Thoracic biopsies and ablation

1. M. BORENSZTEIN* – J GARNON° – A GANGI°
Department of Interventional Radiology
*Buenos Aires/Argentina
° Strasbourg/France
THORACIC BIOPSIES AND ABLATIONS
How to avoid errors

2. so many things can go wrong...

4. - 72 y.o patient
- suspicion of lung cancer
- biopsy is scheduled
CASE1

5. fast growing pneumothorax => the target lesion is moving and cannot be entered
with the biopsy needle

6. lessons learned:
• choose the shorter transpulmonary access

7. lessons learned:
• drain the pneumothorax if it occurs before the biopsy

9. the radiologist fired anyway => hemoptysis

10. lessons learned:
• turn the patient on the ipsilateral side to limit the
diffusion of bleeding to the other lung

11. - 74 y.o non surgical patient
- adenocarcinoma of the left lower lobe
- RFA is scheduled
CASE2

12. 1st control
2nd control: hemothorax
puncture with the coaxial system

13. biopsy through the coaxial system
3rd control: hematoma is growing

14. RFA with the exandable probe
Before RFA
After 20 min of RFA
After 40 min of RFA
Good covering of the tumor (ground glass)
Stability of the hematoma

15. • Ablation is finished
• Hematoma is stable
• The risk of active bleeding can still occur…
• …care should be taken when withdrawing the needle
At this point:

16. Withdrawal of the coaxial system in the intercostal space
Arterial back-flow through the coaxial needle
The hematoma is growing
end of RFA
1st control with the coaxial system
in the intercostal space

17. • deployment of the RFA probe and ablation in the
intercostal space => vessel coagulation
• then insertion of two coils through the coxial
• then injection of hemostatic matrix through the coaxial
At this point:

18. coils hemostatic matrix
no back-flow through the coaxial needle anymore
stability of hematoma

19. • Stability of hemothorax
• No active bleeding
• No direct contact between the coils and the intercostal artery: small collateral?
post-procedural angio CT

21. lessons learned:
• puncturing juste above the rib is not 100% protective of
incidental vessel puncture
• never withdraw the coaxial needle if it bleeds!

22. - 65 y.o non surgical patient
- growing lesion in the left lung
- Microwave ablation + biopsy is performed
CASE3
microwave antenna
biopsy
alveolar bleeding

23. • ablation was not performed = ERROR!
• patient was turned supine and hopefully bleeding
stopped
• patient was extubated the day after the procedure
At this point:

24. lessons learned:
• always check the position of the tru-cut needle before
biopsying

25. lessons learned:
• always check the position of the tru-cut needle before
biopsying
NOT OK OK

26. lessons learned:
• if it bleeds, ablate to coagulate
insertion of
the MW
antenna
biopsy bleeding immediate
ablation =
coagulation

28. CASE4
- 55 y.o patient
- single met from melanoma
- Microwave ablation + biopsy is performed

29. microwave ablation
axial
coronal

30. asymptomatic phrenic palsy
before MW after MW

31. right phrenic nerve

32. • palsy was asymptomatic (but can be devastating in a
patient with repsiratory failure)
• recovery might occur in the following months
At this point:

33. lessons learned:
• know the anatomy!
• prevention!

34. brachial plexus
- think about it for apical tumors

36. artificial pneumothorax
thermosensor between the rib &
the plexus
4 cryoprobes

37. coronal
sagittal
coronal
hydrodissection

38. vagal nerve
- think about it for upper paramediastinal tumors
- risk of laryngeal nerve palsy
left side right side

39. pneumothorax

40. sympathetic nerve
- think about it for upper paravertebral tumors
- risk cervicothoracic ganglia injury
left side

43. CASE5
- 61 y.o patient
- growing lesion in a single lung
- RFA + biopsy is performed

44. • pneumothorax requiring chest tube insertion
• drain had to be left for 17 days before it could be
removed
After the procedure:

45. minimal transpulmonar access
=> increase the rate of bronchis fistula

46. lessons learned:
• choose a long transpulmonary access when ablating
subpleural lesions

47. CASE6
- 63 y.o patient
- single met from renal cancer
- MW ablation is scheduled with a new device

48. MW ablation: 40W – 3 mins at 3 different positions (9 min in total)

49. • no immediate complication
• 3 weeks after the procedure, the patient is readmitted
to the hospital with pain and fever
After the procedure:

50. large bronchopleural fistula

51. • ablation was too large
• 2 risk factors for a poor postablation cicatrisation were
identified: antiangiogenic therapy was not discontinued
and diabetes was discovered
• fistula closed after 2 months of antibiotics 
key points:

52. lessons learned:
• do not rush on new systems!
• be careful on other debilitating factors
• surgery is not the 1st option to manage these
complications

56. lessons learned:
• avoid ablating the diaphragm
• especially on the left side
• protection!

58. CONCLUSION
• complications are frequent in thoracic interventions
• most of them are minor
• most of the major complications can be prevented