Pneumothorax after CT-guided transthoracic lung biopsy: A comparison between immediate and delayed occurrence

Elastography Versus B-Mode Lung Ultrasound for the Diagnosis of Iatrogenic Pneumothorax: An Observational, Monocentric, Prospective Study

Background: Thoracic ultrasound (TUS) has emerged as a viable alternative of computed tomography (CT) for pneumothorax diagnosis. Ultrasound elastography (USE), a technique assessing tissue elasticity, has recently been proposed as a novel tool for pneumothorax evaluation. Methods: This prospective, monocentric, observational study aimed to compare the diagnostic accuracy of static and dynamic USE with TUS in detecting iatrogenic pneumothorax after CT-guided transthoracic needle aspiration (TTNA). Results: Thirty-two patients were enrolled, with pneumothorax confirmed via CT in 40.63% of cases. The results showed that elastographic-mode images had significantly higher sensitivity (76.9% vs. 21.2%, p < 0.001) and improved positive and negative predictive values (67.8% vs. 52.4%, p-value 0.01, 82.6% vs. 61.7%, p-value < 0.001, respectively), compared to B-mode images. Concordance between expert and non-expert evaluators was also higher for elastographic images, suggesting improved interpretability. However, dynamic USE did not demonstrate a statistically significant advantage over B-mode videos. Conclusions: These findings suggest that USE may enhance static ultrasound-based pneumothorax detection and provide an objective imaging marker for reports. Further multicenter studies are needed to confirm these findings and explore the potential role of USE in other settings.

Effect of needle aspiration for treatment of moderate to severe non-tension pneumothorax after transthoracic needle biopsy

Background

Transthoracic needle biopsy (TTNB) is a widely used technique for assessing parenchymal lung diseases. However, pneumothorax often occurs after TTNB and may sometimes require chest tube drainage. We aimed to evaluate the efficacy and safety of simple needle aspiration for treating moderate to severe non-tension pneumothorax following TTNB.

Methods

This prospective, single-center pilot study conducted between May and November 2021. Participants with non-tension pneumothorax measuring >25% in size on radiography after TTNB were included. Simple needle aspirations were performed through the second intercostal space on the midclavicular line using a 16-gauge angio-catheter. Changes in the size of the pneumothorax were assessed using chest radiographs at 1 and 12 h postprocedure.

Results

Seven patients with moderate to severe pneumothorax after TTNB were included. Needle aspirations were successful in all patients without complications. Pneumothoraces improved in five patients after needle aspiration, eliminating the need for chest tube drainage. However, in two patients, pneumothorax of a similar size persisted after needle aspiration and was subsequently resolved with chest tube drainage. The mean duration of hospital stay for the patients with successful needle aspiration was shorter (3.8 d) compared to those requiring chest tube drainage after failed needle aspiration (8 d). Two patients who underwent chest tube drainage reported pain [Numeric Rating Scale (NRS) 4] and received analgesic drugs, while no pain (NRS 0) was reported after needle aspiration.

Conclusions

Needle aspiration is a safe and effective procedure for the treatment of moderate to severe non-tension pneumothorax following TTNB. It may reduce the need for chest tube insertion, shorten hospitalization duration, and decrease procedure-related pain and analgesic use.

Factors affecting the development of pneumothorax in transthoracic fine-needle aspiration biopsies

BackgroundPneumothorax is the most common complication and reason for hospitalization in needle biopsies of lung.PurposeTo investigate the factors that determine the risk and severity of pneumothorax in needle biopsies of lung.Material and MethodsFine-needle aspiration biopsy was performed for diagnostic purposes in 505 patients under the guidance of computed tomography for lung lesions. Findings were analyzed in terms of demographic characteristics of patients' and procedure-related features.ResultsThe mean age of the patients was 65 ± 9.7 years and mean lesion size was 34.31 ± 16.99 mm. Pneumothorax developed in 176 patients. The frequency and severity of pneumothorax were higher in male patients (P < 0.001 and P = 0.003). Emphysema was a risk factor for pneumothorax (P = 0.002). The rate of pneumothorax was higher in lower lobe lesions. Pleural length made a significant difference, especially for the severity of pneumothorax. The severity of pneumothorax increased as dwell time increased (P = 0.029). The need for a chest tube was significantly higher in the group with pneumothorax thickness >1 cm (P < 0.001). The requirement for multiple passes increased the risk of developing pneumothorax (P < 0.001). Procedure-related hemorrhage reduced the risk of pneumothorax and prevented the progression of pneumothorax (P < 0.001 for both). The risk of developing pneumothorax was lowest in the supine position (P = 0.001).ConclusionPatient's sex, presence of emphysema, and lesion location are unchangeable patient-dependent factors for the development of pneumothorax. However, the aim should be to plan the process correctly and complete it with a single entry and a short dwell time.

