Argon plasma coagulation (APC) is a form of noncontact electrosurgery that uses ionized argon as the electrical current. It seems to be a safe alternative to neodymium-doped yttrium aluminium garnet (Nd-YAG) laser and electrocautery for debulking exophytic tumors that obstruct the airways, debridement of stent-related granulation tissue, and tumor ingrowth. APC is effective for controlling hemoptysis and for treating lesions located laterally, radially, or around anatomic corners. Portability of the equipment, compatibility with the flexible bronchoscope, and its relatively low cost make APC ideal for therapeutic applications in the outpatient setting and by the bedside of intensive care unit.
A 60-year-old man presented with hemoptysis and right upper lobe mass on chest x-ray (Fig. 1). Initial bronchoscopy showed tumor infiltration of the right main bronchus (RMB) with 50% patency, and biopsy confirmed squamous cell carcinoma. Staging computed tomography thorax performed 3 weeks later showed complete right lung collapse because of extrinsic compression of RMB by the tumor (Fig. 2). Repeat bronchoscopy (BF-IT 160, Olympus, Tokyo, Japan) showed 90% obstruction of RMB by the tumor with contact bleeding. APC (APC 300, ERBE) at 40 W and 0.8 L/min was applied in short bursts for hemostasis while the patient breathed FiO2 35%. However, massive bleeding (600 mL) occurred as APC was performed along the medial wall of RMB. Endotracheal intubation was performed immediately to secure the airway, and the patient was turned to lie on the right side. The patient was mechanically ventilated and subsequent suctioning of the endotracheal tube indicated that the bleeding had abated. He was extubated the next day after bronchoscopic confirmation that the site had stopped bleeding (Fig. 3), and discharged from the hospital without sequelae. He received radiation therapy and died 9 months later from advanced lung cancer.
APC is a noncontact form of electrosurgery in which high-frequency monopolar electrosurgical current is delivered to the tissue through ionized argon plasma. Coagulated tissue has a higher resistance that drives the argon gas flow to the nearby untreated tissue, which results in homogenous and precise thermal tissue coagulation with limited depth of tissue penetration (3 mm). Thus, APC offers uniform coagulation and is associated with negligible risk for airway perforation when compared with laser or electrocautery.1 In clinical practice, APC is widely used to treat vascular lesions of the gastrointestinal tract, such as angiodysplasia,2 and is used in the airways to control hemoptysis and debulk malignant or benign tracheobronchial tumors.1,3 Notably, a major advantage of APC is the ability to treat lesions lateral to the probe or around a corner that is inaccessible to the laser.1,3 It is also observed to be safe for the ablative therapy of stent-related granulation tissue.4 As APC does not generate a direct thermal reaction with airway devices that do not conduct electricity, risks of igniting endotracheal tubes or other airway catheters are much lower than with the Nd-YAG laser. Similarly, the known risk of Nd-YAG laser-induced retinal injury to the operator and technical personnel does not exist during APC instrumentation.5
We report the first case of massive hemorrhage after APC intended for tumor debulking and hemostasis. Despite its shallow depth of penetration at bursts of 1 to 3 seconds, 40 W, and flow rate of 0.8 L/min, care should be exercised when treating airway lesions that are in close proximity to vascular structures, in our case the right pulmonary artery. Endobronchial ultrasound using the radial probe could play a role in the assessment of central airway tumors before ablative therapy, as better delineation conferred by endobronchial ultrasound in the anatomic relationship and structural involvement by the tumor could aid in the prevention of hemorrhage.6
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