SESSION TITLE: Bronchology Case Report Posters
SESSION TYPE: Case Report Poster
PRESENTED ON: Sunday, March 23, 2014 at 01:15 PM - 02:15 PM
INTRODUCTION: Evaluation of mediastinal masses has become simplified, safe and accurate over the last decade with the advent of endoscopic ultrasound guided fine needle aspiration (EUS-FNA) and endobronchial ultrasound guided transbronchial needle aspiration (EBUS-TBNA). Occasionally one does encounter lesions which are beyond the conventional reach of EBUS or EUS scope; herein we describe a case where we had to resort to transaortic puncture using an EBUS scope to achieve diagnosis.
CASE PRESENTATION: A 62 year old male with left lung mass was taken up for EBUS examination after two attempts of computerised tomography(CT) guided fine needle aspiration failed to establish diagnosis. EBUS-TBNA of left paratracheal lymph node was non diagnostic. A single trans aortic pass taken under real time ultrasound guidance with rapid onsite evaluation (ROSE). Pathologist confirmed squamous cell carcinoma and he was started on palliative chemotherapy.
DISCUSSION: We report initial experience and feasibility of transaortic puncture with EBUS scope. Innovations in medicine must ensure safety of the patient as priority and when there is lack of data regarding specific procedure cues are taken from similar procedures in other specialities. Analysis of 14,550 patients who underwent aortography showed that aortic punctures to be safe with incidence of only seven major (0.05%) and two fatal (0.014%) complications.#1There have been two reports of transaortic punctures using EUS scope till date. Wallace et al#2 first reported a case of successful diagnosis of bronchogenic carcinoma. This was followed by retrospective series of fourteen patients by Bartheld et al#3 with a diagnostic accuracy of 64 %. In the second study, there were two cases suspicious of para aortic hematoma which resolved without intervention. We used a single pass across the aorta as safety beyond one attempt is not known and did not see any hematoma on ultrasound imaging five minutes after puncture.
CONCLUSIONS: As indication for a transaortic puncture are few and far apart due to most lesions being accessible by safer methods, this is likely to remain restricted to case reports and series. While it is comforting to know that such punctures can be done safely it should remain the last resort when all else fails. Our case was inoperable at the outset and transaortic puncture was done after exhaustion of other viable alternatives.
Reference #1: Szilagyi DE, Smith RF, Elliott JP, Jr., Hageman JH. Translumbar aortography: a study of its safety and usefulness. Arch Surg 1977;112:399-408.
Reference #2: Wallace MB, Woodward TA, Raimondo M, Al-Haddad M, Odell JA. Transaortic fine-needle aspiration of centrally located lung cancer under endoscopic ultrasound guidance: the final frontier. The Annals of thoracic surgery 2007;84:1019-21.
Reference #3: von Bartheld MB, Rabe KF, Annema JT. Transaortic EUS-guided FNA in the diagnosis of lung tumors and lymph nodes. Gastrointestinal endoscopy 2009;69:345-9.
DISCLOSURE: The following authors have nothing to disclose: Pattabhiraman Vallandaramam, Arjun Srinivasan, Mahadevan Sivaramakrishnan
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