Air embolism occurred during preoperative localization for pulmonary resection: a case description

Introduction

Computed tomography (CT)-guided percutaneous nodule localization is a widely adopted preoperative procedure for pulmonary resection, which serves to facilitate the intraoperative identification of nodules that are small and not adherent to the visceral pleural surface (1). Air embolism represents a rare complication of pulmonary puncture with an extremely high mortality rate. Studies have reported that the incidence of systemic air embolism following lung biopsy ranges from 0.02% to 0.6% (2,3). Compared with biopsy, preoperative localization has a lower incidence of air embolism due to the absence of tissue sampling, and relevant reports are rare. Herein, we report a case of a patient with pulmonary nodule who suffered a sudden severe ventricular air embolism complicated by cardiopulmonary arrest following preoperative CT-guided anchor wire localization.

Case presentation

A 60-year-old male was admitted to Department of Thoracic Surgery, Peking University Third Hospital with an 11-mm ground-glass nodule in the left lower pulmonary lobe and was scheduled for wedge resection. The patient had no significant past medical history. Given the small size of the nodule and its lack of close adherence to the pleura, CT-guided anchor wire localization was performed preoperatively to facilitate intraoperative identification of the nodule. Two hours prior to surgery, the localization wire was successfully placed adjacent to the target pulmonary nodule, and the procedure was uneventful. After the procedure, a complete thoracic CT scan was performed to document the thoracic conditions. However, immediately after the completion of the final scan, the patient suddenly developed loss of consciousness and subsequent cardiorespiratory arrest, with electrocardiogram monitoring showing ventricular fibrillation. The emergency response system was immediately activated, and high-quality cardiopulmonary resuscitation (CPR) was initiated within 1 minute of recognition. Concurrently, the medical team reviewed the CT images, which revealed approximately 10 mL of gas in the left ventricle (Figure 1A) and a small amount of hemorrhage adjacent to the puncture site (Figure 1B). After two rounds of electrical defibrillation, three doses of epinephrine injection, and 15 minutes of external chest compressions, spontaneous circulation and respiration were restored. The patient exhibited severe precordial pain and significant agitation. He was subsequently transferred to the intensive care unit for endotracheal intubation with mechanical ventilation support, along with sedation, analgesia, maintenance of the Trendelenburg position and hypothermic cerebral protection.

Figure 1 Key imaging findings of air embolism and subsequent recovery. (A) Post-procedure CT scan showing air embolism in the left ventricle (red arrow). (B) Post-procedure CT scan showing a small amount of hemorrhage at the puncture site (orange arrow). (C) CT scan on post-procedure day 19 (before the surgery) demonstrating complete resolution of hemorrhage around the nodule and an unchanged position of the localization needle (orange arrow). (D) Surgically resected specimen (blue arrow indicates the nodule; red arrow indicates the flexible tail of the anchor wire). CT, computed tomography.

On post-procedure day (PPD) 1, a repeat thoracic CT scan showed the disappearance of gas in the left ventricle, and no definite intravascular gas was detected on whole-body CT scanning. Bedside echocardiography on PPD 2 revealed “reduced motion of all walls of the left ventricle, impaired diastolic function, and a left ventricular ejection fraction (LVEF) of 35%”, accompanied by elevated cardiac troponin T (cTnT) of 1.3 ng/mL and N-terminal pro-brain natriuretic peptide (NT-proBNP) of 8,400 pg/mL. Stress cardiomyopathy was considered, and acute heart failure management—including the intravenous administration of diuretics and positive inotropic support—along with continuous cardiac monitoring, was initiated. On PPD 6, echocardiography indicated a thrombus in the apex of the left ventricle, measuring approximately 25×8 mm, and anticoagulation with therapeutic-dose low-molecular-weight heparin (LMWH) was administered. On PPD 8, the patient regained consciousness, and the endotracheal tube was removed. On PPD 9, he was transferred to the general ward, with cTnT and NT-proBNP returning to normal levels. A repeat echocardiography on PPD 14 demonstrated that the intracardiac thrombus had essentially resolved, and the LVEF had recovered to 60%.

