Abstract
Background
Computed tomography (CT)-guided lung biopsy is a widely used technique for the diagnosis of pulmonary lesions and with a high technical success rate and diagnostic accuracy. On the other hand, it is associated with a high risk of complications, especially pneumothorax. Various methods have been tried to reduce the incidence of pneumothorax, but no established method exists. The purpose of this study was to evaluate whether the combination of tract sealing with normal saline and rapid rollover can reduce the rate of pneumothorax and chest tube insertion after CT-guided lung biopsy.
Methods
We reviewed all CT-guided lung biopsies performed at a single institution between October 2016 and December 2021. Before August 2019, no specific additional techniques were employed to mitigate complications (Group 1). In contrast, after September 2019, normal saline for tract sealing was injected during needle removal, and if pneumothorax was observed during the intervention, the patient was rolled over into the puncture-site down position immediately after needle removal (Group 2). The rate of complications was compared between the two groups.
Results
130 patients in Group 1 and 173 in Group 2 were evaluated. There was no significant difference in pneumothorax rate between the two groups (30.0% vs. 23.1%, P = .177). A chest tube was inserted in 10 of 130 patients in Group 1 and only in 1 of 173 in Group 2 (P = .001). There were no complications associated with this combinational technique.
Conclusions
The combination of normal saline injection and rapid rollover significantly reduced the incidence of pneumothorax requiring chest tube insertion after CT-guided lung biopsy. Therefore, normal saline injection and rapid rollover can serve as a preventive method for severe pneumothorax in CT-guided lung biopsy.
Keywords: CT-guided biopsy, Lung biopsy, Pneumothorax, Rapid rollover, Tract sealing
Background
Percutaneous CT–guided lung biopsy has become an established technique for histologic diagnosis of pulmonary lesions, with a technical success rate of almost 100% and high diagnostic accuracy of 83–98% [1–5]. The importance of CT-guided lung biopsy has been increasing due to the growing need for molecular and immunological analyses [6]. On the other hand, CT-guided lung biopsy is associated with higher incidence of complications compared to transbronchial lung biopsy [7, 8]. The most common major complication is pneumothorax with reported rate ranging from 14.8 to 42%, and the prevalence of chest tube insertion also reported within the range of 1.4–10%. The incidence of pneumothorax can vary based on patient characteristics [9–15].
Several techniques have been tried to reduce the incidence of pneumothorax in CT-guided lung biopsy, including rapid rollover, deep expiration and breath holding, injection of a sealant material into the biopsy tract [16–18]. Sealant materials that have been used in clinical studies include autologous blood clot, compressed collagen foam plugs, fibrin glue, normal saline, and hydrogel plugs [19–30]. Previous systematic review and meta-analysis have suggested that these various techniques may reduce pneumothorax [31]. However, there is no established method to reduce the incidence of pneumothorax.
We have chosen a combination of normal saline injection for sealing the needle tract and rapid rollover, which are relatively uncomplicated and cost-effective among the previously reported techniques [29]. Regarding the materials for tract sealing, the injection of foreign substances such as gels or plugs can induce inflammation [29]. In contrast, normal saline avoids the risk of harmful local tissue reactions that may be caused by synthetic materials [29]. Therefore, normal saline was considered the best option. As for the breathing method, we did not adopt any specific technique since our biopsies are performed under natural breathing.
The efficacy of the combination of tract sealing with normal saline and rapid rollover for pneumothorax has already been reported [32]. However, in the previous report, both techniques were used in all cases. In our approach, we performed tract sealing with normal saline in all cases and added rapid rollover only when pneumothorax occurred intraoperatively. Thus, our method seems simpler and, if equally effective or better, may be more beneficial.
The purpose of this study was to assess whether the integration of the two approaches of tract sealing with normal saline and rapid rollover could reduce the rate of pneumothorax and chest tube placement after CT-guided lung biopsy.
Methods
This retrospective study was approved by the institutional review board with waiver of the requirement for patients’ informed consent (IRB No. 22486).
Study population
We evaluated all of the CT-guided lung biopsies which were performed at our institution between October 2016 and December 2021. Among the 130 biopsies conducted before August 2019 (Group 1), no specific additional techniques were employed to mitigate complications. In contrast, for 173 biopsies carried out after September 2019 (Group 2), the combinational method was adopted. All cases of CT-guided lung biopsy performed during the study period were included, with no specific exclusion criteria applied.
