The use of endobronchial ultrasound–guided transbronchial needle aspiration (EBUS-TBNA) for diagnosis and staging of benign and malignant thoracic disease has rapidly evolved into the standard of care in most academic centers and many community hospitals.1,2 The complications associated with this procedure are rare and frequently minor. In comparison with traditional TBNA, this procedure is considered safer and rare complications reported include pneumomediastinum, bleeding, pneumothorax, infections, and mediastinitis. Three deaths have been reported in the medical literature.3–5
The lymph node stations that can be reached by EBUS and EUS are substantially more than those that can be accessed by mediastinoscopy (Fig. 1).6 However, in rare cases, the clinician is faced with extraordinary circumstances in which a minimally invasive approach to the lymph nodes in station 5 is required (Fig. 2). We present our findings in 10 cases, at 7 different institutions, where EBUS was instrumental in reaching a diagnosis.
We retrospectively collected information on EBUS cases at 7 institutions, including 10 EBUS-guided TBNA of lymph nodes or masses in the location of lymph node 5 performed in patients with relative or absolute contraindications for surgery.
We defined the territory of lymph node station 5 according to the IASLC map (7th TNM Classification 2009)7: subaortic lymph nodes lateral to the ligamentum arteriosum with the upper border being the lower border of the aortic arch and the lower border being the upper rim of the left main pulmonary artery.
Nine patients had a significant history of smoking and 1 had history of renal cell carcinoma. The procedures were carried out at 7 different institutions by experienced interventional pulmonologists. Six cases were performed under moderate sedation and endobronchial lidocaine to minimize cough and discomfort. Four cases were performed under general anesthesia and use of laryngeal mask. Every patient was consented for the procedure with particular emphasis on the high risk of complications and the unusual nature of the procedure. All cases were performed in isolation from each other. There were no clinical or echocardiographic signs of pulmonary hypertension. A computed tomography was available before the procedure in all cases. Given the complexity of these cases, a multidisciplinary team was involved at the individual institutions before the decision to proceed with transvascular needle aspiration.
A total of 10 patients between 45 and 83 years of age underwent convex-probe EBUS using a 21 or 22 G needle; diagnostic tissue was obtained from lymph node station 5 by traversing the pulmonary artery.
In 3 cases, the concomitant use of fluoroscopy allowed the clinician to document the location of the lesion during the needle biopsy (Fig. 3A). In comparison, the fluoroscopic image of EBUS-TBNA of lymph node station 4L can be seen in Figure 3B. However, the use of fluoroscopy is not usually necessary as the ultrasonographic findings are sufficient to guide the procedure.
Using the dedicated EBUS bronchoscope, the needle was advanced through the vessel wall and traversing to the other side of the pulmonary artery only once. While the needle was inside the lymph node/mass, the needle was moved in usual manner back and forth approximately 15 times while being careful not to repeatedly puncture the vessel wall. In 3 patients, this was repeated once (Figs. 4, 5 and Video 1, Supplemental Digital Content 1, http://links.lww.com/LBR/A125). Suction was applied during the procedure in all cases.
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 emergence of EBUS in the last 10 years is the result of a growing lung cancer epidemic coupled with the need for a safe and effective way to acquire diagnostic tissue from mediastinal and hilar lymph nodes. Recently, the lung cancer guidelines have evolved into recommending EBUS as a primary procedure to accomplish adequate mediastinal staging.1 EBUS-TBNA has also yielded enough tissue for genetic mutation analysis,4,8–10 while minimizing the time to treatment.11
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.
Previous case reports by Vincent et al19 and Boujaoude et al,20 presented initial evidence that intentionally traversing the pulmonary artery was possible in diagnosing one case of neuroendocrine tumor and two cases of adenocarcinoma respectively. Furthermore, we presented our experience in 4 cases at the ACCP Conference in 2011.21
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
As this technology becomes widely available, the limitations of EBUS in reaching lymph node stations 5, 6, 8, and 9 have become apparent. As more and more patients are referred to undergo this procedure, specialists and high-volume centers are asked to evaluate sicker patients and more complex cases.
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.
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