In the nonvascular field CT-guided lung biopsies are the most well known and frequently performed intervention in this part of the body. Both fine-needle aspiration (FNA) for cytology as well as miniaturized cutting needles (not exceeding 18–20 G) for histology are used for this purpose. Automated biopsy guns have several advantages, including excellent sampling quality and the possibility to perform repeated biopsies using a single access. FNA is more often recommended if a lesion for biopsy is located close to central and vascular structures, in order to avoid major bleeding complications.

Laurent et al. [1] compared the accuracy and the complication rate of FNA and an automated biopsy device. Two consecutive series of 125 (group A) and 98 (group B) biopsies performed using 20- to 22-gauge coaxial FNA (group A) and an automated 19.5-gauge coaxial biopsy device (group B) were investigated. Among the patients in groups A and B were 100 (80%) and 77 (79%) with malignant lesions and 25 (20%) and 18 (21%) with benign lesions, respectively. The two groups did not significantly differ with respect to patient-, lesion-, and procedure-related variables. However, for a diagnosis of malignancy, the difference in sensitivity (group A: 82.7%, group B: 97.4%) between the results obtained with the automated biopsy device vs. FNA were significant. For a diagnosis of malignancy, the false-negative rate of the biopsy result was significantly higher (p<0.005) in group A (17%) than in group B (2.6%). For a specific diagnosis of benignity, no statistically significant difference was found between the two groups (44% vs. 26%) but the automated biopsy device provided fewer indeterminate cases. There was no difference between the two groups concerning the pneumothorax rate (20% in group A and 15% in group B) or the hemoptysis rate (2.4% in group A and 4% in group B). The authors concluded that, for a diagnosis of malignancy, automated biopsy devices have a lower rate of false-negative results than FNA and a similar complication rate.

Richardson et al. [2] carried out a survey of 5444 lung biopsy in the UK. Complications included pneumothorax (20.5% of biopsies), pneumothorax requiring a chest drain (3.1%), hemoptysis (5.3%), and death (0.15%). The timing of post-procedural chest radiography was variable. Centers that performed predominantly cutting-needle biopsies had similar pneumothorax rates to those performing mainly fine-needle biopsies (18.9% vs. 18.3%). There is great variation in practice throughout the UK and most procedures are performed on an outpatient basis. Small pneumothoraces are common but infrequently require treatment. Chojniak et al. [3] carried out a retrospective study of 1,300 consecutive CT-guided biopsies performed within 6 years. Nodules or masses were suspected as the primary malignancy in 845 cases (65%) and as metastases in 455 (35%); 628 of the lesions were thoracic. For any site, sample adequacy and specific diagnosis rate were always better for cutting-needle biopsy. Among 530 lung biopsies, there were 84 cases of pneumothorax (16%) and 2 cases of hemothorax (0.3%), with thoracic drainage in 24 cases (4.9%).

Postbiopsy pneumothorax is a rather frequent complication but in most cases can be treated relatively simply. In asymptomatic patients we recommend not evacuating the pneumothorax earlier than 4 h after biopsy, in order to achieve a durable success. In symptomatic patients or those with drainage failures with a single needle approach, the use of percutaneously introduced Heimlich valves is recommended.

Minimally invasive thoracoscopc procedures have gained widespread acceptance and offer a valid alternative in patients with only a single pulmonary nodule that can be removed both for diagnostic and therapeutic reasons. In such cases, CT-guided hook marking of the nodule allows easy identification of the nodule during thoracoscopy and facilitates its removal.

Poretti et al. [4] described their experience with percutaneous CT-guided placement of hook-wires to localize nodules before video-assisted thoracoscopy (VATS). In their report, 19 patients with newly diagnosed intrapulmonary nodules underwent CT-guided hook-wire localization using a X-Reidy set, followed by a VATS resection of the lesion within a mean time of 30 min (range: 10–48 min). In all cases, resection of the nodules was successful. Eight patients developed an asymptomatic pneumothorax. In four patients, in whom the tumor was hit directly by the needle, local bleeding occurred. In one case, hemoptysis was present. There were no cases of dislocation of the hook-wire system.

The routine commercial availability of stent grafts for the thoracic aorta has drastically changed the treatment of traumatic or iatrogenic pseudoaneurysms, true aneurysms, intramural hematomas, and symptomatic type B aortic dissections. There has been a change of strategy for some types of thoracoabdominal aneurysms but they still present a challenging but luckily small group of cases. There is currently no good endoluminal alternative for type A aortic dissections or other aneurysms of the ascending thoracic aorta.

