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Letters to the Editor |
Department of Radiology, St Luke’s-Roosevelt Hospital Center, 1000 10th Avenue, New York, NY 10019, e-mail: jsilberzweig@slrhc.org
Editor:
In the July 2000 issue of Radiology, Dr Lang and colleagues (1) evaluated the use of an autologous blood clot seal after lung biopsy in an effort to reduce or prevent pneumothorax. The authors injected an autologous clot through the biopsy needle as the needle was withdrawn from the lesion to the visceral pleura. The results of their work suggested that plugging of the biopsy track significantly reduced the frequency of pneumothorax.
Systemic embolization of an autologous clot should be considered a potential risk of the autologous blood clot seal maneuver. Injection of a clot into the pulmonary vein via the biopsy track may occur in the presence of a needle-created communication between the track and the pulmonary vein. Although, to our knowledge, systemic embolization has not been previously reported, fatal systemic air embolization following percutaneous needle lung biopsy, although rare, has been reported (2,3). Theoretically, air embolism may occur either from the introduction of air into the pulmonary vein directly from the needle or from a needle-created communication of the airway with the pulmonary vein.
Meticulous planning of the biopsy needle trajectory to avoid transgression of blood vessels may minimize embolization risk. Injection of a clot into the track at the lung periphery may reduce embolization risk, since the peripheral pulmonary veins are small (4). Engeler et al (5) used collagen foam plugs to obliterate the biopsy needle track. Prior to insertion of the plug, the needle was pulled back so that the needle tip extended no more than 2 cm into the lung parenchyma.
Decreased patient morbidity is the main objective of the blood patch maneuver. However, this procedure must be weighed against potential catastrophic consequences of systemic embolization.
REFERENCES
Department of Radiology, Tulane University Medical, Center 1430 Tulane Avenue, SL54, New Orleans, LA 70112-2699
I am delighted to respond to the letter by Drs Silberzweig and Hilfer.
I fully agree with the theoretic risk of embolization occurring as a result of inadvertent injection of the blood clot into a pulmonary vein that has been transected. However, our technique includes specific measures to safeguard against this occurrence. The biopsy needle trajectory is carefully planned to avoid transgression of blood vessels. Moreover, when we commence to seat the autologous blood clot, supernatant serum is first injected as the coaxial needle is withdrawn. The autologous blood clot itself is seated in the distal 1
cm of lung parenchyma, exiting into the pleura space. Thus, if a larger pulmonary vein is inadvertently entered, supernatant serum would be injected during this phase of withdrawal; the clot itself ejected in the very periphery of the lung parenchyma would not have the opportunity to enter a large pulmonary vein.
Because of these two precautions, I do not believe that the technique of placing an autologous blood clot is attended by any substantial risk, or any risk at all, of inducing embolization.
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