All samples were abnormal. In 9 cases, the information obtained was definitive and 1 required a confirmatory Chamberlain procedure. There were no complications associated with the procedures as verified by ultrasound and chest x-ray in all cases, and contrasted-CT chest in 1 case (Table 1). We did not perform any transaortic needle aspirations. No blood was seen in the aspiration syringe during the procedures.
In all cases, the information obtained led to a change in management. All patients were followed for at least 12 months without any signs of complications from the procedure.
The use of traditional TBNA has significantly decreased as the use of convex-probe EBUS increased.12,13 To those trained in traditional TBNA, the accidental puncture of a blood vessel is not rare,14,15 most often leading to a repeat attempt in a different location. To interventional radiologists, the voluntary or accidental puncture of a blood vessel is common practice.16,17 Furthermore, during complicated mediastinoscopies, thoracic surgeons encountering a structure that is suspected to be the pulmonary artery, frequently use a fine needle to gently penetrate and identify if it is a vessel.18 This procedure has not been associated with severe bleeding or meaningful complications.
In contrast, the pulmonary artery is a thin vessel with low pressures, but high flow and a significant laceration is likely to cause a life-threatening complication.
As for the reasons that may explain a lack of significant bleeding in our series and those previously reported in the literature, we should consider that the pulmonary artery is a high-flow, low-pressure system, and traversing its wall with a fine needle of 21 or 22 G is likely to be immediately sealed upon removal of the needle, as long as there is no laceration of the vessel. This is also the case during mediastinoscopy where intentional needle puncture is perfomed.18
Furthermore, some authors have speculated that bleeding from low-pressure systems such as the SVC or PA would cease without packing and will not result in large hematoma or pseudoaneurysm because of the closed nature of the mediastinal compartment with separation from the pleural cavity or open air space, thus they recommend that packing is not necessary unless the bleeding is profuse.22
However, we all recognize that traversing the pulmonary artery should not be considered a safe alternative to left VATS or Chamberlain procedure, but a last resort procedure. It should be carried out after discussing the significant inherent risks with the patient and under the umbrella of a multidisciplinary team where all options have been considered. Most importantly, it should only be performed if the results will be changing management and only by experienced operators who have access to the necessary surgical expertise. In this instance, it should be remembered that the potential candidates for this procedure are already high-risk patients for surgery and a complication that requires emergent surgery is likely to be fraught with difficulties.
It should be noted that the cytologic findings of these trans-PA biopsies resulted in changes in management. In some instances, they confirmed the high suspicion of malignant disease, but in other cases, further discussion with multidisciplinary teams about the risk-benefit ratio, led to a surgical intervention with good results. In other cases, they resulted in cautionary measures to avoid radiation injury to the nearby vessels.23–25
Although algorithms for differentiating risk levels for patients who are candidates for surgical resection have been published,26 the estimation of the risk is highly dependent on the surgical expertise available at each site, and perceptions of the patient and the multidisciplinary team. Criteria that define marginally resectable as contrasted with unresectable are not standardized, and clinical evaluation by an experienced surgeon is necessary and likely to determine the treatment options offered to the patient (Fig. 6).27
The most significant contribution of our manuscript is the external generalizability—the fact that trans-PA needle aspiration guided by EBUS is possible and did not have any complications in the 10 cases included in this study, while being performed by experienced interventional pulmonologists at 7 different sites. How generalizable are these results in other settings remains to be determined.
1. Silvestri GA, Gonzalez AV, Jantz MA, et al.. Methods for staging
non-small cell lung cancer
: diagnosis and management of lung cancer
, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013;143:e211S–e2150.
2. Kinsey CM, Arenberg DA. Endobronchial ultrasound
-guided transbronchial needle aspiration for non-small cell lung cancer staging
. Am J Respir Crit Care Med. 2014;189:640–649.
3. Miller DR, Mydin HH, Marshall AD, et al.. Fatal haemorrhage following endobronchial ultrasound
-transbronchial needle aspiration: an unfortunate first. QJM. 2013;106:295–296.
4. Navani N, Brown JM, Nankivell M, et al.. Suitability of endobronchial ultrasound
-guided transbronchial needle aspiration specimens for subtyping and genotyping of non-small cell lung cancer
: a multicenter study of 774 patients. Am J Respir Crit Care Med. 2012;185:1316–1322.
5. Asano F, Aoe M, Ohsaki Y, et al.. Deaths and complications
associated with respiratory endoscopy: a survey by the Japan Society for Respiratory Endoscopy in 2010. Respirology. 2012;17:478–485.
