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CASE LETTER
Year : 2019  |  Volume : 36  |  Issue : 5  |  Page : 461-462  

A rare complication during endobronchial ultrasound-guided transbronchial needle aspiration: Needle assembly malfunction


Department of Pulmonology, Critical Care and Sleep Medicine, Fortis Memorial Research Institute, Gurugram, Haryana, India

Date of Web Publication23-Aug-2019

Correspondence Address:
Manoj K Goel
Department of Pulmonology, Critical Care and Sleep Medicine, Fortis Memorial Research Institute, Gurugram, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/lungindia.lungindia_36_19

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How to cite this article:
Goel MK, Kumar A, Maitra G. A rare complication during endobronchial ultrasound-guided transbronchial needle aspiration: Needle assembly malfunction. Lung India 2019;36:461-2

How to cite this URL:
Goel MK, Kumar A, Maitra G. A rare complication during endobronchial ultrasound-guided transbronchial needle aspiration: Needle assembly malfunction. Lung India [serial online] 2019 [cited 2019 Nov 18];36:461-2. Available from: http://www.lungindia.com/text.asp?2019/36/5/461/265175



Sir,

The endobronchial ultrasound (EBUS) scope is delicate equipment through which a dedicated needle assembly is passed for performing the transbronchial needle aspiration. Here, we describe a rare complication of needle assembly malfunction due to the separation of the shaft of needle and sheath-sliding mechanism which resulted in the failure to retract the needle within the sheath during the procedure.

A 43-year-old male presented with a history of fever and cough for 3 weeks. A contrast-enhanced computed tomography of the chest revealed a homogenous subcarinal lymph node measuring 20 mm × 25 mm with contrast enhancement. Linear EBUS bronchoscopy was performed using a laryngeal mask airway under general anesthesia. The ultrasound transducer was directly coupled with the bronchial wall without inflating the saline balloon to target the lymph node at station 7 just distal to carina in the right main bronchus. The lymph node was clearly visualized which had a homogenous echogenicity. A fresh 21 Gauze Olympus ViziShot Needle (model NA-201SX-4021) was introduced through the working channel of the EBUS bronchoscope. After the sheath was adjusted appropriately, the needle was pushed within the lymph node by a gentle jab which did not meet any resistance and also did not encounter any cartilage. The stylet was then removed. Back-and-forth movement of the needle slider was done repeatedly, but the needle did not move to and fro even a bit, and it was seen fixed in its position within the lymph node in the ultrasound image [Figure 1]. The needle could not be pulled back within the sheath due to a needle assembly malfunction. Removing the EBUS scope along with the protruded needle outside the sheath might have caused serious injury to the airways. Therefore, the scope was kept as it is within the airway. The needle slider was pulled proximally until it clicked in place. It was secured by locking the needle adjuster. The needle assembly was then subsequently removed through the EBUS scope. It was observed that the needle was protruding outside the sheath, even after completely retracting the needle slider proximally [Figure 2]. The EBUS bronchoscope was then removed from the patient. A video bronchoscopy was done immediately which did not reveal any airway injury. The leak test was done which confirmed that the EBUS scope did not suffer any damage from the needle. The procedure could be successfully performed with another needle which showed a necrotizing granuloma consistent with the diagnosis of tuberculosis. The needle identifier number and batch number were noted and forwarded to the company supplying EBUS-TBNA needles.
Figure 1: Ultrasound image showing needle in the lymph node which was seen fixed in its position as it did not move to and fro with the back and forth movement of the needle slider

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Figure 2: The needle protruding outside the sheath, even after completely retracting the needle slider proximally

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Dhillon and Yendamuri[1] have reported a similar experience. The authors removed the needle after successful passes in the lymph node when they observed that the needle was unexpectedly still outside the sheath despite fully retracting the needle slider. While Dhillon could notice this needle malfunction only after removing the needle from the EBUS scope, we could observe this during the procedure before removing the needle. In both these cases, the broken needle was still attached to the rest of the apparatus and was thus removed in one piece without any remnants left in the patient, and this did not cause any damage to the bronchoscope.

The first case of needle breakage was reported by Özgül et al.,[2] followed by some other reports.[3],[4],[5],[6] In all these cases, the retrieval of the broken fragment of EBUS needle by flexible bronchoscopy could not be done which were either coughed up by the patient or retrieved in stool. Rottem et al.[7] reported a case of EBUS needle breakdown resulting in severe and almost fatal hemorrhage.

There could be some risk factors for needle breakdown. Özgül et al.[2] and Tariq[6] believed that the junction between the long, shiny electroplated portion and the coarse end of the needle is the weakest point in the needle assembly. Rottem et al.[7] hypothesized that this complication may be related to lymph node stiffness. Certain endoscopic maneuvers as torquing, multiple punctures, fanning in a hard lymph node, and hitting the cartilage could all be predisposing factors,[2],[7],[8] which should be as far as possible avoided.

The needle breakage is rare and mostly in the form of snapping of its tip. In our case, we could not retract the needle within the sheath due to needle assembly malfunction which is highly unusual. Needles projecting inappropriately outside the sheath can not only damage the bronchoscope but can also cause injury to airways and patient. The clinicians should be aware of such complication and should check the needle assembly before using it.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Dhillon SS, Yendamuri S. Needle assembly malfunction: An unusual complication related to endobronchial ultrasound-guided transbronchial needle aspiration. J Bronchology Interv Pulmonol 2013;20:252-5.  Back to cited text no. 1
    
2.
Özgül MA, Çetinkaya E, Tutar N, Özgül G. An unusual complication of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA): The needle breakage. Ann Thorac Cardiovasc Surg 2014;20 Suppl: 567-9.  Back to cited text no. 2
    
3.
Moughrabieh M, Zamora F, Dincer H, Podgaetz E, Gibson H. Ebus needle breakage leaving foreign body behind: Thematic poster session. Am J Respir Crit Care Med 2015;191:A3097.  Back to cited text no. 3
    
4.
Hanna A, Crutu A, Baldeyrou P. Needle tip fracture, an unusual EBUS-TBNA complication. J Bronchology Interv Pulmonol 2018;25:e23-4.  Back to cited text no. 4
    
5.
Vial MR, O'Connell JO, Grosu HB, Ost DE, Eapen GA, Jimenez CA, et al. Needle fracture during endobronchial ultrasound-guided transbronchial needle aspiration. Am J Respir Crit Care Med 2016;193:213-4.  Back to cited text no. 5
    
6.
Tariq SM. Accidental fracture of EBUS-TBNA needle during sampling of an enlarged mediastinal lymph node. Oxf Med Case Reports 2016;2016:59-61.  Back to cited text no. 6
    
7.
Rottem K, Avraham A, Zvi GF, Neville B. Endobronchial ultrasound needle breakdown during transbronchial needle aspiration. J Bronchol Interv Pulmonol 2016;3:e32-3.  Back to cited text no. 7
    
8.
Adamowicz B, Manière T, Déry V, Désilets É. Needle fracture during endoscopic ultrasound-guided fine-needle aspiration of suspicious thoracic lymph nodes. Case Rep Med 2016;2016:2526789.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2]



 

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