Invited commentary

Abstract

This report by Watanabe and colleagues introduces an interesting technique that may be of significant value in planning lung resections. Obviously, one must question the cost of CT angiography in all routine lung resections. The authors imply that since routine CT scanning is a standard method in the preoperative evaluation of patients with known or suspected lung cancer, there would be no additional cost for processing data to provide 3D-CTA. However, the data processing requires increased technician time, and evaluation by a radiologist who will certainly bill. It would be hard to justify the use of this technique for the routine open thoracotomy lobectomy for a peripheral cancer. The authors correctly point out the great degree of variability in the branching of pulmonary arteries. However, since most experienced thoracic surgeons are well aware of the potential abnormalities, and have developed dissection techniques to search for them, the risk of inadvertently injuring an unsuspected abnormal vessel is quite low. There are certain circumstances where precise preoperative knowledge of the anatomy would be of great help. One example is in the operative planning for a patient with limited pulmonary reserve and a central tumor questionably involving the main pulmonary artery, for instance at the origin of the apical anterior branch. Involvement with tumor presents a high risk for requiring a pneumonectomy. Foreknowledge of the anatomy in such a patient might prevent needless exploration. The authors note the ability to perform video-assisted lobectomy, a technique that is becoming routinely performed by many surgeons. Such lobectomies are frequently performed in a sequence different from standard lobectomies, and the ability to carefully dissect pulmonary branches would be greatly enhanced by a road map of the patient’s anatomy. We have used this technique in selecting donors for living related lower lobe donations to recipients with cystic fibrosis. In these operations, the branching of pulmonary arteries is critical. When problems occur, they are usually on the left side where the relationship between the upper lobe lingular branch and the lower lobe superior segmental branch is critical. We have had the misfortune of encountering unfavorable situations such as a great distance between these two branches, or multiple superior segment branches. In such circumstances, use of the lower lobe requires a difficult implantation, sacrificing the donor lingular artery or performing a complex graft to revascularize this vessel. Thus, when we have two or three potential donors, we perform CT angiography to select appropriate donors and sides.