Biopsy procedure
All 303 consecutive biopsies were conducted by a single primary attending operator (M. N.) with 18 years of experience or under his direct supervision. All CT-guided biopsy procedures were performed on a Discovery CT750HD Optima CT 660 (GE Healthcare) with a 17-gauge coaxial needle and an 18-gauge semiautomatic core biopsy needle. Patients were placed in prone, supine, or lateral decubitus positions, depending on the location of the target lesion. The biopsies were planned with the initial inspiratory and expiratory non-contrast chest CT scan. The supervisor determined the optimal trajectory to the target lesion for lung biopsy, considering both safety and specimen adequacy. This trajectory avoided the inter-lobar fissure and large pulmonary vessels. Following insertion of a 17-gauge coaxial needle into the target lesion, an 18-gauge semiautomatic core biopsy needle was inserted through the coaxial needle to obtain a specimen. The needle was inserted during expiration under spontaneous breathing without breath holding. Multiple core samples were collected until the macroscopic sample volume was sufficient.
Prevention of pneumothorax and postprocedural care
Following the biopsy procedure, in Group 1, the coaxial needle was promptly withdrawn without the injection of normal saline. Conversely, in Group 2, we injected 1–5 ml of normal saline into the tract while withdrawing the coaxial needle (Fig. 1). The coaxial needle was withdrawn at a rate of approximately 1 cm per second, with 1 mL of normal saline injected per centimeter during the withdrawal. CT fluoroscopy was employed at each 1 cm increment to ensure the accurate injection of normal saline. The angle of the coaxial needle was maintained consistent with the insertion angle during its removal.
Fig. 1.
Normal saline injection. (a) CT fluoroscopic image before needle puncture. White arrow shows target lesion. (b) CT fluoroscopic image immediately after tract sealing with normal saline. White arrow shows tract sealant and black arrowhead shows the coaxial needle
Subsequently, a post-procedure chest CT scan was conducted to detect potential complications. All participants were subjected to a two-hour bed rest period after the procedure, followed by a chest radiograph. If the chest radiograph revealed no pneumothorax or only an asymptomatic small pneumothorax (defined as less than 2 cm depth at the level of the hilum), the participant was discharged the following day. The classification of pneumothorax was based on the following criteria: “hyperacute” if detected during the procedure with the coaxial needle still situated within the pleural space, “acute” if ascertained on a chest CT scan immediately subsequent to the procedure, and “delayed” if discerned on a chest radiograph obtained 2 h later.
When pneumothorax occurred, in Group 1, we performed pleural air aspiration when the coaxial biopsy needle was still positioned within the pleural space, i.e., hyperacute pneumothorax. In Group 2, we withdrew the coaxial needle to the air space in the pleural space while sealing the tract with normal saline followed by pleural air aspiration in a similar manner (Fig. 2). Pleural air aspiration was manually performed using a 20 mL syringe, a three-way stopcock, and an extension tube, with the objective of reducing the air in the pleural cavity to less than 1 cm. Additionally, in Group 2, patients were repositioned with the puncture site downward as soon as possible after needle removal (Fig. 3). This rapid rollover was performed by a team of 4 to 6 physicians, nurses, and radiologic technologists, who lifted and rotated the patients. This procedure was completed within 15 s of needle removal. If pneumothorax continued to progress despite these procedures, we inserted a chest tube (8 Fr. aspiration kit, Cardinal Health, Inc., Dublin, OH). When pneumothorax was observed on the post-procedure CT scan immediately after the biopsy, i.e., acute pneumothorax, the coaxial needle was once again punctured into the pleural space, and the same procedures were conducted. If pneumothorax persisted without improvement, a chest tube was inserted. Furthermore, if the chest radiograph taken two hours post-procedure revealed a moderate or larger pneumothorax (defined as symptomatic and/or extending more than 2 cm depth at the level of the hilum), i.e., delayed pneumothorax, we promptly proceeded to place a chest tube. The flow chart is shown in Fig. 4.
Fig. 2.
Aspiration and rapid rollover. (a) Initial CT scan image for biopsy planning. White arrow shows target lesion. (b) CT fluoroscopic image during biopsy. A small pneumothorax appeared. (c) The pneumothorax increased, but biopsies continued until sufficient sample volume was obtained. White arrow shows the tip of the coaxial needle. (d) While injecting normal saline, the coaxial needle was withdrawn to the air space and aspiration was performed. White arrow shows the tip of the coaxial needle. (e) CT scan image after aspiration, removal of the needle, and rapid rollover. Tiny pneumothorax exist without expansion
Fig. 3.
Schematic diagram of rapid rollover. (a) Lateral view before rapid rollover. (b) Cranial view before rapid rollover. (c) Lateral view after rapid rollover. (d) Cranial view before rapid rollover. In all schematics, the red arrows indicate the puncture site
Fig. 4.
