POLICY CHANGES AFTER A RARE COMPLICATION OF EBUS-TBNA: EXPECTORATION OF A METAL SHEATH

Abstract

SESSION TITLE: Wednesday Fellows Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Since the first application of ultrasound in the airway in 1992, endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has become a widely-used effective and minimally invasive method of diagnosing and staging mediastinal lymph nodes and masses. The procedure is generally well-tolerated. Major complications involving EBUS-TBNA are low, but there are increasing reports of procedure-related complications. We present a case of a retained inner metal sheath of the Olympus EBUS-TNBA needle catheter after instrument malfunction. CASE PRESENTATION: A 47-year old male was referred for EBUS-TBNA for worsening cough for the past year. A computed tomography of the chest revealed bilateral hilar and mediastinal adenopathy concerning for sarcoidosis. Endobronchial ultrasound was used to assist with guiding biopsy of hilar and mediastinal regions. An EBUS-TBNA was performed using an Olympus EBUS-TBNA 22-gauge needle. Specimens were obtained from the 7, 10R, and 11L lymph nodes. During sampling of the left interlobar lymph node, there was unexpected resistance when attempting to advance the needle. The needle was repositioned and the lymph node was aspirated without further difficulty. Rapid On-Site Evaluation revealed non-necrotic granulomatous tissue of the subcarinal lymph node. The tracheobronchial tree was examined to at least the first sub-segmental level. Bronchial mucosa and anatomy were normal with no endobronchial lesions, secretions or foreign bodies visualized. The patient tolerated the procedure well and was discharged. On his way home, the patient reported expectorating “a metal sheath.” The Olympus EBUS-TBNA needle catheter was examined and it was discovered that the inner metal sheath located in the distal plastic sheath of the needle catheter was missing which corresponded to the inner metal sheath of the needle catheter. The patient did not have any complications from this event. DISCUSSION: EBUS-TBNA is the preferred modality in the diagnosis and staging of mediastinal lymph nodes and masses with high specificity and sensitivity. Serious EBUS complication rates range from 0.15-0.16%, including mediastinal abscess, empyema, needle fracture, and hemo-pneumomediastinum, Literature review showed a single case report of an expectorated “stent” from EBUS-TBNA. Due to the malfunction of the needle catheter, a root-cause analysis was performed and protocol changes were subsequently made to our institutional policy. CONCLUSIONS: EBUS-TBNA is accepted as a safe, well-tolerated procedure with low major complication rates. Our case is only the second reported case of assembly malfunction causing unexpected deployment of the inner metal sheath into the bronchi. While no serious complications resulted from this, providers performing EBUS-TBNA need to be aware of this potential device malfunction. We recommend routine inspection of the needle apparatus pre- and post-procedure. Reference #1: Caglayan BYilmaz A, et al. Complications of Convex-Probe Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration: A Multi-Center Retrospective Study. Respir Care. 2016 Feb;61(2):243-8. Reference #2: Zamora FD, Moughrabieh A, et al. An Expectorated "Stent": An Unexpected Complication of EBUS-TBNA. J Bronchology Interv Pulmonol. 2017 Jul;24(3):250-252. Reference #3: Asano F, Aoe M, Ohsaki Y, et al. Complications associated with endobronchial ultrasound-guided transbronchial needle aspiration: a nationwide survey by the Japan Society for Respiratory Endoscopy. Respir Res. 2013;14:50 DISCLOSURES: No relevant relationships by Michael Ayers, source=Web Response No relevant relationships by Ngoc-Tram Ha, source=Web Response No relevant relationships by Cynthia Tsai, source=Web Response