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(Radiology. 2000;216:93-96.)
© RSNA, 2000

Vascular and Interventional Radiology

Autologous Blood Clot Seal to Prevent Pneumothorax at CT-guided Lung Biopsy1

Erich K. Lang, MD, Richard Ghavami, MD, Virginia C. Schreiner, MD, Steven Archibald, MD and Jorje Ramirez, MD

1 From the Department of Radiology, Tulane University School of Medicine, 1430 Tulane Ave, New Orleans, LA 70112 (E.K.L.); the Department of Radiology, State University of New York Health Science, Brooklyn (R.G.); the Department of Radiology, Louisiana State University School of Medicine, New Orleans (V.C.S., S.A.); and the Department of Radiology, Duke University Medical Center, Durham, NC (J.R.). Received February 18, 1999; revision requested April 5; final revision received September 28; accepted October 4. Address correspondence to E.K.L.


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
PURPOSE: To determine whether the use of autologous blood clot seal (ABCS) after biopsy of lung lesions can reduce or prevent pneumothorax.

MATERIALS AND METHODS: The authors evaluated 100 patients (63 men, 37 women; age range, 27–78 years) with pleural (n = 23) or deep (n = 77) lesions. Thirty-eight patients had emphysema. Patients were randomly assigned to one of two groups: those in whom the biopsy track was sealed with autologous blood clot (n = 50) and those who did not receive autologous blood clot (n = 50). Biopsy was performed with computed tomographic (CT) guidance and a 19-gauge coaxial system. The autologous blood clot, which ranged from 0.5 to 4.5 mL, was injected while the sheath was being withdrawn.

RESULTS: Pneumothorax developed in four of the 23 patients (17%) with pleural lesions and 19 of the 77 patients (24%) with deep lesions. Pneumothorax occurred in four of the 45 patients (9%) who had deep lesions and received autologous blood clot and in 15 of the 32 patients (47%) who had deep lesions and did not receive autologous blood clot (P < .001). In patients with emphysema, pneumothorax occurred in three of the 20 patients (15%) who received autologous blood clot and 10 of the 14 (71%) who did not (P < .001). There were seven large pneumothoraces necessitating treatment; all occurred in patients who did not receive autologous blood clot.

CONCLUSION: Plugging of biopsy tracks with ABCS, particularly after biopsy of deep lung lesions, significantly reduced the frequency of pneumothorax—particularly of large pneumothoraces—and, therefore, the need for treatment and the attendant cost.

Index terms: Lung, biopsy, 60.126 • Lung, CT, 60.12115 • Pneumothorax, 60.732


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
The effectiveness of transthoracic needle aspiration biopsy for enabling the diagnosis of chest lesions with acceptable sensitivity and specificity, with a relatively low rate of major complications, and in a cost-effective manner has been recognized (1–15). Pneumothorax, however, which is the most common complication of transthoracic needle aspiration biopsy, can substantially increase costs by converting an outpatient procedure to one mandating hospitalization and treatment with a chest tube for at least a day (2,6–13). A multitude of techniques have been used to seal the resultant track that is responsible for the pneumothorax with fibrin, isobutyl-2-cyanoacrylate, and blood clot seal; all have met with varying success (13,15–19). We performed this study to determine whether a modified technique with use of an autologous blood clot seal (ABCS) can prevent or reduce postbiopsy pneumothorax. Herein we clarify the contradictory results reported in the literature.


   MATERIALS AND METHODS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
Between January 1996 and March 1998, 100 consecutive biopsies were performed in 100 patients with undiagnosed pulmonary nodules at University Hospital Louisiana State University, New Orleans; Charity Hospital—Medical Center of Louisiana, New Orleans; University Hospital, University of Medicine and Dentistry of New Jersey, Newark; and East Orange Veterans Affairs Hospital, NJ. The patients were assigned at random to undergo biopsy either with or without the use of an ABCS. There were 63 men and 37 women ranging in age from 27 to 78 years (mean age, 51 years). Informed consent was obtained from all patients.

The location of the lesion and imaging characteristics were known in all patients from previously obtained computed tomographic (CT) scans. CT was performed with 10-, 8-, 5-, and 4-mm-thick sections with fourth-generation scanners (CGR, Baltimore, Md; GE Medical Systems, Milwaukee, Wis; and Siemens Medical Systems, Iselin, NJ). A spiral technique was used in about 38% of patients.

The location of the lesion was transferred to a skin marker indicating the shortest skin-to-lesion distance. Twenty-three lesions were pleural (parenchymal lesions had direct contact with the pleural surface); of these, six were also adjacent to the diaphragm. Seventy-seven lesions were deep (lesions were separated from the pleura by aerated lung). The lesions were located 1.0–8.0 cm (mean, 3.6 cm) from the pleural surface. The nodules ranged in diameter from 0.8 to 5.2 cm (mean, 2.2 cm). Cavitation was present in three of the 100 lesions (3%).

