To begin, upload the patient's thin slice CT chest to the planning software. After selecting the targets in the lungs, plan a pathway to each target site. and review the plan in the axial, coronal, and sagittal views in virtual bronchoscopy.
After preparing for the procedure, maneuver the catheter through the airways to the target lesion following the planned pathway. Using the preview path feature, follow the images of the airways if divergence is noted. Remove the vision probe when the catheter is within five to 10 millimeters of the target lesion and advance the radial endobronchial ultrasound or R-EBUS probe with rotation under fluoroscopy to the pleural border.
Retract the R-EBUS probe under fluoroscopy approximately 10 millimeters from the pleural border to the anticipated biopsy target site. Visualize the target area to assess the surrounding parenchyma and any vasculature. After removing the R-EBUS probe, insert the 1.1 millimeter touch cryo probe via the catheter and extend under fluoroscopy to the predetermined target area for biopsy.
Perform cone beam CT spin per system specific protocol. Interpret and compare the intra procedure imaging to the pre-procedure CT chest, and plan for the correct catheter position. If augmented fluoroscopy is available on the CBCT, segment the target for visualization with 2D fluoroscopy during biopsy.
Adjust the catheter based on fluoroscopy CBCT and R-EBUS to ensure that sampling occurs in the appropriate location. Press the pedal to activate the freeze cycle from four to six seconds, and retract the probe in one motion while depressing the pedal. Release the pedal as the probe tip with tissue is placed in 0.9%sodium chloride or fixative to release it.
After the final biopsy, inject one to two milliliters of normal saline and air in a 10 milliliter Luer lock syringe into the catheter to clear any blood or secretions. Insert the vision probe to view the sampling site and retract the catheter slowly. Finally, if there is no evidence of bleeding, retract the catheter to the trachea.
Post procedure chest radiograph in an posterior view showed bilateral interstitial densities with no pneumothorax or pleural effusion.