Percutaneous transthoracic needle biopsy of lung lesions is a safe method associated with a very low risk of pleural recurrence

AIM

Percutaneous transthoracic needle biopsy (PTNB), an alternative to bronchoscopic confirmation of lung lesions, is today being associated with a risk of pneumothorax and hemorrhage. Further, there are no data on the possible risk of malignant disease spreading to the pleura at the site of the PTNB. Previous studies have dealt with this risk in stage I non-small cell lung cancer only. The aim of this study was thus to assess the risk of pleural recurrence for all types of lung lesions. Secondary objectives included assessment of diagnostic yield and safety with respect to the incidence of pneumothorax and hemorrhage.

METHODS

Clinical data of all patients from the University Hospital in Pilsen who had undergone PTNB of lung lesions between 1.1.2018 and 31.12.2022 were included in this retrospective study.

RESULTS

Following PTNB, ipsilateral pleural effusion occurred in 4.8% of patients without prior pleural infiltration. The effusion was confirmed as malignant in one patient (0.7%). Diagnostic yield of the method was 86.6%. We recorded pneumothorax or hemorrhage in the lung parenchyma or pleural space requiring medical intervention in 3.4% and 1.1% of patients, respectively.

CONCLUSION

In our study, percutaneous transthoracic needle biopsy of lung lesions showed high sensitivity and low degree of acute complications requiring an invasive solution. The risk of pleural recurrence after a biopsy was very low. Consequently, we continue to consider this method to be an alternative to bronchoscopy biopsies.

CT-guided transthoracic needle biopsy: How we do it

CT-guided transthoracic needle biopsy is a well-established method for diagnosing pulmonary lesions. However, despite extensive literature on the subject, many aspects of the procedure remain unexamined in large controlled trials. Consequently, practices vary across centers due to differences in local facilities, operators' preferences, and experience. This article summarizes the essential steps of CT-guided transthoracic needle biopsy, covering patient selection to technical tips and tricks, complication management, and rapid onsite cytology evaluation. The techniques described here are based on years of clinical practice, research findings, and close collaboration with colleagues from various specialties, aiming to maximize tissue retrieval while minimizing complications. Moreover, given the growing importance of molecular analyses in the diagnosis and management of lung cancer, this article provides a concise and practical guide on proper biopsy specimen handling.

Risk factors associated with air embolism following computed tomography-guided percutaneous lung biopsy: a retrospective case-control study

Background

Retrospective analysis to identify the risk factors for air embolism following computed tomography (CT)-guided percutaneous transthoracic needle biopsy (TNB).

Methods

A retrospective analysis of patients who underwent CT-TNB at The First Affiliated Hospital of Zhengzhou University and Xuzhou Cancer Hospital from January 2017 to December 2021 was performed. A total of 21 factors relevant to air embolisms were collected. Risk factors associated with air embolisms were determined by the least absolute shrinkage and selection operator (LASSO). The receiver-operator characteristic (ROC) was used to assess the ability of these factors to identify air embolisms.

Results

Of these 32,748 patients, 28 experienced air embolisms (19 at The First Affiliated Hospital of Zhengzhou University (incidence, 1.46%) and nine at Xuzhou Cancer Hospital (incidence, 0.69%); total incidence, 2.16%). Only seven patients exhibited symptoms (symptom rate, 25.00%). A total of 21 patients were asymptomatic at the time of swept-source CT. No deaths occurred. We found through univariate and multivariate analysis that eight out of these 21 factors are associated with the occurrence of air embolism. The area under the ROC curve was 0.721, indicating good predictive power (P < 0.05).

Conclusion

Cough during the procedure, hemoptysis during the procedure, the distance between the mass and the pulmonary vein, the presence of a cavity in the lesion, lesion location, number of samples, abnormalities in the patient's coagulation mechanism, and the puncture position may be the risk factors for air embolism in CT-TNB.

