title: Pneumothorax Complicating Coaxial and Non-coaxial CT-Guided Lung Biopsy: Comparative Analysis of Determining Risk Factors and Management of Pneumothorax in a Retrospective Review of 650 Patients.
abstract: OBJECTIVE
  To assess the scope and determining risk factors related to the development of pneumothorax throughout CT-guided biopsy of pulmonary lesions in coaxial and non-coaxial techniques and the outcome of its management.
  
  
  METHODS
  The study included CT-guided percutaneous lung biopsies in 650 consecutive patients (407 males, 243 females; mean age 54.6 years, SD 5.2) from November 2008 to June 2013 in a retrospective design. Patients were classified according to lung biopsy technique into coaxial group (318 lesions) and non-coaxial group (332 lesions). Exclusion criteria for biopsy were lesions <5 mm in diameter, uncorrectable coagulopathy, positive-pressure ventilation, severe respiratory compromise, pulmonary arterial hypertension, or refusal of the procedure. Risk factors related to the occurrence of pneumothorax were classified into: (a) Technical risk factors, (b) patient-related risk factors, and (c) lesion-associated risk factors. Radiological assessments were performed by two radiologists in consensus. Mann-Whitney U test and Fisher's exact tests were used for statistical analysis. p values <0.05 were considered statistically significant.
  
  
  RESULTS
  The incidence of pneumothorax complicating CT-guided lung biopsy was less in the non-coaxial group (23.2 %, 77 out of 332) than the coaxial group (27 %, 86 out of 318). However, the difference in incidence between both groups was statistically insignificant (p = 0.14). Significant risk factors for the development of pneumothorax in both groups were emphysema (p < 0.001 in both groups), traversing a fissure with the biopsy needle (p value 0.005 in non-coaxial group and 0.001 in coaxial group), small lesion, less than 2 cm in diameter (p value of 0.02 in both groups), location of the lesion in the basal or mid sections of the lung (p = 0.003 and <0.001 in non-coaxial and coaxial groups, respectively), and increased needle track path within the lung tissue of more than 2.5 cm (p = 0.01 in both groups). The incidence of pneumothorax in the non-coaxial group was significantly correlated to the number of specimens obtained (p = 0.006). This factor was statistically insignificant in the coaxial group (p = 0.45). The biopsy yield was more diagnostic and conclusive in the coaxial group in comparison to the non-coaxial group (p = 0.008). Simultaneous incidence of pneumothorax and pulmonary hemorrhage was 27.3 % (21/77) in non-coaxial group and in 30.2 % (26/86) in coaxial group. Conservative management was sufficient for treatment of 91 out of 101 patients of pneumothorax in both groups (90.1 %). Manual evacuation of pneumothorax was efficient in 44/51 patients (86.3 %) in both groups and intercostal chest tube was applied after failure of manual evacuation (7 patients: 13.7 %), from which one patient developed a persistent air leakage necessitating pleurodesis.
  
  
  CONCLUSIONS
  Pneumothorax complicating CT-guided core biopsy of pulmonary lesions, showed the insignificant difference between coaxial and non-coaxial techniques. However, both techniques have the same significant risk factors including small and basal lesions, increased lesion's depth from pleural surface, and increased length of aerated lung parenchyma crossed by biopsy needle and passing through pulmonary fissures in the needle tract.
authors.affiliation: Institute for Diagnostic and Interventional Radiology, Johan Wolfgang Goethe - University Hospital, Theodor-Stern-Kai 7, 60590, Frankfurt, Germany. nour410@hotmail.com.|Department of Diagnostic and Interventional Radiology, Cairo University Hospital, Cairo, Egypt. nour410@hotmail.com.
authors.forename: Nour-Eldin A
authors.initials: NE
authors.lastname: Nour-Eldin
authors.affiliation: Institute for Diagnostic and Interventional Radiology, Johan Wolfgang Goethe - University Hospital, Theodor-Stern-Kai 7, 60590, Frankfurt, Germany. mohammedal_subhi@yahoo.com.
authors.forename: Mohammed
authors.initials: M
authors.lastname: Alsubhi
authors.affiliation: Institute for Diagnostic and Interventional Radiology, Johan Wolfgang Goethe - University Hospital, Theodor-Stern-Kai 7, 60590, Frankfurt, Germany. morgan101002@hotmail.com.
authors.forename: Ahmed
authors.initials: A
authors.lastname: Emam
authors.affiliation: Institute for Diagnostic and Interventional Radiology, Johan Wolfgang Goethe - University Hospital, Theodor-Stern-Kai 7, 60590, Frankfurt, Germany. thomas.lehnert@kgu.de.
authors.forename: Thomas
authors.initials: T
authors.lastname: Lehnert
authors.affiliation: Institute for Diagnostic and Interventional Radiology, Johan Wolfgang Goethe - University Hospital, Theodor-Stern-Kai 7, 60590, Frankfurt, Germany. beeres@gmx.net.
authors.forename: Martin
authors.initials: M
authors.lastname: Beeres
authors.affiliation: Institute for Diagnostic and Interventional Radiology, Johan Wolfgang Goethe - University Hospital, Theodor-Stern-Kai 7, 60590, Frankfurt, Germany. volkmar.jacobi@kgu.de.
authors.forename: Volkmar
authors.initials: V
authors.lastname: Jacobi
authors.affiliation: Institute for Diagnostic and Interventional Radiology, Johan Wolfgang Goethe - University Hospital, Theodor-Stern-Kai 7, 60590, Frankfurt, Germany. tatjanagruber2004@yahoo.com.
authors.forename: Tatjana
authors.initials: T
authors.lastname: Gruber-Rouh
authors.affiliation: Institute for Diagnostic and Interventional Radiology, Johan Wolfgang Goethe - University Hospital, Theodor-Stern-Kai 7, 60590, Frankfurt, Germany. janerikscholtz@gmail.com.
authors.forename: Jan-Erik
authors.initials: JE
authors.lastname: Scholtz
authors.affiliation: Institute for Diagnostic and Interventional Radiology, Johan Wolfgang Goethe - University Hospital, Theodor-Stern-Kai 7, 60590, Frankfurt, Germany. t.vogl@em.uni-frankfurt.de.
authors.forename: Thomas J
authors.initials: TJ
authors.lastname: Vogl
authors.affiliation: Institute for Diagnostic and Interventional Radiology, Johan Wolfgang Goethe - University Hospital, Theodor-Stern-Kai 7, 60590, Frankfurt, Germany. nagynnn@yahoo.com.|Department of Diagnostic and Interventional Radiology, Alexandria University Hospital, Alexandria, Egypt. nagynnn@yahoo.com.
authors.forename: Nagy N
authors.initials: NN
authors.lastname: Naguib
mesh_terms: D005260:Female; D006801:Humans; D061705:Image-Guided Biopsy / Q000009:adverse effects*; D008171:Lung Diseases / Q000473:pathology*; D008297:Male; D008875:Middle Aged; D011030:Pneumothorax / Q000209:etiology* / Q000628:therapy*; D015641:Radiography, Interventional; D012189:Retrospective Studies; D012307:Risk Factors; D014057:Tomography, X-Ray Computed
keywords: CT-guided; Coaxial; Lung biopsy; Non-coaxial; Pneumothorax