Flowchart after pneumothorax occurrence
Data collection
The following variables related to the characteristics of the patients, target lesion, and biopsy procedure were recorded retrospectively. Patient characteristics were age, sex, emphysema detected at CT, and previous lung surgery on the biopsy side. Lesion factors were size, location (lobes), distance from pleura to target, and nodule type. The largest dimension of the lesion was measured on preoperative CT images, using the maximum long axis diameter. Procedural related factors were patient position, whether the biopsy needle was traversing aerated lung or not, intrapulmonary biopsy tract length, number of samplings, presence of pneumothorax and air embolism, and type of histologic findings. Pneumothorax on CT was defined as air in the pleural space of more than 1 cm wide because a small amount of air was found in many patients after needle biopsy. Biopsy diagnoses were categorized as malignancy, benign, or non-diagnostic. The result was defined as non-diagnostic if the specimens obtained were inadequate for diagnosis.
Statistical analysis
Statistical analyses were performed using R (version 4.2.0). Variables between these two groups were compared using the independent-samples t-test and Pearson’s chi-square test as appropriate. To determine risk factors for pneumothorax occurrence and chest tube placement, multivariate logistic regression analysis was performed using variables with a P-Value of less than 0.05 at univariate analyses. A P-Value < 0.05 was considered to indicate a statistically significant difference. The data were shown as mean ± standard deviation (SD) unless otherwise indicated.
Results
Baseline characteristics
The characteristics of the patients, lesions, and procedures used are shown in Table 1, indicating 130 patients in Group 1 and 173 patients in Group 2. No significant differences were found between the two groups regarding the characteristics of the patients. With respect to the lesion characteristics, the lesion size was significantly smaller in Group 2 (19.2 ± 11.6 mm) than in Group 1 (25.7 ± 20.8 mm, P < .001). In all cases, the pleura was passed by the coaxial needle only once. In terms of procedural related factors, Group 2 had a significantly higher number of biopsies that traversed aerated lung tissue.
Table 1.
Baseline characteristics in the two groups
| Variables | Group 1 (N = 130) | Group 2 (N = 173) | P-Value | |
|---|---|---|---|---|
| Age (years; mean ± SD) | 69.7 ± 11.5 | 71.5 ± 10.2 | 0.139 | |
| Sex; Male/Female | 84/46 | 105/68 | 0.486 | |
| Emphysema | 61 (46.9) | 80 (46.2) | 0.906 | |
| Previous lung surgery on the biopsy side | 11 (8.5) | 8 (4.6) | 0.173 | |
| Lesion size (mm; mean ± SD) | 25.7 ± 20.8 | 19.2 ± 11.6 | < 0.001 | |
| Lesion location; RUL/RML/RLL/LUL/LLL | 37/8/21/34/30 | 53/8/45/38/29 | 0.213 | |
| Pleura-target distance (mm; mean ± SD) | 8.4 ± 12.0 | 7.8 ± 10.9 | 0.658 | |
| Nodule type; solid/part solid GGO/GGO | 98/8/24 | 123/34/16 | < 0.001 | |
| Patient position; Supine/Prone/Lateral | 42/54/34 | 46/84/43 | 0.430 | |
| Traversing aerated lung | 88 (67.7) | 144 (83.2) | 0.002 | |
| Intrapulmonary biopsy tract length (mm; mean ± SD) | 15.7 ± 16.0 | 18.3 ± 16.0 | 0.165 | |
| Number of sampling (mean ± SD) | 3.5 ± 1.5 | 3.4 ± 1.0 | 0.356 | |
RUL right upper lobe, RML right middle lobe, RLL right lower lobe, LUL Left upper lobe, LLL Left lower lobe, GGO Ground-Glass Opacity
The numbers within the parentheses represent percentages
Comparative analysis of complications in two groups
Complications occurred in both groups are shown in Table 2. The incidence of pneumothorax was 40 of 173 patients (23%) in Group 2 whereas 39 of 130 participants (30%) in Group 1 (OR; 0.701, 95%CI; 0.419–1.175, P = .177). Acute pneumothorax tended to be less common in Group 2, with statistical significance (P = .018). The chest tube insertion rate was significantly less in Group 2 compared to Group 1 (0.6% vs. 7.7%, OR; 0.070, 95%CI; 0.009–0.552, P = .001). In addition, Group 2 (3.8%) had a significantly lower chest tube insertion rate than Group 1 (32%, P = .007) in patients with hyperacute and acute pneumothorax.
Table 2.
