{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,11,2]],"date-time":"2025-11-02T10:06:40Z","timestamp":1762078000632,"version":"build-2065373602"},"reference-count":23,"publisher":"MDPI AG","issue":"12","license":[{"start":{"date-parts":[[2022,12,6]],"date-time":"2022-12-06T00:00:00Z","timestamp":1670284800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Diagnostics"],"abstract":"<jats:p>Background: Electromagnetic navigation bronchoscopy (ENB) and robotic-assisted bronchoscopy (RAB) systems are used for pulmonary lesion sampling, and utilize a pre-procedural CT scan where an airway, or \u201cbronchus sign\u201d, is used to map a pathway to the target lesion. However, up to 40% of pre-procedural CT\u2019s lack a \u201cbronchus sign\u201d partially due to surrounding emphysema or limitation in CT resolution. Recognizing that the branches of the pulmonary artery, lymphatics, and airways are often present together as the bronchovascular bundle, we postulate that a branch of the pulmonary artery (\u201cartery sign\u201d) could be used for pathway mapping during navigation bronchoscopy when a \u201cbronchus sign\u201d is absent. Herein we describe the navigation success and safety of using the \u201cartery sign\u201d to create a pathway for pulmonary lesion sampling. Methods: We reviewed data on consecutive cases in which the \u201cartery sign\u201d was used for pre-procedural planning for conventional ENB (superDimension\u2122, Medtronic) and RAB (Monarch\u2122, Johnson &amp; Johnson). Patients who underwent these procedures from July 2020 until July 2021 at the University of Minnesota Medical Center and from June 2018 until December 2019 at the University of Chicago Medical Center were included in this analysis (IRB #19-0011 for the University of Chicago and IRB #00013135 for the University of Minnesota). The primary outcome was navigation success, defined as successfully maneuvering the bronchoscope to the target lesion based on feedback from the navigation system. Secondary outcomes included navigation success based on radial EBUS imaging, pneumothorax, and bleeding rates. Results: A total of 30 patients were enrolled in this analysis. The median diameter of the lesions was 17 mm. The median distance of the lesion from the pleura was 5 mm. Eleven lesions were solid, 15 were pure ground glass, and 4 were mixed. All cases were planned successfully using the \u201cartery sign\u201d on either the superDimension\u2122 ENB (n = 15) or the Monarch\u2122 RAB (n = 15). Navigation to the target was successful for 29 lesions (96.7%) based on feedback from the navigation system (virtual target). Radial EBUS image was acquired in 27 cases (90%) [eccentric view in 13 (43.33%) and concentric view in 14 patients (46.66%)], while in 3 cases (10%) no r-EBUS view was obtained. Pneumothorax occurred in one case (3%). Significant airway bleeding was reported in one case (3%). Conclusions: We describe the concept of using the \u201cartery sign\u201d as an alternative for planning EMN and RAB procedures when \u201cbronchus sign\u201d is absent. The navigation success based on virtual target or r-EBUS imaging is high and safety of sampling of such lesions compares favorably with prior reports. Prospective studies are needed to assess the impact of the \u201cartery sign\u201d on diagnostic yield.<\/jats:p>","DOI":"10.3390\/diagnostics12123059","type":"journal-article","created":{"date-parts":[[2022,12,7]],"date-time":"2022-12-07T02:49:35Z","timestamp":1670381375000},"page":"3059","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":8,"title":["The Feasibility of Using the \u201cArtery Sign\u201d for Pre-Procedural Planning in Navigational Bronchoscopy for Parenchymal Pulmonary Lesion Sampling"],"prefix":"10.3390","volume":"12","author":[{"given":"Elliot","family":"Ho","sequence":"first","affiliation":[{"name":"Division of Pulmonary & Critical Care Medicine, Interventional Pulmonology, Department of Medicine, Loma Linda University, 11234 Anderson St., Loma Linda, CA 92354, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9952-3367","authenticated-orcid":false,"given":"Roy Joseph","family":"Cho","sequence":"additional","affiliation":[{"name":"Division of Pulmonary & Critical Care Medicine, Interventional Pulmonology, Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Joseph C.","family":"Keenan","sequence":"additional","affiliation":[{"name":"Division of Pulmonary & Critical Care Medicine, Interventional Pulmonology, Department of Medicine, University of Minnesota, Minneapolis, MN 55455, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Septimiu","family":"Murgu","sequence":"additional","affiliation":[{"name":"Division of Pulmonary & Critical Care Medicine, Interventional Pulmonology, Department of Medicine, University of Chicago, Chicago, IL 60637, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1968","published-online":{"date-parts":[[2022,12,6]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"988","DOI":"10.1001\/jama.2021.1077","article-title":"Evaluation of the Benefits and Harms of Lung Cancer Screening With Low-Dose Computed Tomography: Modeling Study for the US Preventive Services Task Force","volume":"325","author":"Meza","year":"2021","journal-title":"JAMA"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"816","DOI":"10.1378\/chest.15-1216","article-title":"Technical Aspects of Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration: CHEST Guideline and Expert Panel Report","volume":"149","author":"Wahidi","year":"2016","journal-title":"Chest"},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"1753","DOI":"10.1016\/j.chest.2020.05.534","article-title":"Sensitivity and Safety of Electromagnetic Navigation Bronchoscopy for Lung Cancer Diagnosis: Systematic Review and Meta-analysis","volume":"158","author":"Folch","year":"2020","journal-title":"Chest"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"845","DOI":"10.1016\/j.chest.2020.08.2047","article-title":"Robotic Bronchoscopy for Peripheral Pulmonary Lesions: A Multicenter Pilot and Feasibility Study (BENEFIT)","volume":"159","author":"Chen","year":"2021","journal-title":"Chest"},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"274","DOI":"10.1097\/LBR.0000000000000536","article-title":"Cone-Beam CT With Augmented Fluoroscopy Combined With Electromagnetic Navigation Bronchoscopy for Biopsy of Pulmonary Nodules","volume":"25","author":"Pritchett","year":"2018","journal-title":"J. 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