Hemorrhagic complications during pleural interventions—such as thoracentesis and chest tube insertion—remain a significant clinical concern, primarily due to inadvertent injury of the intercostal artery (ICA). The highly variable ICA anatomy is frequently not visualized on conventional imaging, limiting the reliability of landmark-based techniques. Color Doppler thoracic ultrasound (CDUS) has emerged as a non-invasive, real-time modality capable of identifying ICAs and their anatomical variants prior to pleural access. This narrative review synthesizes current evidence on CDUS-guided ICA screening, focusing on its technical principles, diagnostic performance, and clinical applicability. While feasibility and utility are supported by multiple observational studies, robust evidence demonstrating a reduction in bleeding complications is still lacking. Barriers to widespread implementation include heterogeneous scanning protocols, operator dependency, and the absence of standardized training. We discuss the anatomical rationale for pre-procedural vascular mapping and highlight emerging protocols aimed at standardizing ICA visualization. Although not yet incorporated into major clinical guidelines, CDUS represents a promising tool to enhance procedural safety. Emerging AI applications may further improve vessel detection by reducing operator dependency and enhancing reproducibility. High-quality prospective studies are essential to validate potential clinical benefits, optimize implementation strategies, and support integration into routine pleural practice.

Background: CA-PE remains a major health problem, due to its impact on prognosis. Little is known about risk assessment in LCA-PE. Aims: to assess the performance of validated prognostic tools for PE in lung cancer (LC) patients. Methods: consecutive LC outpatients attending our Pulmonary Unit in Pisa from 2019 to 2021 were retrospectively studied; PE was diagnosed by computed tomography pulmonary angiography (CTPA). Among LCA-PE patients, clinical course and death were recorded; comorbidities, histotype and Khorana risk score (KRS) were collected. Based on current guidelines, troponin/NT-proBNP alteration, right ventricle to left ventricle diameter ratio (RV/LV) and main pulmonary artery diameter (øPA) on CTPA, shock index (SI), PE severity indices (PESI, sPESI) were considered for risk assessment. Student’s t test, Mann-Whitney test, ANOVA, and Kaplan-Meier survival analysis were used as appropriate. Results: among 512 patients, 40 cases of PE were detected (incidence 7.81%); after PE diagnosis, 8 patients died within 1 month, 22 patients died within 6 months. Unlike PESI, sPESI and øPA, troponin/NT-proBNP and SI were significantly different between survivors and non-survivors (p1 had a longer survival at 1 month (p=0.04). Patients’ survival significantly decreased from KRS=1 to KRS=2 and, even more, to KRS=3 (p<0.001), regardless histotype. Conclusions: comparing to previous studies, a higher incidence of LCA-PE was detected. Some PE-prognostic factors performed sub-optimally; prognosis seemed to be influenced more by the natural history of the tumor than by PE severity. KRS may be considered a prognostic tool in LCA-PE, regardless histotype. Further studies are needed.

Background: The incidence of cancer-associated thromboembolism has been extensively investigated, but mostly in heterogeneous cancer populations. Prognostic risk assessment is crucial in pulmonary embolism, but the accuracy of the commonly used tools remains uncertain in patients with cancer. Methods: We retrospectively included outpatients with consecutive lung cancer attending the Pulmonary Unit in Pisa from July 2019 to June 2021. The study population was the subgroup of patients who developed at least one episode of pulmonary embolism. For all patients, clinical data within 72 h of pulmonary embolism diagnosis, Khorana Risk Score, and overall survival time were collected. Results: A total of 512 patients with lung cancer attended the clinic; 40 patients developed pulmonary embolism (cumulative incidence of 7.81%). Eight patients (20%) died within a month, and twenty-two patients (55%) died within 6 months. Troponin, N-terminal pro-brain-type natriuretic peptide and shock index were significantly different between survivors and non-survivors (p < 0.05). Pulmonary artery diameter and the right to left ventricle index were not significantly different between survivors and non-survivors. Patients’ survival significantly decreased with the increase in Khorana Risk Score. Conclusions: Compared to previous studies, a higher incidence of pulmonary embolism in lung cancer was detected by our study. The prognosis of patients with lung cancer with pulmonary embolism seemed to be influenced more by the natural history of cancer than by the severity of pulmonary embolism. Khorana Risk Score might be considered as a prognostic tool in patients with lung cancer and may be used in the prognostic work-up for lung cancer-associated thromboembolism after a prospective validation.

Background: Coronavirus Disease 19 (COVID-19)-associated pneumonia is characterized by a broad spectrum of severity. Endothelial injury is a prominent component of the disease, but the relative contribution of vessels of different sizes to this condition has not been extensively investigated. Quantitative computed tomography (CT) represents a potential tool to evaluate pulmonary vascular involvement. Objectives: To investigate the relative contribution of vessels of different sizes in COVID-19-associated pneumonia of different severity using the Computer-Aided Lung Informatics for Pathology Evaluation and Rating (CALIPER) software. Methods: We conducted a single-center retrospective study, including patients admitted to the Pisa University Hospital between March and April 2020 with COVID-19-associated pneumonia. We excluded patients with severe motion artifacts, inadequate CALIPER segmentation, or inconclusive etiologic confirmation. All CT scans were analyzed using CALIPER, which automatically segmented lung parenchyma and vascular-related structures (VRSs). VRS volumes were stratified by vessel cross-sectional area (20 mm²). Results: We analyzed 258 patients. We observed that an increase in the percentages of VRSs with cross-sectional areas up to 20 mm² was associated with the need for lower intensity of care and with better gas exchange. The opposite trend was observed for the percentages of >20 mm². Conclusions: Our data provide novel information on the involvement of blood vessels of different sizes in the gas exchange impairment of COVID-19 patients. CALIPER represents a promising application for the study of vascular structures of the lung.