Comparative analysis of complications in two group
| Group 1 (N = 130) | Group 2 (N = 173) | P-Value | |
|---|---|---|---|
| Pneumothorax | 39 (30) | 40 (23) | 0.177 |
| hyperacute | 19 (14.6) | 21 (12.1) | 0.528 |
| acute | 12 (9.2) | 5 (2.9) | 0.018 |
| delayed | 8 (6.2) | 14 (8.1) | 0.512 |
| Chest tube insertion | 10 (7.7) | 1 (0.6) | 0.001 |
| hyperacute | 5 (3.8) | 0 (0) | 0.009 |
| acute | 5 (3.8) | 1 (0.6) | 0.043 |
| delayed | 0 (0) | 0 (0) | N/A |
| Air embolism | 1 (0.8) | 1 (0.6) | 0.839 |
| Diagnostic histologic finding | |||
| Malignancy | 110 (84.6) | 152 (87.9) | 0.414 |
| Benign | 19 (14.6) | 21 (12.1) | 0.528 |
| Non-diagnostic lesion | 1 (0.8) | 0 (0) | 0.248 |
N/A denotes not applicable
The numbers within the parentheses represent percentages
One case of asymptomatic air embolism was observed in each group. In both cases, air resolved with only rest and observation. The histologic findings were diagnostically conclusive in 129 out of 130 patients (99%) in Group 1 and in all patients in Group 2. There was no significant difference in the percentage of benign and malignant cases between the two groups. A non-diagnostic case, in which only necrotic tissue and inflammatory cells were observed, was diagnosed as methotrexate-associated polymorphic lymphoproliferative disorders on a skin biopsy.
Risk factors associated with pneumothorax
Univariate analyses showed that the significant risk factors for pneumothorax were sex, emphysema, lesion size, distance from pleura to target, patient position, and intrapulmonary biopsy tract length (Table 3). Pneumothorax was more common in males, patients with emphysema, smaller lesions, and lesions more distant from the pleura. Among procedural factors, pneumothorax was more common in the lateral decubitus position and was positively correlated with the length of the intrapulmonary biopsy tract. Significant risk factors for chest tube insertion in univariate analyses were emphysema, number of sampling, and normal saline injection (Table 4).
Table 3.
Univariate analyses to determine the risk factors associated with overall pneumothorax
| Variables | No Pneumothorax (N = 224) |
Pneumothorax (N = 79) |
P-Value | |
|---|---|---|---|---|
| Age (years; mean ± SD) | 70.4 ± 11.0 | 71.7 ± 10.4 | 0.347 | |
| Sex; Male | 131 (58.5) | 58 (73.4) | 0.014 | |
| Emphysema | 94 (42.0) | 47 (59.5) | 0.005 | |
| Previous lung surgery on the biopsy side | 11 (4.9) | 8 (10.1) | 0.109 | |
| Lesion size (mm; mean ± SD) | 23.3 ± 17.9 | 18.6 ± 11.1 | 0.031 | |
| Lesion location; RUL/RML/RLL/LUL/LLL | 65/12/45/55/47 | 25/4/21/17/12 | 0.246 | |
| Pleura-target distance (mm; mean ± SD) | 6.7 ± 10.0 | 11.9 ± 13.9 | < 0.001 | |
| Nodule type; solid/part solid GGO/GGO | 164/33/27 | 57/9/13 | 0.610 | |
| Patient position; Supine/Prone/Lateral | 64/115/45 | 24/23/32 | 0.019 | |
| Traversing aerated lung | 166 (74.1) | 66 (83.5) | 0.078 | |
| Intrapulmonary biopsy tract length (mm; mean ± SD) | 15.9 ± 15.3 | 21.1 ± 17.7 | 0.016 | |
| Number of sampling (mean ± SD) | 3.5 ± 1.4 | 3.4 ± 0.9 | 0.572 | |
| Normal saline injection | 133 (59.4) | 40 (50.1) | 0.487 | |
RUL right upper lobe, RML right middle lobe, RLL right lower lobe, LUL Left upper lobe, LLL Left lower lobe, GGO Ground-Glass Opacity
The numbers within the parentheses represent percentages
Table 4.
