Background: A 71-year-old female with a medical history of hypertension, congestive heart failure, pulmonary arterial hypertension, end-stage renal disease on hemodialysis, and colorectal adenocarcinoma status postsigmoid colectomy. The patient underwent a computed tomography (CT) of the chest, which identified multiple bilateral pulmonary nodules measuring up to 1.9 cm, which were FDG avid on PET-CT and concerning for pulmonary metastases. Therefore, she was referred for and underwent CT-guided percutaneous biopsy of the dominant pulmonary nodule in the right upper lobe, without immediate complication. There was expected minimal postbiopsy regional hemorrhage in the lung parenchyma. Postprocedure, follow-up chest radiographs obtained at 1 and 3 h demonstrated rapidly enlarging confluent opacity in the right lung, with poor aeration and leftward mediastinal shift, concerning for hemorrhage secondary to the biopsy. Clinically, the patient was becoming increasingly tachypneic, with respiratory rate in 20 s. She was also having increasing O2 demand, requiring up to 8 l/min to maintain normal oxygen saturations. A CT angiogram of the chest was urgently performed, which demonstrated a large right hemothorax secondary to active hemorrhage from a suspected segmental pulmonary arterial branch in the region of biopsy in the anterior segment of the right upper lobe. Her respiratory status continued to decline, requiring urgent intubation. A right chest tube was also placed, which drained 1300 mL of sanguineous fluid. The patient was transferred to interventional radiology for emergent embolization of presumed active pulmonary hemorrhage. Methods: After appropriate informed consent was obtained and procedural time-out was performed, the patient was placed in supine position and right groin was prepped and draped in usual sterile fashion. The right common femoral vein was accessed under ultrasound guidance and a 7 French vascular sheath was placed. A 6 French pigtail catheter was positioned in the right pulmonary artery, and pulmonary arterial pressures were obtained, measuring 82/32 mmHg (mean arterial pressure 51). A right pulmonary angiogram was then performed, demonstrating contrast extravasation from a right upper lobe segmental pulmonary artery, consistent with active hemorrhage. A 2.4 French microcatheter was then coaxially advanced into the right upper lobe for selective segmental pulmonary angiograms, which confirmed active pulmonary arterial hemorrhage likely from a branch of the anterior segment of the right upper lobe. Gel foam slurry was then administered transcatheter into the anterior segmental pulmonary arterial branch until stasis was achieved. Following that, three Medtronic Concerto detachable coils were deployed. Completion right pulmonary angiogram demonstrated resolution of previously noted contrast extravasation, consistent with effective cessation of hemorrhage. Catheter and sheath were then removed, and adequate hemostasis was achieved at the right common femoral venotomy without complication. Results: Right upper lobe anterior segmental pulmonary arterial hemorrhage related to recent percutaneous lung biopsy was effectively controlled with gel foam and coil embolization. Postprocedure, the patient required intensive care for several days, where her right hemothorax was drained via a large bore chest tube and her respiratory status markedly improved. She remained hospitalized for approximately 5 weeks due to her multiple other comorbidities. Of note, her biopsied lung nodule was positive for metastatic colorectal adenocarcinoma. She was discharged in stable condition without any recurrence of pulmonary hemorrhage during the remainder of her hospital stay. Conclusion: In this case report, we present a very uncommon massive hemothorax from pulmonary artery hemorrhagic complication of a relatively common procedure, percutaneous lung biopsy. There are several known risks of percutaneous lung biopsy, the most common being pneumothorax and pulmonary hemorrhage. Several institutions have reported their experiences with pulmonary hemorrhage related to percutaneous lung biopsy. Incidence of hemorrhage is reported between 20% and 41%, the vast majority of which do not result in any clinical complication. Incidence of hemothorax has been reported as 0.1%–1.3%, with massive hemothorax requiring surgical intervention only described in two cases across several reports including thousands of patients. The etiology of our patient's rapidly enlarging hemothorax was active hemorrhage from the pulmonary arterial vasculature, which was suspected on CT angiogram and confirmed on digital subtraction pulmonary angiography. The patient's history of pulmonary arterial hypertension is classically thought to be a contributing risk factor. However, a recent study by Digumarthy et al. found no significantly increased risk of hemorrhage in patients with pulmonary arterial hypertension. To our knowledge, this is the first case of life-threatening massive hemothorax from postlung biopsy pulmonary artery hemorrhage in our institutional experience.
