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CASE REPORT
Year : 2021  |  Volume : 38  |  Issue : 1  |  Page : 80-83  

Accidental breakage of needle tip during endobronchial ultrasound-guided transbronchial needle aspiration: A case report and review of literature


Department of Pulmonary and Critical Care Medicine, Medeor JCS Institute of Pulmonary, Critical Care and Sleep Medicine, New Delhi, India

Date of Web Publication31-Dec-2020

Correspondence Address:
Jagdish Chander Suri
Chairman, Department of Pulmonary and Critical Care Medicine, Medeor JCS Institute of Pulmonary, Critical Care and Sleep Medicine, B-33/34, Qutab Institutional Area, New Delhi- 110 016
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/lungindia.lungindia_537_19

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   Abstract 


Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is commonly recommended for the diagnosis of mediastinal lymphadenopathy with malignant and nonmalignant etiology. EBUS-TBNA has been preferred over mediastinoscopy because of several advantages such as comparable diagnostic accuracy, safety, cost-effectiveness, and less invasiveness. Hemorrhage, mediastinitis, pneumonia, mediastinal abscess, empyema, lung abscess, pericarditis, and pneumothorax have been reported as major complications of EBUS-TBNA. Equipment malfunction has been observed mostly in the form of breakage of EBUS scope parts such as working channel, optical fibers, and ultrasound probe. Needle malfunction either involving assembly leading to inability to retract the needle within the sheath or accidental breakage of the needle tip has also been reported but the evidence is still limited. We encountered an accidental breakage of needle tip while performing EBUS-TBNA procedure in a 58-year-old male having subcarinal lymphadenopathy suspected to have lung cancer. We were able to successfully retrieve the broken fragment bronchoscopically without any complications.

Keywords: Endobronchial ultrasound-guided transbronchial needle aspiration, mediastinal lymphadenopathy, needle malfunctiona


How to cite this article:
Bante N, Singh A, Gupta A, Mittal A, Suri JC. Accidental breakage of needle tip during endobronchial ultrasound-guided transbronchial needle aspiration: A case report and review of literature. Lung India 2021;38:80-3

How to cite this URL:
Bante N, Singh A, Gupta A, Mittal A, Suri JC. Accidental breakage of needle tip during endobronchial ultrasound-guided transbronchial needle aspiration: A case report and review of literature. Lung India [serial online] 2021 [cited 2021 Jan 19];38:80-3. Available from: https://www.lungindia.com/text.asp?2021/38/1/80/306024




   Introduction Top


Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is commonly recommended for the diagnosis of mediastinal lymphadenopathy with varying etiology.[1] It can establish diagnosis and staging of lung cancer with comparable diagnostic accuracy (pooled sensitivity of 88%–93% and specificity of 100%) to mediastinoscopy considered as gold standard.[2],[3] EBUS-TBNA now preferred over mediastinoscopy because of safety, cost-effectiveness and less invasiveness.[4] It provides real time ultrasound guidance for the confirmation of needle puncture site that facilitates the accurate collection of a sample from the lesion for pathological diagnosis. Hemorrhage, mediastinitis, pneumonia, mediastinal abscess, empyema, lung abscess, pericarditis, and pneumothorax have been reported as major complications of EBUS-TBNA in recent years.[5],[6] A survey from Japan has described equipment malfunction as complication in 1.33% of cases.[4] This has been observed mostly in the form of breakage of EBUS scope parts such as working channel (74%), optical fibers (16%), and ultrasound probe (7%). Malfunction of needle involving assembly leading to inability to retract the needle within the sheath has been reported.[7],[8],[9] Needle malfunction in the form of accidental breakage or snapping of its tip during the procedure has also been reported.[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20] We herein report an accidental breakage of needle tip as a rare complication while performing EBUS-TBNA procedure in a 58-year-old male suspected to have lung cancer.


