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To compare the success rates, complication rates, and radiation doses of conventional computed tomography (CCT) versus computed tomography with fluoroscopy (CTF) during image-guided percutaneous needle biopsies of intrathoracic lesions.We conducted a retrospective analysis of 1143 consecutive intrathoracic biopsies performed under computed tomography guidance at a single tertiary care center. For each procedure we recorded patient age and sex, lesion size and location, and radiation dose administered to the patient. Thereafter, appropriate tests of statistical significance were applied to compare rates of success, complications, and radiation between CCT and CTF guidance.After correcting for lesion size, CTF was associated with an odds ratio (OR) of 6.07 [95% confidence interval (CI): 2.23-16.50] for technical procedural success, an OR of 0.79 (95% CI: 0.55-1.15) for fine-needle aspiration success, an OR of 2.11 (95% CI: 1.02-4.38) for core-needle biopsy success, and an OR of 1.45 (95% CI: 1.00-2.21) for overall success when compared with CCT. CTF was associated with an OR of 1.10 (95% CI: 0.35-3.48) for complications when compared with CCT. Mean dose-length product per procedure was 1332 mGy cm for CCT and 1730 mGy cm for CTF (P=0.027).CCT and CTF are both valuable tools for intrathoracic biopsy. CTF improves technical and core-needle biopsy success at the expense of higher radiation doses to the patient. Operator confidence with CCT and CTF in light of lesion characteristics should guide the choice to select one over the other.