Univariate analyses to determine the risk factors associated with pneumothorax requiring chest tube insertion
| Variables | No tube (N = 292) | tube (N = 11) | P-Value | |
|---|---|---|---|---|
| Age (years; mean ± SD) | 70.6 ± 11.0 | 73.7 ± 6.5 | 0.354 | |
| Sex; Male | 180 (61.6) | 9 (81.8) | 0.176 | |
| Emphysema | 131 (44.9) | 10 (90.9) | 0.003 | |
| Previous lung surgery on the biopsy side | 18 (6.2) | 1 (9.1) | 0.695 | |
| Lesion size (mm; mean ± SD) | 22.3 ± 16.7 | 14.4 ± 3.9 | 0.117 | |
| Lesion location; RUL/RML/RLL/LUL/LLL | 87/15/64/68/58 | 3/1/2/4/1 | 0.873 | |
| Pleura-target distance (mm; mean ± SD) | 7.8 ± 11.2 | 14.2 ± 13.4 | 0.068 | |
| Nodule type; solid/part solid GGO/GGO | 213/41/38 | 8/1/2 | 0.806 | |
| Patient position; Supine/Prone/Lateral | 82/135/75 | 6/3/2 | 0.082 | |
| Traversing aerated lung | 221 (75.7) | 11 (100) | 0.062 | |
| Intrapulmonary biopsy tract length (mm; mean ± SD) | 17.0 ± 16.2 | 24.5 ± 12.4 | 0.126 | |
| Number of sampling (mean ± SD) | 3.5 ± 1.3 | 2.7 ± 0.7 | 0.048 | |
| Normal saline injection | 172 (68.9) | 1 (9.1) | < 0.001 | |
RUL right upper lobe, RML right middle lobe, RLL right lower lobe, LUL Left upper lobe, LLL Left lower lobe, GGO Ground-Glass Opacity
The numbers within the parentheses represent percentages
In multivariate logistic regression analyses, emphysema was the only significant risk factor for the pneumothorax occurrence (Table 5). For chest tube insertion, significant risk factors were emphysema, number of sampling, and normal saline injection (Table 6).
Table 5.
Multivariate logistic regression analysis to determine the risk factors associated with overall pneumothorax
| Variables | Odds ratio | 95% Confidence interval | P-Value |
|---|---|---|---|
| Sex | 1.565 | 0.637–3.330 | 0.157 |
| Emphysema | 2.215 | 0.842–2.963 | 0.007 |
| Lesion size | 1.016 | 0.996–1.040 | 0.115 |
| Pleura-target distance | 0.98 | 0.955–1.001 | 0.139 |
| Patient position | |||
| Supine | Reference | ||
| Prone | 0.567 | 0.287–1.110 | 0.098 |
| Lateral | 1.742 | 0.892–3.412 | 0.104 |
| Intrapulmonary biopsy tract length | 0.993 | 0.974–1.013 | 0.495 |
Table 6.
Multivariate logistic regression analysis to determine the risk factors associated with pneumothorax requiring chest tube insertion
| Variables | Odds ratio | 95% Confidence interval | P-Value | |
|---|---|---|---|---|
| Emphysema | 11.334 | 2.374-113.883 | 0.001 | |
| Number of sampling | 2.535 | 1.182–6.207 | 0.015 | |
| Normal saline injection | 0.078 | 0.008–0.358 | < 0.001 | |
Discussion
In this study, we demonstrated that the combination of normal saline injection and rapid rollover tended to decrease the incidence of pneumothorax. It is notable that this combinational method significantly reduced pneumothorax requiring chest tube insertion without complications. A previous systematic review reported that pneumothorax occurred in 25.9%, and pneumothorax requiring chest tube insertion occurred in 6.9% [33]. The incidence of pneumothorax in this study was 24%, but most pneumothorax were asymptomatic and self-limiting. The marked reduction in pneumothorax cases requiring chest tube insertion, which can significantly influence a patient’s quality of life and length of hospitalization, appears to offer substantial benefits. Additionally, this study included patients with emphysema and pulmonary fibrosis, which have been reported as risk factors for pneumothorax. Despite this, it is noteworthy that the tube insertion rate was lower compared to previous reports [33].
Tract sealing with normal saline is hypothesized to reduce pneumothorax by filling needle-induced defects in the lung parenchyma and visceral pleura. This saline filling impedes air leakage into the pleural cavity. The rapid rollover maneuver is hypothesized to reduce pneumothorax by exploiting gravity. Gravity induces lung drop, which facilitates apposition of the lung parenchyma and chest wall at the puncture site, promoting adhesion. This creates a tamponade effect, minimizing air leakage from the puncture site.
The significant reduction of hyperacute pneumothorax was not observed between the two groups, as hyperacute pneumothorax occurs prior to the administration of normal saline injection. After normal saline injections, on the other hand, the acute pneumothorax rate was significantly reduced. Therefore, the incidence of acute pneumothorax is considered to reflect the effect of normal saline injection. In hyperacute and acute pneumothorax in Group 2, rapid rollover was performed immediately following aspiration of the pleural air. Chest tube insertion was significantly less frequent in cases of hyperacute and acute pneumothorax in this study. This suggests that rapid rollover may potentially prevent exacerbation of pneumothorax, even if it occurs.
