It is more likely to occur in patients with abnormal coagulation or pulmonary arterial hypertension. Cutting needles especially those are larger than 18 gauge are

associated with an increased risk for hemorrhage [10], [27], [40] and [58]. Lesion depth especially at greater than 2 cm has been identified as the most important risk factor for hemorrhage [59]. However, other lesions risk factors include size smaller that 2 cm, vascularity, cavitations, presence of enlarged bronchial vessels in the vicinity, and central location [59] and [60]. If significant hemorrhage occurs, the patient should be Etoposide price placed in decubitus position with the biopsy side down to prevent transbronchial aspiration of blood. However, if the patient is hemodynamically unstable, appropriate supportive management with fluid resuscitation with or without blood transfusion is required. 5 FU Rarely, bronchial or pulmonary arterial transcatheter embolization is required. Air embolism is the most severe complications but it is one of the least frequent (0.07%)

[61] and [62]. It occurs when air enters the pulmonary venous system and can lead to systemic air embolism. Air embolism can cause myocardial infarction, arrhythmia,

stroke and death. Once air embolism is suspected, the patient should be placed in the left lateral decubitus position or in Trendelenberg position to prevent residual air in the left atrium from entering the cerebral circulation. Supplemental 100% oxygen should be administer and general symptomatic support should be provided [10]. Randomized evidence suggests that the technique of biopsy should be dropped in favor of image guidance where available in cases of suspected lung lesion, on the basis of higher nearly diagnostic yield. The choice between image guidance modalities is largely dependent on lesion characteristics on CT images and an understanding of which image-guided technique will be safer. Recently, C-arm cone-beam CT (CBCT) with a flat-panel detector system in which a cone-beam X-ray tube and a flat-panel detector are integrated with a C-arm gantry has been developed for interventional purposes [63]. It has both CT and fluoroscopy image capabilities and offers greater flexibility in orientating the detector around the patient than closed CT gantry systems in addition to advanced real-time fluoroscopic and three-dimensional CT capabilities [64].