RARE CASE OF A DELAYED HEMOTHORAX AS A COMPLICATION OF EBUS-TBNA

Abstract

SESSION TITLE: Medical Student/Resident Procedures Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is the standard of care in staging lung cancer and is regarded as a safe, minimally invasive procedure with low complication rates (0.16-1.44%) as reported in a systematic review of 226 studies of EBUS-TBNA. This case highlights a rare occurrence of a hemothorax secondary to mediastinal hemorrhage post TBNA of mediastinal adenopathy. CASE PRESENTATION: A 66 year-old former smoker with DM, HTN, HLD, and CAD presented for workup of a 6 x 4 cm left lower lobe pulmonary mass. He underwent EBUS-TBNA of hilar and mediastinal lymph nodes and the lung mass. The mass revealed bronchogenic squamous cell carcinoma and TBNA of stations 4R, 4L, 11L and 7 were negative for malignancy. He resumed Rivaroxaban for history of pulmonary embolism (PE) the day after the procedure. Five days after his EBUS, he presented with acute pleuritic right-sided chest pain, dyspnea, and minimal hemoptysis. He had a heart rate of 110, systolic blood pressure of 80 mmHg and required 3L/minute nasal cannula oxygen. Computed tomography of the chest ruled out PE and pneumothorax but revealed interval development of a large right-sided pleural effusion. His hemoglobin dropped to 8 g/dL from 12.4 g/dL five days prior. A 24-French chest tube was placed for a right-sided hemothorax, which drained 1.5L of bloody fluid. The chest tube was maintained until drainage subsided and anticoagulants were held until his follow-up visit. Two weeks later, he presented with recurrent right-sided hemothorax requiring thoracentesis with removal of 1.26L of blood. Pleural studies were negative for malignant and infectious etiologies. He underwent placement of a retrievable inferior vena cava filter while awaiting further therapeutic plans. DISCUSSION: This patient's hemothorax as a hemorrhage-related complication of TBNA is uncommon. One study found that of 7345 patients who had an EBUS-TBNA, 90 patients (1.23%) had a complication, with hemorrhage seen overall in only 50 patients (0.68%) followed by infection (0.19%). A study reviewing 42 cases of hemorrhage-related complications post EBUS-TBNA, noted station 7 in 34 patients (43.0%), followed by 4R in 24 patients (30.4%) as the likely sites. Stations 4R and 7 were sampled in this patient, which likely explain the etiology of his hemothorax. One other case reports mediastinal hematoma as an adverse event of EBUS-TBNA4. This patient was on aspirin though literature suggests that aspirin does not increase risk of bleeding during transbronchial lung biopsy. The patient was not on a P2Y12 inhibitor, a class known to increase bleeding risk. We believe the recurrence of the hemothorax may have been re-accumulation of residual blood. CONCLUSIONS: While the complication rate is low for EBUS-TBNA, this case broadens the bronchoscopist's and patient’s understanding of hemothorax as a potential but rare complication from EBUS-TBNA. Reference #1: Vaidya PJ, Munavvar M, Leuppi JD, Mehta AC and Chhajed PN. Endobronchial ultrasound-guided transbronchial needle aspiration: Safe as it sounds. Respirology. 2017; 22: 1093–1101. doi:10.1111/resp.13094. Reference #2: 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. doi:10.1186/1465-9921-14-50 Reference #3: Herth FJ, Becker HD, Ernst A. Aspirin does not increase bleeding complications after transbronchial biopsy. Chest. 2002; 122: 1461–1464. DISCLOSURES: No relevant relationships by Venkata Bandi, source=Web Response No relevant relationships by Donald Lazarus, source=Web Response No relevant relationships by Cameron McBride, source=Web Response No relevant relationships by Ritika Singh, source=Web Response