We conclude that EVS is an unlikely cause of MS since it is not present in most patients early in the disease and rarely involves more than one extracranial vein. It is likely to be a late secondary phenomenon.

VASCULAR AND INTERVENTIONAL RADIOLOGY Percutaneous image-guided needle biopsy of the lung is a well-established and accurate method used to diagnose pulmonary lesions with 93%-95% diagnostic accuracy (1-3). The demand for lung biopsy is increasing, given the increasing rates of lung cancer, the higher detection rate of asymptomatic lung nodules, and the demand for tissue for new molecular profiling and genomic analysis (4).The most common complication of percutaneous lung biopsy is pneumothorax. Most series report incidences of 20%-25% for pneumothorax and 4%-8% for chest tube placement, although rates as high as 47% and 22%, respectively, have been reported (5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19). The economic burden of a complicated lung biopsy is substantial, with increased costs of 300%-400% (20,21). There is great interest in reducing the occurrence of iatrogenic pneumothorax, which should translate into a lower rate of chest tube placement and subsequent hospital admission.Pneumothorax is caused by air leaking out of the lung through the needle puncture site at the visceral pleura once the needle is removed (22,23). Several studies have shown that sealing the pleural puncture site with a variety of materials, including autologous blood, hydrogel plug, fibrin glue, gelatin sponge slurry or plug, or saline, reduces the risk of pneumothorax and chest tube placement (9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19). Two of the best-studied sealants are autologous blood patch injection (ABPI) and a manufactured hydrogel plug called BioSentry, which was formerly known as Bio-Seal (Surgical Specialties, Wyoming, Pa), with proven efficacy based on prospective randomized studies (13,14). ABPI uses the participant's own blood to seal the biopsy track. The hydrogel plug expands on contact with moisture and seals the biopsy track.We hypothesized that ABPI is noninferior to a hydrogel plug regarding the rate of iatrogenic pneumothorax in CT-guided needle biopsy of the lung. We conducted a prospective single-center randomized controlled trial to test this hypothesis.

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