Computed-Tomography-Guided Lung Biopsy: A Practice-Oriented Document on Techniques and Principles and a Review of the Literature

Computed tomography (CT)-guided lung biopsy is one of the oldest and most widely known minimally invasive percutaneous procedures. Despite being conceptually simple, this procedure needs to be performed rapidly and can be subject to meaningful complications that need to be managed properly. Therefore, knowledge of principles and techniques is required by every general or interventional radiologist who performs the procedure. This review aims to contain all the information that the operator needs to know before performing the procedure. The paper starts with the description of indications, devices, and types of percutaneous CT-guided lung biopsies, along with their reported results in the literature. Then, pre-procedural evaluation and the practical aspects to be considered during procedure (i.e., patient positioning and breathing) are discussed. The subsequent section is dedicated to complications, with their incidence, risk factors, and the evidence-based measures necessary to both prevent or manage them; special attention is given to pneumothorax and hemorrhage. After conventional CT, this review describes other available CT modalities, including CT fluoroscopy and cone-beam CT. At the end, more advanced techniques, which are already used in clinical practice, like fusion imaging, are included.

Impact of Respiratory Phase during Pleural Puncture on Complications in CT-Guided Percutaneous Lung Biopsy

Purpose

This study investigated whether the respiratory phase during pleural puncture in CT-guided percutaneous transthoracic needle biopsy (PTNB) affects complications.

Materials and Methods

We conducted a retrospective review of 477 lung biopsy CT scans performed during free breathing. The respiratory phases during pleural puncture were determined based on the table position of the targeted nodule using CT scans obtained during free breathing. We compared the rates of complications among the inspiratory, mid-, and expiratory respiratory phases. Logistic regression analysis was performed to control confounding factors associated with pneumothorax.

Results

Among the 477 procedures, pleural puncture was performed during the expiratory phase in 227 (47.6%), during the mid-phase in 108 (22.6%), and during the inspiratory phase in 142 (29.8%). The incidence of pneumothorax was significantly lower in the expiratory puncture group (40/227, 17.6%; p = 0.035) and significantly higher in the mid-phase puncture group (31/108, 28.7%; p = 0.048). After controlling for confounding factors, expiratory-phase puncture was found to be an independent protective factor against pneumothorax (odds ratio = 0.571; 95% confidence interval = 0.360-0.906; p = 0.017).

Conclusion

Our findings suggest that pleural puncture during the expiratory phase may reduce the risk of pneumothorax during image guided PTNB.

The effectiveness of the puncture channel plugging for reduction of complications after CT-guided percutaneous transthoracic needle biopsy

The effect of plugging the puncture channel with a mixture of hemocoagulase injection on the complications of CT-guided percutaneous transthoracic need biopsy (PTNB) was discussed. The medical records of PTNB were retrospectively studied from June 2017 to May 2022. In the study, the puncture channel of 626 patients were blocked, while remain 681 patients' were not. The Mantel Haenszel method performed layered analysis and evaluated the correlation of adjusted confounding factors. The Odds Ratio and its 95% confidence interval were calculated using the Woof method. The incidence of high-level pulmonary hemorrhage was significantly reduced in patients with lesions ≤ 2 cm and different needle lengths. Patients with different pleural-needle tip angle and perineedle emphysema were blocked, and the incidence of pneumothorax and thoracic implants was significantly reduced. Through puncture channel plugging, the incidence of pulmonary hemorrhage, pneumothorax and thoracic catheterization of PTNB under CT guidance was reduced.

Supplementary benefits of CT-guided transthoracic lung aspiration biopsy for core needle biopsy

Objective

This study aimed to investigate the diagnostic efficacy of computed tomography (CT)-guided transthoracic lung core needle biopsy combined with aspiration biopsy and the clinical value of this combined routine microbial detection.

Materials and methods

We retrospectively collected the electronic medical records, CT images, pathology, and other data of 1085 patients with sequential core needle biopsy and aspiration biopsy of the same lung lesion under CT guidance in the First Affiliated Hospital of Wenzhou Medical University from January 2016 to January 2021. GenXpert MTB/RIF detection and BD BACTEC™ Mycobacterium/fungus culture were applied to identifying the microbiological results of these patients. We then compared the positive diagnostic rate, false negative rate, and diagnostic sensitivity rate of three methods including core needle biopsy alone, aspiration biopsy alone, and both core needle biopsy and aspiration biopsy.

