EBUS TBNA

Vascular Navigation

Dicky Soehardiman
Interventional Pulmonology and Respiratory Care Division
Respiratory Medicine Department
University of Indonesia/Persahabatan Hospital
Jakarta
 Relations:
Airways - Lymphnodes - Vessels
• Anatomic knowledge:
– facilitate to localize lympnode and lesion
– avoid inadvertent access to vascular
structure
 Front cross section of tracheobronchial tree
(anterior view)

AORTA
V. Azygos

Ant-right 1/3 distal trachea Ant-left 1/3 distal trachea

 Front cross section of tracheobronchial tree
(posterior view)

AORTA
V. Azygos
Ant-left 1/3 distal trachea
Ant-right 1/3 distal trachea
 Above the aortic arch
Ant-right 1/3 distal trachea
Ant-left 1/3 distal trachea
Superior vena cava
AORTA

Right pulmonary artery

Left pulmonary artery

Left carotid artery

Right innominate vein

Right innominate artery

Left innominate vein
 At aortic arch level

AORTA

Superior vena cava

Left pulmonary artery

V. Azygos

Right pulmonary artery

 Below the carina

Superior vena cava

Left pulmonary artery AORTA

AORT
A Right pulmonary artery
 Right main bronchus

Right upper pulmonary vein

Right pulmonary artery

 Right upper lobe bronchus

Right upper pulmonary vein

Right pulmonary artery

Right middle and lower lobe bronchus

Right lower pulmonary vein

Right upper pulmonary vein Right pulmonary artery

 Left main bronchus

Left upper pulmonary vein

Left pulmonary artery

 Left upper lobe bronchus

Left pulmonary artery

Left upper pulmonary vein

 Left lower lobe bronchus

Left lower pulmonary vein

Left pulmonary artery

 Cavaliere S, Beamis J.
Atlas of therapeutic bronchoscopy laser – stents.
Brescia: RIB; 1991
 Lympnode Station

4R

11R 7

12R ?
12L ?
Lymphnode 4R Station
Lymphnode 4R Station
• 1 or 2 tracheal rings
above the main
Carina
• Before the bifurcation
on the right
posterolateral aspect
Lymphnode 7 Station
Lymphnode 7 Station
• 3-5 cm below on
either side of the main
Carina
• Lateral to
inferomedial entry
Lymphnode 11R Station
Lymphnode 11R Station
• Right second Carina:
right upper lobe
bifurcate from
bronchus intermedius
• Left second Carina:
left upper lobe
bifurcates from the
left main bronchus
Lymphnode 12R Station ?
Lymphnode 5 or 6 Station?
Lymphnode 5 or 6 Station?
• Difficult
• Anchored at lateral
tracheal wall of distal
trachea
• At the level of Carina
• Subsequent downward
or inferior movement of
the entire bronchoscopy
• Facilitate the needle
laterally
Lymphnode 11L Station?
Yurigaoka, September 22, 2010

Flexible Bronchoscopy

Ko Pen Wang
Atul Mehta
J Francis Turner
Baltimore: Blackwell Publishing; 2004