In the patients treated with ABCS, a mean of 1.72 needle passes were made per lesion; a mean of 1.80 needle passes per lesion were made in patients who did not receive autologous blood clot. There was no statistically significant difference in the ages or lesion sizes of patients treated without ABCS (mean age, 48 years; mean lesion size, 2.4 cm) and with ABCS (mean age, 54 years; mean lesion size, 2.0 cm). Thirty-eight patients had emphysema (21 treated with ABCS; 17 treated without ABCS), which was classified as moderate in 32 patients and severe in six. Three of the patients with severe emphysema did not receive autologous blood clot.

After proper preparation and draping, a local anesthetic was instilled to the level of the parietal pleura. The 22-gauge needle was left in position and a CT scan was obtained to confirm the proper location in relation to the lesion. A coaxial 19-gauge needle system (Temno Coaxial, Bauer, Clearwater Fla; DCBS 100, Cook, Bloomington, Ind) was then advanced to the near margin of the lesion. Advancement of the coaxial needle was carried out after a small inspiration. This minimizes subsequent excursion of the coaxial sheath during breathing and reduces the risk of pleural tear. For deep lesions, a track was selected that allows a perpendicular puncture and avoids fissures, blebs, and large vessels. For pleural lesions, a tangential approach was used. Proper location was confirmed with CT, and one to four aspiration biopsies were performed with 20–22-gauge needles (Chiba and Francene; Cook) (Fig 1a). The specimens were assessed with cytopathologic examination (n = 100), histopathologic examination (n = 86), and flow cytometry (n = 18).



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  		Figure 1a. (a) Transverse CT scan obtained with the patient supine shows advancement of the coaxial sheath (arrowhead) to the near margin of a lesion containing a cavity (arrow). Two aspiration biopsies with a Francene needle (Cook) were performed at the viable rim of the lesion. (b) Transverse CT scan in a supine patient. Injection of supernatant and autologous blood clot commences as the sheath is retracted from its position in the lesion to visceral pleura. Note the hyperattenuating clot and serum (arrowhead) filling the track to the visceral pleura.

 


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  		Figure 1b. (a) Transverse CT scan obtained with the patient supine shows advancement of the coaxial sheath (arrowhead) to the near margin of a lesion containing a cavity (arrow). Two aspiration biopsies with a Francene needle (Cook) were performed at the viable rim of the lesion. (b) Transverse CT scan in a supine patient. Injection of supernatant and autologous blood clot commences as the sheath is retracted from its position in the lesion to visceral pleura. Note the hyperattenuating clot and serum (arrowhead) filling the track to the visceral pleura.

 
Malignant disease was diagnosed in 68 patients (bronchogenic carcinoma in 48, metastatic carcinoma in 17, lymphoma in three), and benign disease was diagnosed in 18 (granuloma in 15, mycetoma in one, abscess in two). Findings were inconclusive in 14 patients; however, malignant disease was subsequently diagnosed in nine of the 14 patients, and benign disease was diagnosed in three. Two patients are currently undergoing follow-up for presumed benign disease.

After completion of the biopsy, supernatant serum and autologous blood clot were injected in 50 patients while the coaxial sheath was being withdrawn, placing the clot from the biopsy site to the visceral pleura (Fig 1b). In the other 50 patients, the coaxial sheath was withdrawn in one swift motion.

The ABCS was prepared by removing 4.0–8.0 mL of blood from an antecubital vein and allowing the blood to clot in the syringe. Then, 0.5–3.0 mL of clot and 0.5–1.5 mL of supernatant were injected at the level of the biopsied nodule, filling the entire track to the visceral pleura (Figs 1b, 2, 3b). The supernatant was primarily deployed at the level of biopsied nodule, the solid clot elements in the peripheral track, and at the point of exit from the visceral pleura.



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  		Figure 2. Transverse CT scan obtained after completion of biopsy procedure with the patient in the prone position demonstrates the biopsy track filled to the visceral pleura with a hyperattenuating fresh blood clot (arrows). Note the small pneumothorax at the level of the puncture site. No treatment was needed, and the patient was discharged after 4 hours of uneventful observation.

 


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  		Figure 3a. (a) Transverse CT scan obtained with the patient prone shows a moderate-sized pneumothorax (arrowheads) resulting from biopsy of a lesion based on the visceral pleura. After injection of an autologous blood clot through the sheath, a seal was attained. (b) Transverse CT scan in a prone patient. The pneumothorax (arrowheads) was aspirated before retracting the sheath from the pleural space, and no further leakage of air occurred during follow-up.