Results

The pathological results of cutting histopathology and aspiration of cell wax were examined for 1085 patients. The diagnostic rates of cutting and aspiration pathology were 90.1% (978/1085) and 86.3% (937/1085), respectively, with no significant difference (P > 0.05). Considering both cutting and aspiration pathologies, the diagnostic rate was significantly improved, up to 98% (1063/1085) (P < 0.001). A total of 803 malignant lesions were finally diagnosed (803/1085, 74.0%). The false negative rate by cutting pathology was 11.8% (95/803), which was significantly lower than that by aspiration biopsy [31.1% (250/803), P < 0.001]. Compared with core needle biopsy alone, the false negative rate of malignant lesions decreased to 5.6% (45/803) (P < 0.05). Next, the aspirates of the malignant lesions highly suspected of corresponding infection were cultured. The results showed that 16 cases (3.1%, 16/511) were infected with Mycobacterium tuberculosis complex, Aspergillus niger, and Acinetobacter baumannii, which required clinical treatment. 803 malignant tumors were excluded and 282 cases of benign lesions were diagnosed, including 232 cases of infectious lesions (82.3%, 232/282). The diagnostic rate of Mycobacterium/fungus culture for infectious lesions by aspiration biopsy (47.4%) was significantly higher than that by lung core needle biopsy (22.8%; P < 0.001). The diagnostic rate of aspiration biopsy combined with core needle biopsy was 56% (130/232). The parallel diagnostic rate of aspirated biopsy for GenXpert detection and Mycobacterium/fungal culture combined with core needle biopsy was 64.7% (150/232), which was significantly higher than that of lung core needle biopsy alone (P < 0.001). Finally, pulmonary tuberculosis was diagnosed in 90 cases (38.8%) of infectious lesions. Compared with the sensitivity of core needle biopsy to detect tuberculosis (27.8%, 25/90), the sensitivity of aspirating biopsy for GenXpert detection and Mycobacterium/fungal culture was significantly higher, at 70% (63/90) and 56.7% (51/90), respectively. Although there was no significant difference in the sensitivity of aspirated biopsy for GenXpert and Mycobacterium/fungal culture to detect pulmonary tuberculosis, the sensitivity was significantly increased to 83.3% (P < 0.05) when the two tests were combined. Moreover, when aspirated biopsies were combined with GenXpert detection, Mycobacterium/fungus culture, and core needle biopsy, the sensitivity was as high as 90% (81/90).

Conclusion

CT-guided lung aspiration biopsy has a significant supplementary effect on core needle biopsies, which is indispensable in clinical application. Additionally, the combination of aspiration biopsy and core needle biopsy can significantly improve the diagnostic rate of benign and malignant lesions. Aspiration biopsy showed that pulmonary malignant lesions are complicated with pulmonary tuberculosis, aspergillus, and other infections. Finally, the diagnostic ability of lung puncture core needle biopsy and aspiration biopsy combined with routine microbial detection under CT positioning in the diagnosis of pulmonary infectious diseases was significantly improved.

Biopsy-tract haemocoagulase injection reduces major complications after CT-guided percutaneous transthoracic lung biopsy

AIM

To determine whether the injection of haemocoagulase into the biopsy tract can reduce pneumothorax and pulmonary haemorrhage after computed tomography (CT)-guided percutaneous transthoracic lung biopsy (PTLB).

MATERIALS AND METHODS

A retrospective study was performed involving patients with undiagnosed pulmonary lesions scheduled for PTLB between January 2020 and March 2021. Patients were assigned to the haemocoagulase group or the non-haemocoagulase group. After CT-guided biopsies were performed with a 17 G coaxial system, patients in the haemocoagulase group received a haemocoagulase injection (0.2-0.5 units) in the biopsy tract as the sheath was withdrawn. Postoperative image studies were performed to evaluate complications, including pneumothorax and pulmonary haemorrhage. Factors, including the patient's position, lesion location, and pathological results, were evaluated to determine their associations with the complications.

RESULTS

A total of 100 patients were included, with 44 men and a mean age of 53 years old. The overall incidences of pneumothorax and pulmonary haemorrhage were 15% and 13%, respectively. The incidences of pneumothorax and pulmonary haemorrhage were statistically significantly lower in the haemocoagulase group (8% and 6%, respectively) than in the non-haemocoagulase group (22% and 20%, respectively; p=0.04 and 0.03, respectively). There was no statistically significant difference in haemoptysis between the haemocoagulase (6%) and non-haemocoagulase (2%) groups (p=0.23). There were also no statistically significant associations of pneumothorax or pulmonary haemorrhage with the patients' positions, lesion location, or pathological results.

