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• W3152803469 abstract "The authors reported no conflicts of interest.The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest. The authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest. We read with great interest Dr Siloe's reply to our letter regarding transvascular ultrasound-guided fine-needle aspiration (TVUS-FNA).1Sihoe A. Reply: Further studies are required.J Thorac Cardiovasc Surg. 2021; ([In press])Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar,2Soumagne T. Fortin M. Trans-aortic endosonographic-guided needle biopsy: a word of caution.J Thorac Cardiovasc Surg. 2021; ([In press])Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar As mentioned by Dr Siloe, the intended lesson behind our case report is not that TVUS-FNA is associated with prohibitive risks, but that in patients with severe vascular atherosclerosis, it is associated with potential risks. These risks should be put into the balance before performing TVUS-FNA. First, the impact on the management of the patient of the biopsy result should be taken into account. The result of the biopsy has to change management significantly. All cases of TVUS-FNA should be discussed in a multidisciplinary tumor board before the procedure. Will the patient require neoadjuvant chemotherapy if the biopsy is positive? Will he be reoriented from a surgical therapy toward chemotherapy and radiation? Second, safer procedures should be performed previously to ensure a transvascular EBUS is necessary. Stations not requiring a transvascular access (eg, station 4 or 7) should be biopsied first with rapid on-site evaluation. Furthermore, rapid on-site evaluation may allow the number of passes to be minimized if TVUS-FNA is necessary after an initial negative sampling of safer stations, reducing the risk of adverse events. Third, alternative techniques, such as transcervical extended mediastinal lymphadenectomy (TEMLA) and anterior mediastinotomy, should be considered in cases in which here the intended TVUS-FNA target is a lymph node in station 5 or 6. TEMLA requires a high degree of expertise and is not performed routinely even in most high-volume centers. Relatively low morbidity but a significant rate of recurrent laryngeal nerve palsy and excellent sensitivity have been reported.3Yendamuri S. Battoo A. Dy G. Chen H. Gomez J. Singh A.K. et al.Transcervical extended mediastinal lymphadenectomy: experience from a North American cancer center.Ann Thorac Surg. 2017; 104: 1644-1649Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar, 4Zieliński M. Transcervical extended mediastinal lymphadenectomy: results of staging in two hundred fifty-six patients with non–small cell lung cancer.J Thorac Oncol. 2007; 2: 370-372Abstract Full Text Full Text PDF PubMed Scopus (78) Google Scholar, 5Zielinski M. Szlubowski A. Kołodziej M. Orzechowski S. Laczynska E. Pankowski J. et al.Comparison of endobronchial ultrasound and/or endoesophageal ultrasound with transcervical extended mediastinal lymphadenectomy for staging and restaging of non–small cell lung cancer.J Thorac Oncol. 2013; 8: 630-636Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar The vast majority of the published literature on the subject originates from a single center that demonstrated increased sensitivity of TEMLA over endoscopic needle techniques without TVUS-FNA. A large confidence interval remains around the complication rates associated with these relatively low-volume procedures even in referral centers. The more experience gathered, the narrower this interval will become. Operator experience and patient characteristic may shift this interval to the left or right. We feel that Molina and colleagues as well as Garcia-Sumalla and colleagues, with 150 TVUS-FNAs without significant complications in patients without severe vascular atherosclerosis, have provided sufficient data to demonstrate that TVUS-FNA is associated with a low risk of complications in experienced hands. This risk profile is even more reassuring when compared with alternative procedures, but TVUS-FNA is not without risk and severe vascular atherosclerosis should be considered a relative contraindication.6Garcia-Sumalla A. Subtil J.C. de la Serna C. Maisterra S. Aparicio J.R. Bojorquez J.C. et al.Endoscopic ultrasound-guided transvascular needle biopsy of thoracic and abdominal lesions: a multicenter experience.Endosc Int Open. 2020; 8: E1900-E1908Crossref PubMed Google Scholar,7Molina J.C. Chaudry F. Menezes V. Ferraro P. Lafontaine E. Martin J. et al.Transvascular endosonographic-guided needle biopsy of intrathoracic lesions.J Thorac Cardiovasc Surg. 2020; 159: 2057-2065Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar Reply: Further studies are requiredThe Journal of Thoracic and Cardiovascular SurgeryVol. 163Issue 1PreviewExperienced journal editors and reviewers tend to roll their eyes when reading submitted articles whose concluding sentences begin with, “Further studies are required to…” These vacuous words often suggest that authors are hedging their bets by offering hesitant qualifications to their study's findings instead of delivering an unambiguous take-home message for readers. However, there are times in surgery when these words are truly necessary. Full-Text PDF" @default.
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• W3152803469 title "Reply: Nothing ventured, nothing gained" @default.
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