Webb Tracey N, Flenaugh Eric, Martin Ralitza, Parks Christopher, Bechara Rabih I
Emory University.
Morehouse School of Medicine, Atlanta, GA.
J Bronchology Interv Pulmonol. 2019 Jan;26(1):10-14. doi: 10.1097/LBR.0000000000000493.
Endobronchial ultrasonography has proven to be highly sensitive and specific in the diagnoses of patients with mediastinal and hilar adenopathy. Many of these patients are on a combination of clopidogrel (a compound that inhibits adenosine diphosphate-induced platelet aggregation) and aspirin due to neurological and/or cardiac-related comorbidities, and stopping anticoagulation may place these patients at high risk for potential complications. Our group has previously showed that thoracentesis with an 8-french catheter is safe in patients receiving clopidogrel and aspirin with low risk of complications. In this manuscript, we report the outcomes of the largest prospective multicenter series of patients undergoing endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) while receiving clopidogrel.
Patients presenting to our institutions with mediastinal/hilar adenopathy, requiring EBUS-TBNA, and actively taking clopidogrel and aspirin were included in the study. If the medication could be held for 5 to 7 days before the procedure, the patient was excluded. EBUS-TBNA was performed by an interventional pulmonology faculty on a total of 42 patients. All patients received total intravenous anesthesia, and a total of 92 nodes were sampled. First, 3 passes were performed with a 22-G needle. If no complications were encountered, we followed with additional 3 passes with a 21 G. Rapid onsite evaluation was performed in all patients. Bleeding at the puncture site was considered significant if it required cold saline, topical sympathomimetic, or balloon tamponade for hemostasis. Bleeding was considered nonsignificant if no interventions were required to achieve hemostasis.
We were able to perform all procedures successfully using both the 21 and 22-G needles. One patient required 30 mL cold saline installation to accomplish hemostasis with the 21 and 22-G needles. Our yield was comparable with the current literature. No statistically significant complications occurred during the procedure. All patients were contacted within 24 hours, and none reported bloody sputum.
We suggest that EBUS-TBNA, using 22 and 21-G needles, is safe with high yields in patients with mediastinal/hilar adenopathy, actively taking clopidogrel and aspirin, and are at high risk for thrombotic complications if the medication is discontinued.
经支气管超声检查已被证明在诊断纵隔和肺门淋巴结肿大患者时具有高度敏感性和特异性。由于神经和/或心脏相关合并症，这些患者中的许多人同时服用氯吡格雷（一种抑制二磷酸腺苷诱导的血小板聚集的化合物）和阿司匹林，停用抗凝药物可能使这些患者面临潜在并发症的高风险。我们的研究小组此前表明，对于接受氯吡格雷和阿司匹林治疗且并发症风险较低的患者，使用8法式导管进行胸腔穿刺是安全的。在本手稿中，我们报告了接受氯吡格雷治疗的患者中最大规模的前瞻性多中心系列经支气管超声引导下经支气管针吸活检（EBUS-TBNA）的结果。
本研究纳入了因纵隔/肺门淋巴结肿大就诊于我们机构、需要进行EBUS-TBNA且正在积极服用氯吡格雷和阿司匹林的患者。如果在手术前可以停用药物5至7天，则该患者被排除。共有42例患者接受了介入肺科医生进行的EBUS-TBNA。所有患者均接受全静脉麻醉，共采集了92个淋巴结样本。首先，使用22G针进行3次穿刺。如果未遇到并发症，我们接着使用21G针再进行3次穿刺。对所有患者进行了快速现场评估。如果穿刺部位出血需要冷盐水、局部拟交感神经药或球囊压迫止血，则认为出血严重。如果无需干预即可止血，则认为出血不严重。
我们使用21G和22G针均成功完成了所有手术。一名患者使用21G和22G针时需要注入30mL冷盐水以实现止血。我们的取材率与当前文献相当。手术过程中未发生统计学上显著的并发症。在24小时内联系了所有患者，无一例报告有血痰。
我们建议，对于纵隔/肺门淋巴结肿大、正在积极服用氯吡格雷和阿司匹林且停用药物会有血栓形成并发症高风险的患者，使用22G和21G针进行EBUS-TBNA是安全的，取材率高。
