Procedure
The IonTM Endoluminal System by Intuitive was used. A
CT with 1.5 mm thick slices was uploaded into the
PlanPointTM software. After airway segmentation by the
software, target lesions were identified in both the right upper and
lower lobes, pathways were planned and reviewed through a virtual
simulation. The patient was intubated with a 6.0 endotracheal tube
(ETT). A 4.2 mm bronchoscope (Olympus BF-P190TM) was
first used to complete a standard airway examination and aspirate
secretions. The Ion system was then docked to the ETT via a magnetic
adapter and the 3.5mm catheter with the vision probe inside it was
inserted into the ETT. A standard registration including verification of
the main carina and airways in each of the four quadrants was performed.
The catheter was then navigated close to the right lower lobe target
lesion under direct visualization and in accordance with the virtual
navigation path created using the pre-procedure CT scan. Due to the
small size of sub-segmental airways, we could not get closer than 22 mm
from the RUL target nodule, and 32 mm from the RLL target nodule.
However, we chose the RLL target for biopsy as we were able to introduce
the catheter into an airway leading directly to the nodule (Figure 2).
There was no appreciable CT-to-body divergence. The vision probe was
then removed, and a rEBUS probe was inserted, which revealed a
concentric signal. The rEBUS probe was then removed and multiple forceps
biopsies were performed using the Olympus EndoJaw Disposable Biopsy
Forceps with fluoroscopic guidance using a overlay of an image of the
rEBUS probe extended to the distal end of the nodule. After several
pieces of tissue were obtained, a BAL was performed. There were no
immediate complications and a post-operative chest X-ray was
unremarkable without evidence of pneumothorax.
The infectious work up was again negative. The pathology slides showed
benign, distorted/hemorrhagic lung parenchyma with minimal inflammatory
infiltrate, occasional hemosiderin-laden macrophages and several foci of
dystrophic calcification (Figure 1). Due to right-sided unilaterality,
vascular dysfunction was considered but CT angiography, trans-esophageal
echocardiogram, and cardiac catheterization showed normal flow within
the right-sided vessels and anastomosis.