   Case Report Top


A 58-year-old male, chronic reformed smoker with severe chronic obstructive pulmonary disease was admitted with cough, breathlessness, and significant weight loss since the past 2 months. Contrast-enhanced computed tomographic imaging of thorax revealed bilateral emphysematous changes and pleural based soft-tissue density mass lesion of size 50 mm × 49 mm having irregular margin located in the anterior segment of the left upper lobe along with subcarinal lymphadenopathy of size 28 mm × 20 mm as shown in [Figure 1]a and [Figure 1]b. Positron emission tomographic imaging showed fluorine-deoxyglucose avid enhancement in both mass lesion (standardized uptake value [SUV] max-16.4) as well as subcarinal lymph node (SUVmax-6). The possibility of lung cancer with subcarinal lymph node metastasis suspected. EBUS-TBNA was performed with EBUS scope (EB19-J10U; Pentax Medical, Montvale, New Jersey, USA) under general anesthesia from subcarinal lymph node station (station-7) for the diagnosis and staging of lung cancer using a 22 G Echo Tip Pro Core needle (High Definition, Cook Endoscopy Inc., Limerick, Ireland). The first and second aspirations to obtain core tissue from lymph node were performed without any complication but the tissue yield was inadequate. Needle movement was smooth inside the lymph node. During the third aspiration, a resistance was felt initially while piercing the node, but the needle had penetrated the node as confirmed on ultrasonic imaging as shown in [Figure 1]c. However, the needle did not move back and forth smoothly and ultrasound vision of needle was lost subsequently. The scope was retained as it is within the airway to prevent injury. The needle slider was pulled proximally until a clicking sound was heard and needle adjuster was locked for ensuring safety. It was ensured with bronchoscopic view of EBUS scope that needle was not protruding outside the sheath, after complete retraction of the needle slider proximally. However, a broken needle tip was localized in the lateral wall of carina during inspection of airways as shown in [Figure 1]d. The needle assembly was then gently removed. EBUS Scope was also withdrawn subsequently. Conventional bronchoscopy (EB19-J10, Pentax Medical, Montvale, New Jersey, USA) was performed immediately and broken needle fragment was removed using alligator forceps without any complications. Broken proximal end of needle has shown in in [Figure 1]e. The size of the fragment was 15 mm as shown in [Figure 1]f. We did not observe any damage to the EBUS scope by the broken needle tip. Repeat EBUS as well as X-ray fluoroscopy after the successful removal of the broken tip confirmed no other residual materials. EBUS procedure was completed using a new needle and aspirate sample was sent for analysis. There was no evidence of malignancy based on the results of cytological and histopathological examinations of aspirate specimens obtained from the enlarged lymph node. However, the diagnosis of squamous cell carcinoma was established on histopathological examination of sample obtained from ultrasound-guided transthoracic biopsy from mass lesion. The patient was discharged the next day without any procedure-related complications. The complication as well as needle batch number were notified and forwarded to the company manufacturing EBUS-TBNA needles.
Figure 1: (a) Axial cuts of computed tomography thorax showing pleural based soft tissue density mass lesion of size 50 mm × 49 mm having irregular margin located in anterior segment of left upper lobe (b) subcarinal lymphadenopathy of size 28 mm × 20 mm (indicated by horizontal arrow) (c) ultrasonic image showing needle stuck in the subcarinal lymph node (station 7) (d) endobronchial ultrasound bronchoscopic view showing flash view of broken metallic needle fragment left in lateral wall of the carina at 2 o' clock position (e) broken proximal end of endobronchial ultrasound needle (f) broken needle tip after removal with length 15 mm

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   Discussion Top


EBUS-TBNA is generally considered a safe procedure, with an overall complication rate of 1.4%.[5] Needle tip breakage is a rare complication of EBUS-TBNA as observed in our case which was successfully removed with alligator biopsy forceps under bronchoscopic guidance. Various authors have reported similar experience as described in [Supplementary Table 1 [INLINE:2]].[7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20] A nationwide survey by the Japan Society for Respiratory Endoscopy focused on complications associated with EBUS-TBNA aspiration and reported the breakage of the puncture needle in 15 (0.20%) cases.[4] The details of this complication were not described although reported for first time. The first case of needle tip breakage was reported in detail by Özgül et al.,[10] followed by other reports.[11],[12],[13],[14],[15],[16],[17],[18],[19],[20] The retrieval of the broken fragment of EBUS needle by flexible bronchoscopy was successfully reported in most of these cases.[11],[12],[14],[16],[18],[19],[20] Unsuccessful attempts were also reported where fragments migrated to dependent lobes of lung which were expelled by spontaneous coughing[8],[13],[17] or migrated to gastrointestinal tract followed by expulsion in faeces.[10] Vial et al. observed retained needle fragment within the lymph node with mucosal thickening and inflammatory changes at same area that could not be retrieved with bronchoscopy.[15] The consequences of needle fragment retention have not been identified but could include migration with vascular disruption or embolization and a chronic inflammatory reaction to foreign body. Invasive procedures such as thoracotomy might be required if there are higher risks of complication. However, final decision for removal depends on the clinician considering risk-benefit ratio. Kuint et al. reported a case of EBUS needle breakdown resulting in fatal hemorrhage requiring mechanical ventilation.[13] Few studies have also reported needle assembly malfunction due to the separation of the shaft of needle and sheath-sliding mechanism[7],[9] or involvement of spring/coil mechanism,[8] resulting in failure to retract the needle within the sheath during or after the procedure. The broken needles were still attached to the rest of the apparatus even after withdrawal of whole assembly but removed in one piece without any residue materials in the patients. Needles projecting inappropriately outside the sheath can not only damage the bronchoscope but can also cause injury to airways. No mortality has been reported with EBUS needle malfunction. Few reasons have been proposed for needle malfunction. These include manufacturing defect,[7],[10],[17] kinking of weakest point in the needle assembly (junction between the long, shiny electroplated portion, and the coarse end of the needle),[10],[12],[14] multiple punctures,[16] accessing a hard lymph node or hitting the bronchial cartilage,[12],[13],[17] excessive load on needle tip by operator that might have less experience and tangential position of the needle requiring more angulation and excessive bending.[7],[12],[16],[17],[20] All these factors except lymph node hardness, might be responsible for this complication in the present case. There could be increased risk of complication in elderly where the cartilaginous rings of airways are calcified and distance between rings is also less. The length of broken tip fragment in majority of cases including current one, are reported to be around 15 mm which seems to be the weakest point of needle and are more prone to kinking or snapping on multiple passes. Needle breakage has been observed irrespective of needle type. We have encountered this complication at our center with 22G Echo Tip Pro Core needle whereas previous studies have reported mostly with 21G/22G Olympus ViziShot or 22G Cook ECHO-HD-EBUS-P needles.[7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20] Technical modifications need to be improvised to rectify this existing issue. SonoTip EBUS needles comprising nitinol (nickel and titanium alloy) can be used to overcome these limitations. Advantages of these needles are resistance to permanent bends and kinks at curved or angulated positions, maintenance of integrity even after multiple passes and also adoption of twist-lock technology for precise sheath and needle length adjustments.[21] Although theoretically this needle may sound to be better, the experience with it is limited. There are not enough comparative data to suggest that this needle is better than others. The expanding evidence regarding this complication of EBUS-TBNA needle breakage could be of major concern for bronchoscopists in near future. The complication can be minimized by avoiding excessive needle bending, thorough inspection of needle assembly before proceeding for every pass and maintaining visual inspection of needle integrity during and after the procedure.



