Risk Factors for Pulmonary Hemorrhage Following Ultrasound-Guided Percutaneous Biopsy of Peripheral Lung Lesions
Lung cancer remains one of the leading causes of cancer-related deaths worldwide, with its morbidity and mortality rates steadily increasing over the past few decades. While imaging techniques are essential for initial detection, they often fall short in providing a definitive diagnosis. Pathologic evaluation of tissue samples is crucial for accurate diagnosis, particularly for peripheral lung lesions, which account for a significant portion of lung cancers. Adenocarcinomas, which constitute approximately 40% of all lung cancers, frequently occur in the peripheral regions of the lungs. This makes them accessible for ultrasound-guided percutaneous biopsy, a technique that has gained prominence due to its ability to provide real-time imaging and minimize complications compared to other methods.
Ultrasound-guided transthoracic cutting needle biopsy is widely regarded as a safe and efficient method for obtaining pathologic diagnoses of peripheral lung lesions. However, like any invasive procedure, it is not without risks. Complications such as air embolism, pneumothorax, pulmonary hemorrhage, and tumor seeding have been reported. Among these, pulmonary hemorrhage is particularly concerning due to its potential severity. Severe hemoptysis, a manifestation of pulmonary hemorrhage, can necessitate emergency interventions such as endobronchial tamponade, arterial embolization, or even surgery, and can be life-threatening in some cases. Despite the clinical significance of this complication, there is a paucity of data regarding the risk factors associated with pulmonary hemorrhage following ultrasound-guided percutaneous lung biopsy.
This study aimed to identify the risk factors associated with pulmonary hemorrhage following ultrasound-guided transthoracic needle biopsy of peripheral lung lesions. The research was conducted as a retrospective analysis of patients who underwent the procedure between June 2010 and June 2016 at the Department of Ultrasound, the First Affiliated Hospital of Guangxi Medical University, China. The study included patients with peripheral lung lesions adherent to the pleura, as confirmed by chest X-ray, magnetic resonance imaging (MRI), or computerized tomography (CT). Patients with severe lung or heart dysfunction, severe arrhythmia, susceptibility to bleeding, or those unable to undergo the procedure due to cough or hemoptysis were excluded.
The biopsy procedure was standardized and performed by two experienced radiologists proficient in ultrasound diagnosis and percutaneous lung biopsy techniques. The procedure began with sonography, using chest CT data as a reference to assess the size, location, and sonographic features of the pulmonary lesions. Ultrasound systems such as the Logiq E9 (GE Healthcare) or Acuson S2000 (Siemens) were employed, equipped with convex array probes operating at frequencies of 2.5–4.0 MHz or 3.5–5.5 MHz. In some cases, the Preirus or EUB6500 ultrasound diagnostic instruments were used, with special puncture probes operating at frequencies of 1–5 MHz or 2–5 MHz. The lesions were measured based on the maximum diameter from superficial to deep on sagittal sectional ultrasound images. Color Doppler imaging was routinely used to delineate large vessels and abnormal arteries, enabling the operator to avoid puncturing them during the biopsy. The biopsy was performed using an 18-gauge automatic cutting needle (Bard Magnum Biopsy Instrument).
The study analyzed several clinical variables, including patient age, sex, presence or absence of a bronchus sign, target lesion position, target lesion size (longest diameter), target lesion blood flow, number of punctures during the biopsy, and lesion pathologic characteristics. Lesion size was categorized as small (longest diameter ≤2 cm), intermediate (>2 cm and ≤5 cm), or large (longest diameter >5 cm). Lesion position was categorized by lung lobe (left upper, left lower, right upper, right middle, or right lower). Blood flow was classified as rich or poor based on the characteristics of the color blood flow signals in the peripheral lung lesions. Pathologic diagnoses were classified as malignant tumor, benign tumor, or inflammatory disease.
All patients were followed up for one week post-biopsy, with careful monitoring for complications such as chest pain, shortness of breath, or hemoptysis. Pulmonary hemorrhage was defined as new ground-glass opacities on post-biopsy CT imaging (indicating alveolar hemorrhage), hemoptysis, bloody sputum, or hemothorax necessitating intervention. Statistical analysis was performed using SPSS 21.0, with data presented as frequencies and percentages. Comparisons between groups were made using the Chi-square test or Fisher’s exact test, and binary logistic regression analyses were conducted to identify factors independently associated with pulmonary hemorrhage.
The study included 914 patients, of whom 661 (72.32%) were men, with a mean age of 54.27 ± 14.44 years (range: 14–87 years). The target lesion size ranged from 7 to 138 mm. Pathologic diagnoses included malignant lesions in 412 patients (45.08%), benign tumors in 76 patients (8.32%), and inflammatory lesions in 426 patients (46.61%). Post-biopsy pulmonary hemorrhage occurred in 105 patients (11.49%), with manifestations including hemoptysis in 35 patients (3.83%), bloody sputum in 28 patients (3.06%), hemothorax in 2 patients (0.22%), and alveolar hemorrhage in 40 patients (4.38%). All patients with post-biopsy hemorrhage recovered after symptomatic treatment.
Univariable analysis revealed that patients with post-biopsy pulmonary hemorrhage had a significantly higher proportion of smaller lesions and lesions with a rich blood supply. Multivariable logistic regression analysis confirmed that lesion size (OR, 0.418; 95% CI: 0.298–0.588; P < 0.001) and a rich blood supply to the lesion (OR, 2.238; 95% CI: 1.363–3.247; P = 0.001) were independently associated with pulmonary hemorrhage. Lesion location, bronchus sign, age, and gender were not significantly associated with the complication.
The study’s findings align with previous research indicating that inflammatory lesions and malignant tumors are more susceptible to pulmonary hemorrhage due to intralesional vascular remodeling and increased collateral circulation. The negative correlation between lesion size and pulmonary hemorrhage may be attributed to the use of color Doppler flow imaging, which allows for careful planning of the biopsy trajectory to avoid major vessels. Real-time ultrasound monitoring during the procedure is particularly crucial for small lesions, where the risk of hemorrhage is higher. Adjusting the needle path, inserting the needle at a large angle or parallel to the chest wall, and increasing the sampling volume can help reduce the number of passes and minimize the risk of hemorrhage.
The study also highlighted that the number of needle passes did not significantly affect the incidence of pulmonary hemorrhage, provided that biopsies avoided major vessels or lesions with a positive bronchus sign. This suggests that the procedure is safe even with up to four needle passes if proper precautions are taken. However, the authors recommend several measures to further reduce the risk of pulmonary hemorrhage: effective communication with patients to alleviate anxiety, careful evaluation of the disease condition before biopsy, strict control of puncture depth, and avoidance of blood vessels during the procedure, particularly in lesions with a rich blood supply.
In conclusion, this study identified rich lesion blood supply and small lesion size as significant risk factors for pulmonary hemorrhage following ultrasound-guided biopsy of peripheral lung lesions. These findings provide valuable insights for clinicians aiming to minimize complications and improve the safety of the procedure. By adhering to the recommended precautions and leveraging real-time ultrasound monitoring, the risk of pulmonary hemorrhage can be significantly reduced, enhancing the overall efficacy and safety of ultrasound-guided lung biopsies.
doi.org/10.1097/CM9.0000000000001788
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