A previous meta-analysis reported normal saline injection significantly reduced overall pneumothorax and significantly reduced pneumothorax requiring chest tube insertion [31]. In contrast, rapid rollover did not significantly differ in the incidence of overall pneumothorax, but did significantly reduce pneumothorax requiring chest tube insertion [31]. In the current study, the incidence of pneumothorax requiring chest tube insertion was significantly reduced. The odds ratio for chest tube insertion in this study was lower than the respective odds ratios in previous studies of normal saline injection alone and rapid rollover alone, suggesting that a synergistic effect may have been created by combining these two approaches.
Another previous study reported a protocol of combination of patient postprocedural repositioning, needle removal during expiration, autologous blood patch sealing, rapid rollover, and pleural patching [34]. This method reduced overall pneumothorax from 37 to 16% and pneumothorax requiring chest tube insertion from 13 to 1%. Compared to the protocol of the previous study, the combination of normal saline injection and rapid rollover is uncomplicated and cost-effective. A key strength of this study is the reduction in severe pneumothorax achieved using a simpler method, without increasing the incidence of other complications. The present study is superior in the rate of pneumothorax requiring chest tube insertion, suggesting that the combined approach used is more effective.
Our study had several limitations. First, it was a single-center retrospective study, which may have introduced bias. Second, we did not measure the time taken to complete the rapid rollover after coaxial needle removal. Theoretically, a shorter time would be associated with a lower risk of pneumothorax. Finally, there may have been learning biases among the multiple operators. However, all biopsies in this study were performed or supervised by a single operator, which likely minimized the impact of varying levels of operator experience. Optimizing the volume, injection rate, and injection pressure of normal saline might further reduce the incidence of pneumothorax using the method employed in this study.
Conclusions
The combination of normal saline injection and rapid rollover significantly reduced the incidence of pneumothorax requiring chest tube insertion after CT-guided lung biopsy. Therefore, normal saline injection and rapid rollover can serve as a preventive method for pneumothorax in CT-guided lung biopsy.
Acknowledgments
Not applicable.
Abbreviations
- CT
Computed tomography
Author contributions
N.T. is the guarantor of the content of the manuscript, including the data and analysis. M.N. and A.K. conceptualized the study. H.S., M.N., K.T., and Y.O. performed the data collection and investigation. H.S. performed formal analysis and data visualization, which were supervised and supported by M.N., and H.S. wrote the original draft. M.N., H.H. and Y.K. revised the manuscript. All authors participated in the interpretation of the data, critically reviewed the manuscript, provided final approval for submission, and took responsibility for the accuracy and integrity of the work.
Funding
Not applicable.
Data availability
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.
Declarations
Ethics approval and consent to participate
This study was approved by the institutional review board of Osaka Medical Hospital with waiver of the requirement for patients’ informed consent. (Approval number: 22486)
Consent for publication
Not applicable.
Competing interests
The authors declare that they have no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
References
- 1.Priola AM, Priola SM, Cataldi A, Errico L, Di Franco M, Campisi P, et al. Accuracy of CT-guided transthoracic needle biopsy of lung lesions: factors affecting diagnostic yield. Radiol med. 2007;112:1142–59. [DOI] [PubMed] [Google Scholar]
- 2.Hiraki T, Mimura H, Gobara H, Iguchi T, Fujiwara H, Sakurai J, et al. CT fluoroscopy-guided biopsy of 1,000 pulmonary lesions performed with 20-Gauge Coaxial cutting needles. Chest. 2009;136:1612–7. [DOI] [PubMed] [Google Scholar]
