Abstract Rationale With the expansion of lung cancer screening programs worldwide, the need for minimal invasive diagnostic techniques for peripheral pulmonary lesions (PPLs) continues to rise. Augmented fluoroscopy (AF) provides real-time guidance by overlaying computed tomography (CT)-derived virtual targets onto fluoroscopic images. For centers without cone-beam CT (CBCT) availability, AF represents a cost-effective and radiation-sparing alternative for real-time guidance. However, its diagnostic utility remains poorly evaluated. The predictive significance of tool-in-virtual-lesion (TIVL) confirmation across multiple fluoroscopic planes has not been systematically investigated. Methods We retrospectively analyzed 226 AF-assisted bronchoscopic procedures for PPLs performed between December 2019 and March 2024 using virtual bronchoscopic navigation (VBN) and radial endobronchial ultrasound (R-EBUS). TIVL was assessed across five standard planes (postero-anterior, 30° towards, 30° away, 30° clockwise, 30° counterclockwise). Diagnostic yield was defined according to strict criteria. Multivariable logistic regression with backward selection based on the Akaike information criterion (AIC) for model selection was used to identify predictors of diagnostic success. Results Of 226 lesions, 101 (44.7%) showed no R-EBUS signal, while 125 (55.3%) exhibited eccentric or concentric patterns. Among lesions without an R-EBUS signal, diagnostic yield increased from 0% with ≤1 TIVL plane to 42% with ≥4 planes (Fig. 1). In this subgroup, TIVL confirmation in three planes was associated with a more than fivefold higher likelihood of diagnostic success (odds ratio OR = 5.57; p 0.05), and in ≥ 4 planes with a nearly fourteenfold higher likelihood (OR = 13.6; p = 0.01). Lesions located within 16 mm of the entry point showed a stepwise yield improvement up to 89% with ≥4 confirmed planes, whereas more distant lesions showed no significant benefit.In cases with ≥3 confirmed TIVL planes, higher body mass index (BMI; OR = 0.66; p = 0.046) and absence of a bronchus sign were associated with lower diagnostic yield. Among intra-procedural factors, cryobiopsy (OR = 3.93; p = 0.002) increased diagnostic success, while use of an ultrathin bronchoscope was negatively associated (OR = 0.28; p 0.001). Conclusions The number of fluoroscopic planes with confirmed TIVL is a crucial determinant of diagnostic yield in AF-guided navigational bronchoscopy, particularly for lesions without R-EBUS signals and those located near the entry point. However, even with successful multiplane TIVL, CT-to-body divergence may still result in non-diagnostic outcomes. AF with multiplane TIVL confirmation offers a feasible alternative for centers lacking CBCT, while both patient- and procedure-related factors significantly influence diagnostic success. This abstract is funded by: None
Büscher et al. (Fri,) studied this question.