Declaration of patient consent

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

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Rivera MP, Mehta AC, Wahidi MM. Establishing the diagnosis of lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest 2013;143:e142S-65.  Back to cited text no. 1
    
2.
Gu P, Zhao YZ, Jiang LY, Zhang W, Xin Y, Han BH. Endobronchial ultrasound-guided transbronchial needle aspiration for staging of lung cancer: A systematic review and meta-analysis. Eur J Cancer 2009;45:1389-96.  Back to cited text no. 2
    
3.
Adams K, Shah PL, Edmonds L, Lim E. Test performance of endobronchial ultrasound and transbronchial needle aspiration biopsy for mediastinal staging in patients with lung cancer: Systematic review and meta-analysis. Thorax 2009;64:757-62.  Back to cited text no. 3
    
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Asano F, Aoe M, Ohsaki Y, Okada Y, Sasada S, Sato S, 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.  Back to cited text no. 4
    
5.
Eapen GA, Shah AM, Lei X, Jimenez CA, Morice RC, Yarmus L, et al. Complications, consequences, and practice patterns of endobronchial ultrasound-guided transbronchial needle aspiration: Results of the AQuIRE registry. Chest 2013;143:1044-53.  Back to cited text no. 5
    
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Vaidya PJ, Munavvar M, Leuppi JD, Mehta AC, Chhajed PN. Endobronchial ultrasound-guided transbronchial needle aspiration: Safe as it sounds. Respirology 2017;22:1093-101.  Back to cited text no. 6
    
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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. 7
    
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Zamora FD, Moughrabieh A, Gibson H, Podgaetz E, Dincer HE. An expectorated “Stent”: An unexpected complication of EBUS-TBNA. J Bronchology Interv Pulmonol 2017;24:250-2.  Back to cited text no. 8
    
9.
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.  Back to cited text no. 9
[PUBMED]  [Full text]  
10.
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. 10
    
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Sharma D, Loh HC, Bellinger C. Where is the rest of that needle? Needle breakage: A rare complication of EBUS-TBNA. Chest 2015;837A.  Back to cited text no. 11
    
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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. 12
    
13.
Kuint R, Abutbul A, Fridlender ZG, Berkman N. Endobronchial ultrasound needle breakdown during transbronchial needle aspiration. J Bronchol Interv Pulmonol 2016;3:e32-3.  Back to cited text no. 13
    
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Chalise SN, Brown C, Bowling MR. A case report of endobronchial ultrasound needle fracture. Int J Respir Pulm Med 2016;3:4.  Back to cited text no. 14
    
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Vial MR, O'Connell JO, Grosu HB, Ost DE, Eapen GA, Jimenez CA. Needle fracture during endobronchial ultrasound-guided transbronchial needle aspiration. Am J Respir Crit Care Med 2016;193:213-4.  Back to cited text no. 15
    
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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.doi:10.1155/2016/2526789.  Back to cited text no. 16
    
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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. 17
    
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Riveiro V, Golpe A, Casal A, Valdés L. Accidental breakage of a transbronchial puncture needle during an endobronchial ultrasound bronchoscopy. Pulmonology 2019;25:305-6.  Back to cited text no. 18
    
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de Vega Sánchez B, Jaurrieta Largo S, Disdier Vicente C. Accidental breakage of an aspiration needle during EBUS-TBNA. Arch Bronconeumol 2019;55:267.  Back to cited text no. 19
    
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Uchimura K, Yamasaki K, Hirano Y, Sakagami K, Kido T, Mukae H, et al. The successful removal of a broken needle as an unusual complication of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA): A case report and literature review. J UOEH 2019;41:35-40.  Back to cited text no. 20
    
21.
Dincer HE, Andrade R, Zamora F, Podgaetz E. A new needle on the block: EchoTip ProCore endobronchial ultrasound needle. Med Devices (Auckl) 2016;9:467-73.  Back to cited text no. 21
    


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