Abia‐Trujillo, David

ABSTRACT Background Shape‐sensing robotic‐assisted bronchoscopy (ssRAB) is a navigation platform for biopsy of indeterminate pulmonary lesions. Large‐scale, real‐world evidence confirming the safety profile of ssRAB compared to transthoracic needle biopsy (TTNB) is needed. Study Design and Methods A retrospective cohort study was performed using the PINC AI healthcare database among patients who underwent ssRAB or TTNB lung lesion biopsy at participating hospitals between April 2019 and March 2023. Outcomes were rates of pneumothorax and pneumothorax requiring chest‐tube intervention within 3 days, and rates of in‐hospital bleeding or all‐cause death. Quasi‐binomial logistic regression analysis was performed after one‐to‐five propensity score matching (PSM) accounting for patient‐ and hospital‐related characteristics. Results A total of 119 424 patients (5121 ssRAB, 114 303 TTNB) were identified with 4554 ssRAB and 14 319 TTNB patients after PSM. Relative to ssRAB, TTNB had significantly higher risk of pneumothorax (18.4% vs. 2.6%, OR = 7.10, p < 0.001) and pneumothorax requiring chest‐tube (10.8% vs. 1.4%, OR = 7.62, p < 0.001). TTNB was associated with a higher risk for bleeding (1.5% vs. 0.6%, OR = 2.20, p < 0.001) and all‐cause death (0.48% vs. 0.15%, OR = 2.47, p = 0.023); however, rates for both outcomes were relatively low. Interpretation In this large‐scale, real‐world database analysis with diverse patient populations, physician experience, and health care settings, ssRAB demonstrated a better safety profile compared to TTNB. Superior safety combined with a potentially comparable performance profile and known advantages of bronchoscopy, including concurrent staging, support ssRAB as an optimal choice for non‐surgical biopsies for suspicious pulmonary lesions.

ABSTRACT Airway perforation is a potentially lethal complication from tracheal or mediastinal malignancies that require complex management. Advanced thyroid cancer is known to have high morbidity, and patients with tracheal metastatic lesions are vulnerable to injury. Therapeutic management typically comprises a combination of surgical and nonoperative treatment modalities, whose adverse effects can lead to significant airway injury. We present the case of a 67‐year‐old man with papillary thyroid carcinoma who developed a tracheocutaneous fistula following proton beam therapy and chemotherapy for metastatic disease. Airway repair and recanalization were successfully achieved through a combined surgical and bronchoscopic approach.

ABSTRACT Pulmonary vein thrombosis (PVT) is an uncommon but potentially fatal condition that is often underdiagnosed due to nonspecific clinical presentation. We report a case of a 47‐year‐old woman with a thrombus in the right inferior pulmonary vein incidentally found during a robotic‐assisted bronchoscopy biopsy (RAB) and endobronchial ultrasound (EBUS) performed for mediastinal evaluation and lymph node sampling. PVT was confirmed with computed tomography pulmonary angiography, and the patient was successfully treated with anticoagulation therapy. A review of the literature revealed that reports of PVT detected via EBUS are exceedingly rare and usually malignant in nature. To our knowledge, this is the first peer‐reviewed case report describing PVT identified incidentally during EBUS, underscoring the potential of this technique to reveal clinically significant vascular abnormalities.