 


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  		Figure 3b. (a) Transverse CT scan obtained with the patient prone shows a moderate-sized pneumothorax (arrowheads) resulting from biopsy of a lesion based on the visceral pleura. After injection of an autologous blood clot through the sheath, a seal was attained. (b) Transverse CT scan in a prone patient. The pneumothorax (arrowheads) was aspirated before retracting the sheath from the pleural space, and no further leakage of air occurred during follow-up.

 
The biopsies were performed by six radiologists with comparable levels of experience (Figs 1b, 2, 3b). Before the patient left the table, 10-mm-thick CT sections were obtained at 5-cm intervals to identify the presence of pneumothorax. The patient then remained in a short stay unit for 4 hours in the recumbent position or with the sampled side dependent.

Finally, a posteroanterior radiograph was obtained before discharge. If a small pneumothorax (5% or less) was present, the patient was either discharged or, if his or her condition was clinically unstable, observation was continued. In patients with a moderate pneumothorax (20%–40%) and particularly in those with emphysema, a 6-F chest tube was introduced. Pneumothoraces of 5% or up to 20% were treated with aspiration through the coaxial sheath and observation for 4 hours. Only those patients with a large pneumothorax who failed to respond to the above measures underwent insertion of a chest tube with waterproof seal and suction.

The frequency of pneumothorax was analyzed according to the presence of emphysema, whether lesions were pleural or deep, and whether ABCS was used in the biopsy track. Statistical calculations were performed by using the {chi}2 test. A P value less than .001 indicated a statistically significant difference.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
DISCUSSION
 REFERENCES
 
As one might expect, the frequency of pneumothorax after CT-guided transthoracic biopsy of pleural lesions was smaller (four of 23 patients [17%]) than that after biopsy of deep lesions (19 of 77 patients [25%]) (Table).


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  		Prevalence of Pneumothorax after Transthoracic Needle Biopsy in Patients with and Patients without ABCS of the Track
 
In the 23 patients with pleural lesions, one small pneumothorax was seen in a patient treated with ABCS. Three of the 18 patients (17%) who did not receive autologous blood clot, however, developed a pneumothorax (Table). We attributed a large hemothorax occurring in this group to a vascular injury representing a different injury than the one causing pneumothorax.

In the 77 patients with deep lesions, pneumothorax occurred in four of the 45 patients (9%) treated with ABCS and 15 of the 32 patients (47%) who did not receive autologous blood clot (P < .001). In patients with emphysema, pneumothoraces occurred in 10 of the 14 patients (71%) who did not receive autologous blood clot and three of the 20 patients (15%) who did (P < .001). Moreover, there was a statistically significant difference in the rate of resultant large pneumothoraces (none of the patients [0%] who received autologous blood clot vs seven of the 32 patients [22%] who did not receive autologous blood clot; P = .001). The need for treatment was influenced by the presence of emphysema and the magnitude of the pneumothorax (20). No patient without emphysema and with a small pneumothorax (5% or less) needed treatment, but three of the eight patients with emphysema and a small pneumothorax had to be treated with aspiration and placement of a Heimlich valve (Bard-Parker; Becton Dickinson, Franklin Lakes, NJ) (Table).

All seven patients with deep lesions and a large pneumothorax required chest tube placement; a Heimlich valve was placed in four of these seven patients. Three patients did not respond to this treatment and underwent prolonged treatment with insertion of a chest tube with a waterproof seal and intermittent suction.

Four patients with a chest tube with suction and waterproof seal and one patient with a chest tube and Heimlich valve, all of which were placed to treat refractory pneumothoraces, were hospitalized for 2–6 days (mean, 3.6 days).


   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
The relatively high frequency of pneumothorax complicating CT-guided biopsy of chest lesions can convert an outpatient procedure to one mandating hospitalization, substantially increasing costs. Many methods and techniques, such as cessation of respiration during the puncture; avoiding transgression of fissures; puncture in a lateral decubitus position; recumbent postoperative position; and sealing the puncture site with blood clot seal, isobutyl-2-cyanoacrylate, and fibrin glue, have been advocated to reduce the risk of pneumothorax but have met with variable success (13,15–20). Meticulous planning of the trajectory to avoid transgression of fissures, blebs, and large blood vessels and to minimize the path through aerated lung has been credited with a substantial reduction of pneumothorax-attendant lung biopsies (21). Determination of the appropriate phase of respiration, usually at minimal inspiration, likewise reduces the subsequent danger of pleural tears (21).