6. VanderLaan PA, Wang HH, Majid A, et al.. Endobronchial ultrasound
-guided transbronchial needle aspiration (EBUS
-TBNA): an overview and update for the cytopathologist. Cancer Cytopathol. 2014;122:561–576.
7. Edge SB. American Joint Committee on Cancer. AJCC Cancer Staging
Manual, 7th ed. New York: Springer; 2010.
8. Vanderlaan PA, Yamaguchi N, Folch E, et al.. Success and failure rates of tumor genotyping techniques in routine pathological samples with non-small-cell lung cancer
. Lung Cancer
9. Folch E, Yamaguchi N, VanderLaan PA, et al.. Adequacy of lymph node transbronchial needle aspirates using convex probe endobronchial ultrasound
for multiple tumor genotyping techniques in non-small-cell lung cancer
. J Thorac Oncol. 2013;8:1438–1444.
10. van der Heijden EH, Casal RF, Trisolini R, et al.. Guideline for the acquisition and preparation of conventional and endobronchial ultrasound
-guided transbronchial needle aspiration specimens for the diagnosis and molecular testing of patients with known or suspected lung cancer
. Respiration. 2014;88:500–517.
11. Navani N, Nankivell M, Lawrence DR, et al.. Lung cancer
diagnosis and staging
with endobronchial ultrasound
-guided transbronchial needle aspiration compared with conventional approaches: an open-label, pragmatic, randomised controlled trial. Lancet Respir Med. 2015;3:282–289.
12. Toloza EM, Harpole L, Detterbeck F, et al.. Invasive staging
of non-small cell lung cancer
: a review of the current evidence. Chest. 2003;123:157S–166SS.
13. Detterbeck FC, Jantz MA, Wallace M, et al.. American College of Chest Physicians. Invasive mediastinal staging
of lung cancer
: ACCP evidence-based clinical practice guidelines (2nd edition). Chest. 2007;132:202S–220SS.
14. Holty JE, Kuschner WG, Gould MK. Accuracy of transbronchial needle aspiration for mediastinal staging
of non-small cell lung cancer
: a meta-analysis. Thorax. 2005;60:949–955.
15. Mehta AC, Jain P. Interventional Bronchoscopy: A Clinical Guide. New York: Humana Press; 2013:51.
16. Gupta S, Seaberg K, Wallace MJ, et al.. Imaging-guided percutaneous biopsy of mediastinal lesions: different approaches and anatomic considerations. Radiographics. 2005;25:763–786. discussion 86-8.
17. Gupta S, Wallace MJ, Morello FA Jr., et al.. CT-guided percutaneous needle biopsy of intrathoracic lesions by using the transsternal approach: experience in 37 patients. Radiology. 2002;222:57–62.
18. Weeden D, Tsang VT. Cardiothoracic Surgery Essential Surgical Technique. Southampton, UK: Springer; 1997:197–232.
19. Vincent B, Huggins JT, Doelken P, et al.. Successful real-time endobronchial ultrasound
-guided transbronchial needle aspiration of a hilar lung mass obtained by traversing the pulmonary artery. J Thorac Oncol. 2006;1:362–364.
20. Boujaoude Z, Pratter M, Abouzgheib W. Transpulmonary artery
needle aspiration of hilar masses with endobronchial ultrasound
: a necessary evil. J Bronchology Interv Pulmonol. 2013;20:349–351.
21. Folch E, Santacruz J, Machuzak M, et al.. Safety and efficacy of EBUS
-guided TBNA through the pulmonary artery: a preliminary report. Chest J. 2011;140:600A-A.
22. Minowa M, Chida M, Eba S, et al.. Pulmonary artery injury during mediastinoscopy controlled without gauze packing. J Cardiothorac Surg. 2011;6:15.
23. Mesurolle B, Qanadli SD, Merad M, et al.. Unusual radiologic findings in the thorax after radiation therapy. Radiographics. 2000;20:67–81.
24. Fajardo LF, Lee A. Rupture of major vessels after radiation. Cancer. 1975;36:904–913.
25. Kang KH, Okoye CC, Patel RB, et al.. Complications
from stereotactic body radiotherapy for lung cancer
. Cancer. 2015;7:981–1004.
26. Brunelli A, Charloux A, Bolliger CT, et al.. ERS/ESTS clinical guidelines on fitness for radical therapy in lung cancer
patients (surgery and chemo-radiotherapy). Eur Respir J. 2009;34:17–41.
27. Pass HI, Ball D, Scagliotta GV. The IASLC multidisciplinary approach to thoracic oncology. International Association for the Study of Lung Cancer