Technically, stent graft implantation into the thoracic aorta is straightforward, as it involves the insertion of a simple tube graft or several tube grafts. Important landmarks are the left subclavian artery, which can be usually covered by a stent graft in case the right vertebral artery is patent; sometimes the left common carotid artery, which should not be covered without performing a carotid-carotid bypass; and the celiac trunk. Elongation of the aortic arch can make an exact and easy placement of the stent graft difficult. Paraplegia is a rare but serious side effect in case the descending aorta is treated but is a less common occurrence than in open surgery.

Matsumura et al. [9] evaluated the safety and effectiveness of thoracic endovascular aortic repair (TEVAR) with a contemporary endograft system compared with open surgical repair of descending thoracic aortic aneurysms and large ulcers. They included 230 patients and compared 16 TEVAR subjects treated with a single type of stent graft with 70 patients undergoing open surgery. The 30-day survival rate was non-inferior (p<0.01) for the TEVAR group compared with the open group (98.1% vs. 94.3%). Cumulative major morbidity scores were significantly lower at 30 days in the TEVAR group than in the open group (1.3±3.0 vs. 2.±3.6, p<0.01). TEVAR patients had fewer cardiovascular, pulmonary, and vascular adverse events. No ruptures or conversions occurred in the first year after the procedure. Reintervention rates were similar in both groups. At 12 months, aneurysm growth was identified in 7.1% (8/112), endoleak in 3.9% (4/103), and migration (>10 mm) in 2.8% (3/107); other device-related problems were infrequent. At 1 year of follow-up, they concluded that thoracic endovascular aortic repair with the Zenith TX2 endovascular graft (William Cook Europe, ApS, Bjaeverskov, Denmark) is a safe and effective alternative to open surgical repair for the treatment of anatomically suitable aneurysms and ulcers of the descending thoracic aorta.

In a prospective trial, Nienaber et al. [10] investigated 140 patients with stable type B aortic dissection who were randomly assigned to elective stent-graft placement in addition to optimal medical therapy (n=72) or to optimal medical therapy (n=68) with surveillance. There was no difference in all-cause mortality: cumulative survival was 97.0%±3.4% with optimal medical therapy vs. 91.3%±2.1% with thoracic endovascular aortic repair (p=0.16). Aorta-related mortality was not different (p=0.42), and the risk for the combined end point of aorta-related death (rupture) and progression (including conversion or additional endovascular or open surgical intervention) was similar (p=0.86). Three neurologic adverse events occurred in the thoracic endovascular aortic repair group (one case each of paraplegia, stroke, and transient paraparesis) vs. one episode of paraparesis with medical treatment. It was concluded that in survivors of uncomplicated type B aortic dissection, elective stent-graft placement does not improve 1-year survival and adverse events.

The same group recently published their long-term results [11], reporting that patients with best medical treatment but no TEVAR had an aortic-related mortality of 3.6% while those with TEVAR did not show late aortic events between 2 and 5 years. This difference was significant although the overall mortality was not different between the two treatment approaches. However, the authors did find stabilization of the dissection in patients with TEVAR beyond 1 year of follow-up, while patients with optimal medical therapy had a constant progression over time. Paraplegia after TEVAR is a significant risk, requiring immediate treatment with corticosteroid and spinal drainage.

Supra-aortic percutaneous transluminal angioplasty (PTA) is mainly performed on the left subclavian artery, but in some cases on the brachiocephalic trunk, the proximal carotid arteries, and the right subclavian artery. Stenosis or occlusions may be caused mainly by atherosclerosis and less by inflammatory processes such as Takayasu arteritis. Indications for interventions are embolic events, neurological symptoms due to steal or malperfusion, or brachial claudication. Dilatation of the left subclavian artery is relatively safe, with a low rate of vertebral embolization. However stent placement is frequently necessary due to an insufficient post-PTA result.

Sixt el al. [12] retrospectively analyzed 108 interventions of atherosclerotic lesions in subclavian arteries or the brachiocephalic trunk, representing 92% of the patients treated for subclavian artery obstructive disease during a 10-year period. The primary success rate was 97%: 100% for stenoses (78/78) and 87% for total occlusions (26/30). Treatment modalities included PTA alone (13%; n=14) or stenting (87%; n=90) with balloon-expandable (n=61) or self-expanding (n=17) devices, or both (n=12). The 1-year primary patency rate of the 97 patients eligible for follow-up was 88%: 79% for the PTA subgroup and 89% for the stenting subgroup (p=0.2).

Babic et al. [13] reported a reasonably high technical success of 82% and a complication rate of 7% in 56 patients treated for chronic total occlusions of the subclavian artery. Patency after 3 years was 83%.