On PPD 19, the patient underwent single-port video-assisted wedge resection of the left lower lobe under general anesthesia. The position of the localization wire was satisfactory (Figure 1C), and the operation was uneventful. Postoperative pathology confirmed minimally invasive adenocarcinoma (Figure 1D). Anticoagulation with LMWH was discontinued 24 hours before surgery. At 24 hours postoperatively, the drainage volume was under 100 mL and the fluid was clear, so prophylactic-dose LMWH was resumed. The thoracic drainage tube was removed on postoperative day 2, and the patient was discharged uneventfully. At the 1-month follow-up, the patient reported no discomfort, had resumed mild physical activities, and chest X-ray showed good lung re-expansion without pleural effusion.

All procedures performed in this study were in accordance with the Declaration of Helsinki and its subsequent amendments. This study was approved by the Ethics Committee of Peking University Third Hospital. Written informed consent was obtained from the patient for the publication of this article and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Discussion

This case represents a successful resuscitation of a severe air embolism secondary to preoperative pulmonary wire localization. Systemic air embolism is an extremely rare but catastrophic complication of this procedure. The underlying mechanisms may include the following: the puncture needle penetrated both the intrapulmonary airspace and small pulmonary vein simultaneously, allowing intrapulmonary air to enter the pulmonary vein directly through the needle tract (4,5). Systemic air embolism can lead to a variety of severe systemic complications, such as neurological symptoms caused by embolism of the intracranial arteries and cardiovascular symptoms induced by embolism of the coronary arteries. The timing of symptom onset is typically immediate or within minutes post-puncture. The volume of air required to induce severe clinical symptoms is minimal: as little as 2 mL can cause severe cerebral ischemia and even death, while the entry of 0.5–1.0 mL of air into the coronary arteries may trigger cardiopulmonary arrest (6,7). In this case, the volume of gas entering the left ventricle, roughly measured on CT, was approximately 10 mL. The patient presented predominantly with cardiac symptoms, including cardiopulmonary arrest, cardiac arrhythmias, and hypotension. The successful resuscitation and subsequent delayed surgical management in this patient was mainly attributed to the timely identification of the abnormalities and the rapid confirmation of the underlying cause. Therefore, continuous monitoring during the puncture procedure and an additional CT scan after the procedure are of crucial importance. Most studies recommended that the localization wires should not be retained for more than 24 hours (8). However, this case challenges current recommendations: the flexible-tailed anchor wire remained stable and safe in vivo for nearly 3 weeks without displacement or secondary pleuropulmonary injury, after which the thoracoscopic resection was successfully completed. We therefore speculate that the flexible-tailed anchor wire can be safely indwelled in the body for over two weeks, provided that strenuous activities are strictly avoided and intermittent imaging re-evaluations are performed. Recently, advanced modalities like cone beam CT (CBCT) in hybrid operating rooms have enhanced the precision of percutaneous lung nodule localization. Detailed technical guidelines, such as CBCT-guided double-marking techniques, provide real-time trajectory verification to optimize localization accuracy and potentially reduce procedural risks (9).

Conclusions

This case describes the successful resuscitation and subsequent completion of surgery in a patient who developed severe air embolism following CT-guided anchor wire preoperative localization. Continuous vital sign monitoring during the procedure and immediate postoperative imaging examinations are crucial. Additionally, this case suggests that the flexible-tailed anchor wire may be safe and effective after nearly 3 weeks of indwelling in selected patients under close surveillance, providing evidence base for the application of this localization technique.

Acknowledgments

None.

Footnote

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://qims.amegroups.com/article/view/10.21037/qims-2026-0644/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the Declaration of Helsinki and its subsequent amendments. This study was approved by the Ethics Committee of Peking University Third Hospital. Written informed consent was obtained from the patient for the publication of this article and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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