Abstract Introduction The diagnosis of fungal lung infections remains challenging as standard tests, such as bronchoalveolar lavage (BAL) antigen testing, often yield variable or inconclusive results. These limitations can delay appropriate therapy and may require additional tissue sampling for definitive diagnosis. Robotic-assisted bronchoscopy (RAB) biopsy has been primarily used as a minimally invasive technique for assessing suspicious peripheral pulmonary lesions (PPL). This case series highlights the diagnostic utility of RAB for identifying fungal infections within PPL when conventional BAL antigen analysis is non-diagnostic. Case Description Four patients with suspected infectious or malignant PPL underwent RAB-guided biopsy for diagnostic clarification, all yielding histopathologic confirmation of fungal disease. The first, a 73-year-old bilateral lung-transplant recipient with hemoptysis, had a negative BAL Aspergillus antigen despite RAB biopsy confirming Aspergillus infection. Similarly, a second 73-year-old man with chronic obstructive pulmonary disease (COPD) and esophageal adenocarcinoma had a negative BAL antigen, while RAB biopsy of bilateral cavitary lesions confirmed Aspergillus. Additionally, a 39-year-old woman with a nodule being evaluated for malignancy, had negative BAL Histoplasma antigen and PCR, whereas RAB biopsy confirmed Histoplasma capsulatum. In contrast, a 56-year-old woman with a right-lower-lobe nodule had a positive BAL Aspergillus antigen that aligned with the histopathologic biopsy findings. Discussion BAL-based antigen testing demonstrates variable diagnostic accuracy in fungal lung disease. Reported sensitivities for Aspergillus detection are typically high in meta-analysis, approximately 80%-90%, but clinical performance in the immunocompromised or high-risk patients is often substantially lower. Similarly, while BAL antigen testing for Histoplasma performs well in disseminated infections, it often fails to detect localized pulmonary disease. In this series, three out of four patients had negative BAL results in the presence of histopathologic confirmation of fungal infection. While current guidelines consider BAL positivity supportive of a “probable” diagnosis, tissue histopathology remains the gold standard for a “proven” infection. These findings emphasize the value and capability of RAB in obtaining direct tissue confirmation when conventional testing, such as BAL antigen analysis, is non-diagnostic. Conclusion RAB-guided biopsy of PPLs offers the opportunity for histopathologic confirmation of fungal infection when BAL testing is non-diagnostic. This approach can enhance upfront diagnostic yield in patients with suspected fungal pulmonary infections, avoiding delays in diagnosis and treatment initiation. This abstract is funded by: None

ABSTRACTTherapeutic treatment of lung nodules by ablation is a new field. Even though not considered standard of care, lung nodule ablation can be appropriate for select cases. Even though ablation is a safe and well‐tolerated procedure, bleeding is a potential complication. We introduce our stepwise approach through two cases on how we AIM (Anticipate/Adjust, Image, Manage) to prevent uncontrolled bleeding during Robotically Assisted Bronchoscopic Ablation: 1. Anticipate structures with high risk for bleeding and adjust accordingly, accounting for the needle ablation field; 2. Image: utilise cone beam CT before the first and after each ablation session to screen for bleeding; 3. Manage bleeding by pre‐emptively utilising Fogarty balloon occlusion.

ABSTRACTAlthough current treatment strategies for nonmalignant airway stenosis may offer short‐term relief, their effectiveness is limited by high recurrence rates, often requiring additional procedures. While paclitaxel‐coated balloons (PCB) have demonstrated effectiveness in treating stenosis across various vascular and nonvascular conditions, their evidence in recurrent airway stenosis remains limited. Here, we present the case of a 35‐year‐old female with bronchial stenosis who underwent multiple bronchoscopic interventions, all of which were complicated by restenosis. Following the addition of a PCB to the therapeutic regimen, the patient achieved sustained airway patency.

ABSTRACTEndobronchial valves have a variety of potential applications, from lung volume reduction in patients with severe emphysema to closing cavities in those with drug‐resistant tuberculosis. This report presents two cases in which endobronchial valves were effectively used to treat pneumomediastinum.

ABSTRACTBronchial dehiscence is a known complication following lung transplantation. In cases involving extensive airway necrosis and air leaks, bronchoscopic placement of self‐expanding metallic stents provides an effective and safe management strategy. These stents facilitate granulation and tissue reepithelialization. We present a case of bronchial anastomotic dehiscence size mismatch after a lung transplant. This complication was successfully managed using three stents placed via a telescoping technique with flexible bronchoscopy.

ABSTRACTRobotic‐assisted bronchoscopy (RAB) has improved lung nodule evaluation, but its feasibility to biopsy aortopulmonary lymph nodes remains underexplored. This study explored the safety and effectiveness of RAB for sampling aortopulmonary lymph nodes suspected of malignancy. We conducted a literature review on RAB for aortopulmonary lymph node biopsy and present a case of a patient with a history of malignancy. Using the Ion Endoluminal System, we navigated to the anterior segment of the left upper lobe to access a subaortic lymph node in a patient with a history of mantle cell lymphoma. Biopsy confirmed disease recurrence. Our literature review identified seven patients who underwent RAB to assess aortopulmonary lymph nodes, with most findings showing small‐cell lung cancer. Our study reports an 88% diagnostic yield, and no complications associated with the procedure. RAB is a safe and effective approach for biopsying aortopulmonary lymph nodes.