Diagnostic Value of Multiplane Tool in Virtual Lesion Confirmation in Augmented Fluoroscopy-Guided Navigational Bronchoscopy for Peripheral Pulmonary Lesions

BACKGROUND: The demand for minimally invasive diagnostic techniques for peripheral pulmonary lesions (PPL) is rising. Augmented fluoroscopy (AF) provides real-time guidance by overlaying CT-derived virtual targets onto fluoroscopic images, yet its diagnostic value remains poorly defined. METHODS: We retrospectively analyzed 226 PPLs targeting procedures performed with navigational bronchoscopy supplemented by AF and R-EBUS between December 2019 and March 2024. TIVL was assessed across 5 standard planes (posteroanterior, 30 degrees toward, 30 degrees away, 30 degrees clockwise, and 30 degrees counterclockwise). Diagnostic yield was defined according to the ATS/ACCP strict criteria. Multivariable logistic regression identified predictors of diagnostic success. RESULTS: Of the 226 analyzed PPLs, 101 (44.7%) showed no R-EBUS signal. In lesions without an R-EBUS signal, diagnostic yield increased from 0% with ≤1 plane to 42% with ≥4 planes. In multivariable analysis, TIVL in 3 planes was associated with a >5-fold higher likelihood of diagnostic success (OR: 5.57; P<0.05), and in ≥4 planes with an almost 14-fold increase (OR: 13.6; P=0.01). Lesions within 16 mm of the point of entry demonstrated stepwise yield improvements up to 89% with ≥4 confirmed planes, while more distant lesions showed no significant benefit. In the ≥3-TIVL-plane subgroup, BMI showed a negative trend toward lower diagnostic yield (OR: 0.92; P=0.059). CONCLUSION: The number of fluoroscopic planes with confirmed TIVL is a significant determinant of diagnostic yield in AF-guided navigational bronchoscopy, particularly in lesions lacking R-EBUS signals. Multiplane TIVL assessment may enhance diagnostic performance in centers without cone-beam CT or digital tomosynthesis availability.