CONCLUSION

Biopsy tract haemocoagulase injection reduced the incidences of postoperative pneumothorax and pulmonary haemorrhage after PTLB.

Complications After Transthoracic Needle Biopsy of Pulmonary Nodules: A Population-Level Retrospective Cohort Analysis

OBJECTIVE

To provide recent population-based estimates of transthoracic needle biopsy (TTNB) complications and risk factors associated with these complications.

METHODS

This retrospective cohort analysis included adults from a nationally representative longitudinal insurance claims data set who underwent TTNB in 2017 or 2018. Complications that were evaluated included pneumothorax, hemorrhage, and air embolism. Separate logistic regression models estimated the association of pneumothorax or hemorrhage with the setting of care (ie, inpatient or outpatient) and selected baseline patient demographic and clinical characteristics including age, gender, history of chronic obstructive pulmonary disease, diagnosis of pleural effusion, tobacco use, use of oral anticoagulants and antiplatelet agents, prior lung cancer screening, previous bronchoscopy within 1 year, and Elixhauser comorbidity index.

RESULTS

Among 16,971 patients who underwent TTNB, 25.8% experienced a complication within 3 days of the procedure (pneumothorax 23.3%, hemorrhage 3.6%, and air embolism 0.02%). Among patients who experienced pneumothorax, 31.9% required chest tube drainage. Among patients undergoing an outpatient TTNB (n = 12,443), 6.9% were hospitalized within 7 days. Biopsy in an inpatient setting, chronic obstructive pulmonary disease diagnosis, and prior bronchoscopy were associated with higher rates of both pneumothorax and hemorrhage. Prior lung cancer screening was associated with an increased risk of pneumothorax, and prior use of oral anticoagulants or antiplatelets was associated with higher rates of hemorrhage.

CONCLUSION

This contemporary population-based cohort study demonstrated that approximately one-quarter of patients undergoing TTNB experienced a complication. Pneumothorax was the most frequent complication, and hemorrhage and air embolism were rare. Among outpatients, complications from TTNB are an important cause of hospitalization.

Lung, Pleural, and Mediastinal Biopsies: From Preprocedural Assessment to Technique and Management of Complications

Biopsies of the lung, pleura, and mediastinum play a crucial role in the workup of thoracic lesions. Percutaneous image-guided biopsy of thoracic lesions is a relatively safe and noninvasive way to obtain a pathologic diagnosis which is required to direct patient management. This article reviews how to safely perform image-guided biopsies of the lung, pleura, and mediastinum, from the preprocedural assessment to reviewing intraprocedural techniques, and how to avoid and manage complications.

Early detection of delayed pneumothorax using lung ultrasound after transthoracic needle lung biopsy: A prospective pilot study

OBJECTIVES

Delayed pneumothorax can cause an emergency room visit and be life-threatening in case of tension pneumothorax after transthoracic needle biopsy. We hypothesized that most delayed pneumothoraces are diagnosed by later enlargement of occult pneumothorax due to the low diagnostic accuracy of a chest X-ray. Lung ultrasound is a highly accurate tool for detection of pneumothorax. The aim of this study is to evaluate the diagnostic accuracy of lung ultrasound for prediction of delayed pneumothorax on chest X-ray.

METHODS

This prospective pilot study was performed between April 2020 and July 2020 in Chungnam National University Hospital. The participants underwent chest X-rays and lung ultrasound before, immediately after, and 3 h after transthoracic needle biopsy, respectively. The presence or absence of lung sliding at each anterior BLUE-point on an ultrasound and pneumothorax on a chest X-ray was recorded.

RESULTS

Pneumothorax occurred in 17 (35.4%) participants, and three of them underwent chest tube replacement. Of the 17 (35.4%) cases of pneumothorax, five participants (10.4%) were diagnosed with delayed pneumothorax. Three out of five participants showed loss of lung sliding on lung ultrasound before the diagnosis of delayed pneumothorax. Therefore, the sensitivity of lung sliding on lung ultrasound for early detection of delayed pneumothorax was 60%. Two undetected cases were asymptomatic, and the pneumothoraces were exceedingly small and recovered spontaneously. Thus, sensitivity for detection of clinically meaningful delayed pneumothorax requiring chest tube replacement was 100% (2/2).

