Mediastinal Hematoma Following Endobronchial Ultrasound-guided Transbronchial Needle Aspiration

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To the Editor:
Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) using convex probe, is a minimally invasive diagnostic procedure which provides the benefit of real-time ultrasonography guidance for sampling with high index sensitivity and specificity.1In this report, we discuss one of the potential hazards for this technique which is injury of mediastinal vessels.
A male patient aged 70 years old presented to our hospital with manifestations of lower respiratory tract infection including productive cough and moderate dyspnea. The patient was chronic smoker (40 pack/year). X-ray was performed and a nodule in the right lung was incidentally discovered. Computed tomography (CT) of chest confirmed the diagnosis of solitary pulmonary nodule in right upper lobe with speculated margins, heterogenous contrast, measuring 18×15×19 mm. Positron emission tomography-CT was also performed and showed high uptake of the pulmonary nodule (6.9 g/mL) and high uptake of mediastinal lymph node at 4R station (2.7 g/mL). It was decided that EBUS-TBNA would be the ideal step for staging and determining the proper line of treatment for this patient. All the routine investigations were performed before the intervention and all the results were within the normal ranges. EBUS was performed using a flexible bronchoscope (BF-UC160F-OL8; Olympus Optical Co. Ltd, Tokyo, Japan) with a 22-G cytology needle specially designed for EBUS-TBNA (NA-201SX-4022; Olympus Optical Co. Ltd). During the intervention, the operators safely sampled station 11L and while sampling station 4L, although the aortic border was clearly visible and cautiously avoided, the operators noticed disturbance in the ultrasonographic images associated with loss of relationship between aortic border and adjacent structures, also rapidly progressive swelling in the tracheal wall led to narrowing of the tracheal lumen. The procedure was terminated immediately and the vital signs of the patient were checked closely to ensure clinical stability. A white light bronchoscopy was immediately performed, confirming the presence of newly developed tracheal narrowing. Following that, an urgent CT chest with contrast was performed and showed mediastinal hematoma with no contrast leak, denoting absence of active hemorrhage (Fig. 1A). The patient was transmitted then to the intensive care unit to be monitored continuously. After 48 hours of continuous monitoring without complications the patient was able to be discharged. Two weeks later the EBUS-TBNA was repeated, during exploration of the 4L station a vascular structure caudal to the lower border of the aorta was noticed in the Doppler mode (Fig. 1B). Sampling of the 4L station was avoided. The procedure was completed without complications and the samples were negative for malignancy. The patient underwent surgery (wedge resection with mediastinal nodal dissection) and the pathology confirmed as an non-small cell lung cancer not otherwise specified stage IA (pT1N0M0).
Although previous reports described mediastinal hematoma following blind TBNA, but according to our knowledge this is the first reported case with mediastinal hematoma following EBUS-TBNA.2 Hemorrhage has been reported as the most common complication after EBUS-TBNA (0.68%) in the largest published survey about EBUS-TBNA hazards, but the reported patients had mild bleedings which did not require special measures.3 Other major hemorrhagic complications of EBUS-TBNA had been described as case reports. Al-Qadi and Maldonado,4 reported an tracheal intramural hematoma after sampling of stations 4R and 10R with EBUS-TBNA. In this case the operators finished the procedure without apparent complications, but after 5 weeks the patient returned with focal tracheal stenosis secondary to tracheal intramural hematoma at the site of 4R puncture and required tracheal stent. Even though these mentioned vascular complications, some authors claimed that even intentional puncture of mediastinal vessels during EBUS-TBNA could be adequately safe. Vincent et al,5 published a successful trial for EBUS-TBNA traversing the pulmonary artery.

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