Pulmonary Artery-Bronchial Territory Mismatch in Segmentectomy and Its Effect on Surgical Resection Margins.

Abstract

Preoperative computed tomographic assessment of segmental anatomy is essential for determining resection lines in segmentectomy. Intraoperative indocyanine green fluorescence delineates intersegmental planes on the basis of pulmonary artery (PA) perfusion, which may not match bronchial (B) ventilation territories. This study quantitatively evaluated the discrepancies between PA and B territories and their relationship with pathologic margins. This study retrospectively analyzed 265 anatomic segmentectomies performed between 2018 and 2025. Preoperative 3-dimensional computed tomographic reconstructions were used to calculate segmental volumes according to PA and B territories and to measure tumor-to-border distances (PA-margin and B-margin). Segmental volumes and margin distances were compared among PA-, B-, and pathologic (path-) margins. The effect of intersegmental vein division on margin adequacy was assessed using the ratio of path-margin to PA-margin. PA territories were slightly smaller than B territories (376.2 mL vs 380.0 mL; P = .06). The PA-margin (18.1 mm) was significantly shorter than both the B-margin (21.1 mm) and path-margin (21.4 mm) (PA vs B: P < .001; PA vs path: P < .001; B vs path: P = .35). The trend was consistent across tumor locations (central or peripheral), lobes (upper/middle or lower), and segmentectomy types (simple or complex). The path-margin to PA-margin was significantly higher in cases with intersegmental vein division than in those without (5.69 vs 3.63; P = .04). PA-margin alone may underestimate the true tumor-to-margin distance during segmentectomy. Resection beyond the fluorescence-defined line is recommended. Intersegmental vein division is an effective intraoperative measure when the indocyanine green line is close to the tumor.