CONCLUSION

Lung ultrasound can probably predict clinically meaningful delayed pneumothorax after transthoracic needle lung biopsy.

Pneumothorax Induced by Computed Tomography Guided Transthoracic Needle Biopsy: A Review for the Clinician

Percutaneous computed tomography (CT)-guided transthoracic needle biopsy (TTNB) is a valuable procedure for obtaining tissue or cells for diagnosis, which is especially indispensable in thoracic oncology. Pneumothorax and hemoptysis are the most common complications of percutaneous needle biopsy of the lung. According to reports published over the past decades, pneumothorax incidence in patients who underwent TTNB greatly varies. The morbidity of pneumothorax after CT-guided TTNB depends on several factors, including size and depth of lesions, emphysema, the number of pleural surfaces and fissure crossed, etc. Attention to biopsy planning and technique and post-biopsy precautions help to prevent or minimize potential complications. Many measures can be taken to help prevent the progression of a pneumothorax, which in turn might reduce the number of pneumothoraces requiring chest tube placement. A multitude of therapeutic options is available for the treatment of pneumothorax, varying from observation and oxygen treatment, simple manual aspiration, to chest tube placement. When a pneumothorax develops during the biopsy procedure, it can be manually aspirated after the needle is retracted back into the pleural space or by inserting a separate needle into the pleural space. Biopsy side down positioning of the patient after biopsy significantly reduces the incidence of pneumothorax and the requirement of chest tube placement. Aspiration in biopsy side down position is also recommended for treating pneumothorax when simple manual aspiration is unsuccessful or delayed pneumothorax occurred. Chest tube placement is an important treatment strategy for patients with a large or symptomatic pneumothorax. Clinicians are encouraged to understand the development, prevention, and treatment of pneumothorax. Efforts should be made to reduce the incidence of pneumothorax in biopsy planning and post-biopsy precautions. When pneumothorax occurs, appropriate treatment should be adopted to reduce the risk of worsening pneumothorax.

Frequency of complications and risk factors associated with computed tomography guided core needle lung biopsies

BACKGROUND

Although transthoracic needle biopsy (TTNB) is an effective method for diagnosis of lung tumors, it has some complications. It is crucial to know the frequency and severity of the complications of TTNB and its risk factors in order to avoid them.

OBJECTIVES

Evaluate the complications and risk factors of computed tomography guided core needle lung biopsies (CT-CNLB).

DESIGN

Prospective evaluation of complications.

SETTING

Single center in Turkey.

PATIENTS AND METHODS

For CT-CNLBs performed between October 2017 and March 2018, the complications of biopsies were noted and classified as major and minor based on guidelines of the Society of Interventional Radiology.

MAIN OUTCOME MEASURES

The complications and risk factors for complications were evaluated.

SAMPLE SIZE

123 adult patients.

RESULTS

The most common complications were pulmonary hemorrhage (30.9%) and pneumothorax (22%). Increased overall pulmonary hemorrhage was observed with underlying emphysema (P=.022), non-peripheral location of the lesion (P<.001), increased needle pathway (P<.001), fissure penetration (P=.011), increased number of pleura penetrations (P=.024), prolonged needle time across pleura (P=.037), and decreased lesion size (P=.033). The pneumothorax rate increased with non-peripheral location of the lesion (P<.007), fissure penetration (P=.021), prolonged needle time across the pleura (P=.013), and decreased lesion size (P=.002). In the logistic regression analyses for he two most common complications, the only risk factor for both alveolar hemorrhage and pneumothorax was a non-peripheral location of the lesion (P<.001, OR=14.7, 95% CI=3.9-55.4 for alveolar hemorrhage) and (P=.001, OR=156.2, 95% CI =7.34-3324.7 for pneumothorax).

CONCLUSION

Most common complications of CT-CNLB were pneumothorax and pulmonary alveolar hemorrhage with a 5.7% major complication rate. Choosing the shortest possible trans-pulmonary needle pathway minimizes the risk of complications.

LIMITATIONS

Limited number of patients, absence of rare complications as death, air embolism, and needle tract seeding.

CONFLICT OF INTEREST

None.