The Interventionalist Journal

The Diagnostic yield and safety of pleural cryobiopsy using a flexible bronchoscope: a retrospective cohort study

Thamayanthy Murugesu, Syahrinnaquiah Samsuddin, Zahrah Tawil, Jen Lye Wan — Wed, 30 Sep 2026 00:00:00 +0000

Abstract

Background
Pleuroscopy is a well-established diagnostic tool for undiagnosed exudative pleural effusion, conventionally performed with rigid or semi-rigid thoracoscopes when less invasive methods fail. Pleural cryobiopsy improves diagnostic yield and tissue quality, but data on its use with a flexible bronchoscope remain limited. In this study, we assessed the diagnostic yield, adequacy for molecular testing, safety, and feasibility of pleuroscopic cryobiopsy using a flexible bronchoscope.

Methods
We conducted a retrospective cohort study of consecutive adult patients with undiagnosed exudative pleural effusion despite thoracocentesis who underwent pleuroscopic cryobiopsy using a flexible bronchoscope at Selayang Hospital, Malaysia, between November 2023 and September 2025.

Results
Thirty patients underwent pleuroscopic cryobiopsy via a flexible bronchoscope. The diagnostic yield was 90.0% (95% confidence interval (CI): 73.5–97.9%), and malignancy was the most common diagnosis (56.7%), with lung adenocarcinoma being the most frequent. 88.9% of lung adenocarcinoma biopsy samples were sufficient for Epidermal Growth Factor Receptor (EGFR) mutation analysis. 30% of the specimens showed granulomatous inflammation, while 10% were non-diagnostic. Median cryoprobe activation time was 5 seconds (interquartile range (IQR) 3-5), procedure duration was 45 minutes (IQR 30 – 46), and biopsy size was 10 mm (IQR 8-16). Minor bleeding occurred in 23.3% (95% CI: 9.9–42.3%) of patients, and moderate bleeding in 6.7% (95% CI: 0.8–22.1%). No major bleeding events occurred. No significant associations were observed between procedural variables and clinical outcomes.

Conclusion
Pleural cryobiopsy performed via a flexible bronchoscope is an effective and feasible diagnostic modality for undiagnosed exudative pleural effusion, with a low bleeding risk, providing high diagnostic yield and adequacy for molecular testing.

Keywords
Pleural effusion; Cryobiopsy; Pleuroscopy; Flexible bronchoscope; Diagnostic yield; Malaysia

The Dilemma of treating Direct Carotico-cavernous fistula : Should we sacrifice the ICA?

MOHD ASHYIRAFF ILANI BIN ISMAIL, KHOIRUL HADI ABD AZIZ — Wed, 30 Sep 2026 00:00:00 +0000

Introduction
Direct carotid-cavernous fistulas (CCFs) require urgent intervention to prevent irreversible ocular morbidity and intracranial hemorrhage. While endovascular reconstruction is the gold standard, device-related complications like stent thrombosis can severely limit transarterial access. We present a case utilizing therapeutic parent artery occlusion as a definitive rescue strategy when conventional reconstructive routes are exhausted.

Materials and Methods
A 16-year-old male with a post-traumatic Barrow Type A CCF underwent initial stent-assisted coiling. An inadvertent interruption of his dual antiplatelet therapy led to acute stent thrombosis, precluding further transarterial navigation. The residual high-flow fistula exhibited persistent cortical venous reflux, posing an imminent hemorrhagic risk. Multiple transvenous salvage attempts via the inferior petrosal sinus, superior ophthalmic vein, and vein of Labbé were unsuccessful due to acquired venous occlusions and acute vessel angulations.

Results
High-resolution C-arm CT was utilized to delineate the complex fistula anatomy. Diagnostic cerebral angiography confirmed robust collateral cross-circulation via the anterior communicating artery (ACom). Given the inaccessible shunt and imminent risk of hemorrhage from cortical reflux, a clinical decision was made to proceed with parent vessel sacrifice. The right internal carotid artery was therapeutically occluded at the cavernous and proximal segments using detachable coils. Post-embolization angiography demonstrated complete fistula exclusion with preserved hemispheric perfusion. The patient achieved rapid clinical stability with no ischemic neurological deficits.

Conclusion
Therapeutic internal carotid artery sacrifice remains a safe, definitive rescue maneuver for complex, residual CCFs when standard endovascular pathways are compromised, provided good contralateral flow from the ACOM or ipsilateral flow from the PCOM. Meticulous angiographic validation of collateral hemodynamics is mandatory to ensure patient safety while neutralizing the risk of secondary hemorrhage.