- 3.Choi JW, Park CM, Goo JM, Park Y-K, Sung W, Lee H-J, et al. C-Arm Cone-Beam CT–Guided percutaneous transthoracic needle biopsy of small (≤ 20 mm) lung nodules: diagnostic accuracy and complications in 161 patients. Am J Roentgenol. 2012;199:W322–30. [DOI] [PubMed] [Google Scholar]
- 4.Lee KH, Lim KY, Suh YJ, Hur J, Han DH, Kang M-J, et al. Diagnostic accuracy of Percutaneous Transthoracic needle lung biopsies: a Multicenter Study. Korean J Radiol. 2019;20:1300. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Liu X-L, Li W, Yang W-X, Rui M-P, Li Z, Lv L, et al. Computed tomography-guided biopsy of small lung nodules: diagnostic accuracy and analysis for true negatives. J Int Med Res. 2020;48:030006051987900. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.O’Shea A, Tam AL, Kilcoyne A, Flaherty KT, Lee SI. Image-guided biopsy in the age of personalised medicine: strategies for success and safety. Clinical Radiology. 2021;76:154.e1-154.e9. [DOI] [PubMed]
- 7.Han Y, Kim HJ, Kong KA, Kim SJ, Lee SH, Ryu YJ et al. R Agarwal editor 2018 Diagnosis of small pulmonary lesions by transbronchial lung biopsy with radial endobronchial ultrasound and virtual bronchoscopic navigation versus CT-guided transthoracic needle biopsy: a systematic review and meta-analysis. PLoS ONE 13 e0191590. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Fu Y, Zhang J, Wang T, Shi Y. Endobronchial ultrasound-guided versus computed tomography‐guided biopsy for peripheral pulmonary lesions: a meta‐analysis. Clin Respiratory J. 2021;15:3–10. [DOI] [PubMed] [Google Scholar]
- 9.Yeow K-M, Su I-H, Pan K-T, Tsay P-K, Lui K-W, Cheung Y-C, et al. Risk factors of pneumothorax and bleeding. Chest. 2004;126:748–54. [DOI] [PubMed] [Google Scholar]
- 10.Tomiyama N, Yasuhara Y, Nakajima Y, Adachi S, Arai Y, Kusumoto M, et al. CT-guided needle biopsy of lung lesions: a survey of severe complication based on 9783 biopsies in Japan. Eur J Radiol. 2006;59:60–4. [DOI] [PubMed] [Google Scholar]
- 11.Yaffe D, Shitrit D, Gottfried M, Bartal G, Sosna J. Ipsilateral Opposite-Side Aspiration in resistant Pneumothorax after CT image guided Lung Biopsy. Chest. 2013;144:947–51. [DOI] [PubMed] [Google Scholar]
- 12.Li Y, Du Y, Yang HF, Yu JH, Xu XX. CT-guided percutaneous core needle biopsy for small (≤ 20 mm) pulmonary lesions. Clin Radiol. 2013;68:e43–8. [DOI] [PubMed] [Google Scholar]
- 13.Rong E, Hirschl DA, Zalta B, Shmukler A, Krausz S, Levsky JM, et al. A Retrospective Multi-site Academic Center Analysis of Pneumothorax and Associated Risk factors after CT-Guided percutaneous lung biopsy. Lung. 2021;199:299–305. [DOI] [PubMed] [Google Scholar]
- 14.Sabatino V, Russo U, D’Amuri F, Bevilacqua A, Pagnini F, Milanese G, et al. Pneumothorax and pulmonary hemorrhage after CT-guided lung biopsy: incidence, clinical significance and correlation. Radiol med. 2021;126:170–7. [DOI] [PubMed] [Google Scholar]
- 15.Ruud EA, Stavem K, Geitung JT, Borthne A, Søyseth V, Ashraf H. Predictors of pneumothorax and chest drainage after percutaneous CT-guided lung biopsy: a prospective study. Eur Radiol. 2021;31:4243–52. [DOI] [PubMed] [Google Scholar]
- 16.O’Neill AC, McCarthy C, Ridge CA, Mitchell P, Hanrahan E, Butler M, et al. Rapid needle-out patient-rollover time after percutaneous CT-guided Transthoracic Biopsy of Lung nodules: Effect on Pneumothorax Rate. Radiology. 2012;262:314–9. [DOI] [PubMed] [Google Scholar]
- 17.Kim JI, Park CM, Lee SM, Goo JM. Rapid needle-out patient-rollover approach after cone beam CT-guided lung biopsy: effect on pneumothorax rate in 1,191 consecutive patients. Eur Radiol. 2015;25:1845–53. [DOI] [PubMed] [Google Scholar]
- 18.Min L, Xu X, Song Y, Issahar B-D, Wu J, Zhang L, et al. Breath-hold after forced expiration before removal of the biopsy needle decreased the rate of pneumothorax in CT-guided transthoracic lung biopsy. Eur J Radiol. 2013;82:187–90. [DOI] [PubMed] [Google Scholar]
- 19.Lang EK, Ghavami R, Schreiner VC, Archibald S, Ramirez J. Autologous blood clot seal to prevent pneumothorax at CT-guided lung biopsy. Radiology. 2000;216:93–6. [DOI] [PubMed] [Google Scholar]
