Posin J.P., Shimshak R.R., Singzon J. Air embolism complicating percutaneous thin needle biopsy of lung. Chest 1987;92:749-751.[Abstract/Free Full Text]
7. Moon S.W., Wang Y.P., Jo K.H., et al. Fluoroscopy-aided thoracoscopic resection of pulmonary nodule localized with contrast media. Ann Thorac Surg 1999;68:1815-1820.[Abstract/Free Full Text]

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This Article Abstract 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): Thomas A. Horan Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Horan, T. A. Articles by Rodrigues, M. R. Search for Related Content PubMed PubMed Citation Articles by Horan, T. A. Articles by Rodrigues, M. R. Related Collections Lung - other