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(Chest. 2002;122:1106-1107.)
© 2002 American College of Chest Physicians

Mediastinal Hematoma Following Transbronchial Needle Aspiration

Luigi Lazzari Agli, MD; Rocco Trisolini, MD; Marcellino Burzi, MD and Marco Patelli, MD, FCCP

Maggiore Hospital, Bologna, Italy

Correspondence to: Marco Patelli, MD, FCCP, Department of Thoracic Diseases, Maggiore Hospital, Largo Nigrisoli 2, 40133 Bologna, Italy; e-mail: marco.patelli{at}ausl.bologna.it

To the Editor:

Transbronchial needle aspiration (TBNA) mediastinal staging has gained increasing popularity in the last 2 decades because it may spare costs and morbidity of surgical procedures in many N2 and N3 cases in the setting of non-small cell lung cancer (NSCLC).1 2 The reported rate of complications is low (< 2% on average), and only anecdotal descriptions of major adverse events such as pneumothorax, pneumomediastinum, and severe infections can be found in a review of the literature.1 The occurrence of a mediastinal, periaortic hematoma following TBNA in the aortopulmonary window is herein reported.

A 57-year-old male smoker known to have NSCLC of the right upper lobe and an enlarged lymph node in the aortopulmonary window (suspected N3 disease) was referred for TBNA mediastinal staging. Since the aorta was inadvertently punctured with the 22-gauge cytology needle, the procedure yielded blood and caused acute posterior chest pain, as well as chills and sweat, leading to interruption of the examination. Arterial BP was found to be as high as 220/120 mm Hg. A contrast-enhanced CT scan performed minutes afterward showed a 1.2 x 1.8 x 4.3 cm periaortic hematoma (Fig 1 ). The patient had no alterations of clotting parameters. Complete, spontaneous resolution of either chest pain and CT evidence of hematoma occurred over a 1-week period.



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  		Figure 1. Contrast-enhanced CT of the chest. Left, A: CT section at the level of the aortic arch before TBNA. Center, B: After TBNA, a periaortic hematoma (arrow) is evident between the left tracheal wall and the aortic arch. Right, C: Coronal CT reconstruction showing the vertical extent of the hematoma (arrows).

 
Puncture of mediastinal great vessels is not uncommon in the practice of TBNA and is usually uneventful. Only one case of hemomediastinum suggested by radiography, notably occurring after TBNA in the aortopulmonary window, has been described.3 The protrusion of the aortic knob into the aortopulmonary window, in fact, makes it difficult to access this lymph node station, thus explaining the lower yields observed for TBNAs performed in this station as compared with those in subcarinal and right paratracheal stations, and makes it easy to puncture the aorta.2 4 Our case confirms that clinically significant mediastinal bleeding may occur after TBNA, especially if a high-pressure vessel such as the aorta is punctured, even in patients without hemorrhagic risks, and in spite of using a small-bore cytology needle. We believe that patients with unexplained persistent and/or intense chest pain after puncture of mediastinal great vessels should undergo contrast-enhanced CT to rule out the occurrence of mediastinal hematoma, which might be life-threatening mainly when subsequent to aortic injury.

References

  1. Dasgupta, A, Metha, AC, Wang, KP (1997) Transbronchial needle aspiration. Semin Respir Crit Care Med 18,571-581
  2. Patelli, M, Lazzari Agli, L, Poletti, V, et al Role of fiberscopic transbronchial needle aspiration in the staging of N2 disease due to non-small cell lung cancer. Ann Thorac Surg 2002;73,407-411[Abstract/Free Full Text]
  3. Kucera, RF, Wolfe, GK, Perry, ME Hemomediastinum after transbronchial needle aspiration [letter]. Chest 1986;90,466
  4. Harrow, EM, Abi-Saleh, W, Blum, J, et al The utility of transbronchial needle aspiration in the staging of bronchogenic carcinoma. Am J Respir Crit Care Med 2000;161,601-607[Abstract/Free Full Text]



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