There is consensus that the frequency of pneumothorax increases sharply when biopsy needles are larger than 18 gauge (15–22). Although a 22-gauge biopsy needle will generally produce an adequate sample, biopsy guns that can be used through an 18-gauge sheath may be useful for diagnosing lesions other than carcinomas (21).

The frequency of pneumothorax in patients treated with a blood clot seal at removal of the biopsy sheath varies widely despite seemingly similar techniques. Surprenant (23) reported a frequency of pneumothorax of 5.5%, Bourgouin et al (19) a rate of 28.8%, and Herman and Weisbrod (24) a rate of 45%. All of these investigators used a similar technique of placing the blood patch. A much lower frequency of resultant pneumothorax of about 12% was reported by Moore (21) when using liquid blood to occlude the last 2 cm of the biopsy track. Part of the success in that series, however, may be attributable to meticulous planning of the biopsy trajectory, thus avoiding complications of pneumothorax. The use of a compressed collagen foam plug to seal the pleural biopsy site has resulted in a rate of postbiopsy pneumothorax of 8% (vs 28% in a control group that did not receive a collagen foam plug) (25).

Our method of plugging the biopsy track with ABCS appears to significantly reduce the occurrence of pneumothorax, particularly of large pneumothoraces, thereby reducing the need for treatment and hospitalization. In deep lesions with 1.0–8.0-cm-long biopsy tracks, ABCS reduced the frequency of pneumothorax from 47% (15 of 32 patients) to 9% (four of 45 patients) (P < .001). Moreover, the four resultant pneumothoraces in patients with ABCS and deep lesions were small, and only one (in a patient with emphysema) necessitated treatment with a chest tube and Heimlich valve for 2 days. Conversely, in our 32 patients with deep lesions who did not receive autologous blood clot, seven of the 15 resultant pneumothoraces were large, necessitating treatment with chest tube and Heimlich valve in four and waterproof sealed suction drainage in three (Table). Three of these large pneumothoraces appeared 4–6 hours after biopsy, which is indicative of continued leakage. Two other patients with small pneumothoraces had to be treated with chest tube and Heimlich valve because of the presence of emphysema (Table).

Similar to the experience reported by Fish et al (11), our rate of complicating pneumothorax necessitating treatment in patients with deep lesions was considerably greater in patients with emphysema than in those without emphysema (six of 34 patients [18%] vs two of 43 patients [5%], respectively). The markedly reduced need for treatment of biopsy complications and hospitalization was primarily responsible for curtailing cost. As judged by limited follow-up of nine patients who underwent CT a mean of 57 days after biopsy (1–62 weeks), ABCS did not induce untoward reactions or late sequela. Although the need for ABCS in patients with pleural lesions may be reduced because the biopsy track traverses an area of pleural fixation, a pneumothorax can result if one is dealing with a visceral pleural lesion and the lung retracts. In such patients, the use of an ABCS may be advantageous (Fig 3).

The seemingly lower rate of pneumothoraces in our series—particularly of large pneumothoraces—compared with that reported in other series may be attributable to a number of modifications in technique (19,22–24). Meticulous planning of the trajectory of the proposed biopsy track to avoid fissures, blebs, large vessels and, if possible, to follow scars that extend to the pleural surface and the use of the perpendicular entry will in themselves reduce the risk of pneumothorax, as has also been shown by other investigators (21). Immediate positioning of the affected side downward will maximize the effect of the ABCS. Our technique of injecting supernatant at the point of entry of the biopsy track into the lesion and clot at the visceral pleural exit site of the track appears to ensure a better seal. Moreover, because of the dependent position, the supernatant will settle toward the visceral pleural entry site of the track and afford further seal. Last, adherence to a 4-hour rest period bridges the most crucial postoperative period during which pneumothoraces develop.

On the basis of our experience, the use of ABCS placed through the coaxial sheath is strongly recommended when performing biopsy of deep lesions because it significantly reduces the frequency of pneumothorax and the subsequent need for chest tube placement and hospitalization.


   ACKNOWLEDGMENTS
 
We acknowledge the efforts and valuable help of Steven Archibald, MD, and Virginia C. Schreiner, MD, in the review of material for this article.


   FOOTNOTES
 
Abbreviation: ABCS = autologous blood clot seal

Author contributions: Guarantor of integrity of entire study, E.K.L.; study concepts and design, E.K.L.; definition of intellectual content, E.K.L.; literature research, E.K.L., R.G.; clinical studies, E.K.L., V.C.S., J.R., S.A.; data acquisition, V.C.S., J.R., S.A.; data analysis, E.K.L., R.G.; statistical analysis, R.G.; manuscript preparation, R.G.; manuscript editing and review, E.K.L.


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 

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