- 20.Malone LJ, Stanfill RM, Wang H, Fahey KM, Bertino RE. Effect of Intraparenchymal Blood Patch on Rates of Pneumothorax and Pneumothorax requiring chest tube Placement after Percutaneous Lung Biopsy. Am J Roentgenol. 2013;200:1238–43. [DOI] [PubMed] [Google Scholar]
- 21.Clayton JD, Elicker BM, Ordovas KG, Kohi MP, Nguyen J, Naeger DM. Nonclotted Blood Patch technique reduces pneumothorax and chest tube Placement Rates after Percutaneous Lung biopsies. J Thorac Imaging. 2016;31:243–6. [DOI] [PubMed] [Google Scholar]
- 22.Graffy P, Loomis SB, Pickhardt PJ, Lubner MG, Kitchin DR, Lee FT, et al. Pulmonary intraparenchymal blood patching decreases the rate of Pneumothorax-Related complications following percutaneous CT–Guided needle biopsy. J Vasc Interv Radiol. 2017;28:608–e6131. [DOI] [PubMed] [Google Scholar]
- 23.Zaetta JM, Licht MO, Fisher JS, Avelar RL. A Lung Biopsy Tract Plug for reduction of Postbiopsy Pneumothorax and other complications: results of a prospective, Multicenter, Randomized, controlled clinical study. J Vasc Interv Radiol. 2010;21:1235–e12433. [DOI] [PubMed] [Google Scholar]
- 24.Grage RA, Naveed MA, Keogh S, Wang D. Efficacy of a dehydrated Hydrogel Plug to Reduce complications Associated with computed tomography–guided Percutaneous Transthoracic Needle Biopsy. J Thorac Imaging. 2017;32:57–62. [DOI] [PubMed] [Google Scholar]
- 25.Ahrar JU, Gupta S, Ensor JE, Mahvash A, Sabir SH, Steele JR, et al. Efficacy of a self-expanding Tract Sealant device in the reduction of pneumothorax and chest tube Placement Rates after Percutaneous Lung Biopsy: a matched controlled study using propensity score analysis. Cardiovasc Intervent Radiol. 2017;40:270–6. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26.Petsas T, Siamblis D, Giannakenas C, Tepetes K, Dougenis D, Spiropoulos K, et al. Fibrin glue for sealing the needle track in fine-needle percutaneous lung biopsy using a coaxial system: part II?clinical study. Cardiovasc Intervent Radiol. 1995;18:378–82. [DOI] [PubMed] [Google Scholar]
- 27.Baadh AS, Hoffmann JC, Fadl A, Danda D, Bhat VR, Georgiou N, et al. Utilization of the track embolization technique to improve the safety of percutaneous lung biopsy and/or fiducial marker placement. Clin Imaging. 2016;40:1023–8. [DOI] [PubMed] [Google Scholar]
- 28.Maybody M, Muallem N, Brown KT, Moskowitz CS, Hsu M, Zenobi CL, et al. Autologous blood Patch Injection versus Hydrogel Plug in CT-guided lung biopsy: a prospective Randomized Trial. Radiology. 2019;290:547–54. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 29.Billich C, Muche R, Brenner G, Schmidt SA, Krüger S, Brambs H-J, et al. CT-guided lung biopsy: incidence of pneumothorax after instillation of NaCl into the biopsy track. Eur Radiol. 2008;18:1146–52. [DOI] [PubMed] [Google Scholar]
- 30.Li Y, Du Y, Luo TY, Yang HF, Yu JH, Xu XX, et al. Usefulness of normal saline for sealing the needle track after CT-guided lung biopsy. Clin Radiol. 2015;70:1192–7. [DOI] [PubMed] [Google Scholar]
- 31.Huo YR, Chan MV, Habib A-R, Lui I, Ridley L. Post-biopsy manoeuvres to reduce Pneumothorax incidence in CT-Guided transthoracic lung biopsies: a systematic review and Meta-analysis. Cardiovasc Intervent Radiol. 2019;42:1062–72. [DOI] [PubMed] [Google Scholar]
- 32.Khorochkov E, Garvin GJ, Potoczny S, Kozak RI. Injection of saline into the Biopsy Tract and Rapid Patient Rollover decreases Pneumothorax size following computed tomography–guided transthoracic needle biopsy. Can Assoc Radiol J. 2018;69:489–92. [DOI] [PubMed] [Google Scholar]
- 33.Huo YR, Chan MV, Habib A-R, Lui I, Ridley L. Pneumothorax rates in CT-Guided lung biopsies: a comprehensive systematic review and meta-analysis of risk factors. BJR. 2020;93:20190866. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 34.Najafi A, Al Ahmar M, Bonnet B, Delpla A, Kobe A, Madani K, et al. The PEARL Approach for CT-guided lung biopsy: Assessment of Complication Rate. Radiology. 2022;302:473–80. [DOI] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.