The utility of three-dimensional computed tomography bronchography and angiography technology in pulmonary sequestration surgery

Introduction

Pulmonary sequestration (PS), first described in Pryce’s seminal 1946 classification, is a rare congenital pulmonary malformation with an estimated prevalence of 0.15–0.64% among developmental lung anomalies (1,2). The pathological hallmark of this disease manifests as a non-ventilated pulmonary tissue mass exhibiting complete anatomic segregation from the native bronchial architecture, accompanied by perfusion through aberrant systemic arterial supply (predominantly originating from the descending aorta branch) (2,3).

The disease is classified into two principal categories: intralobar and extralobar sequestrations. The primary distinction between these categories is the presence or absence of a separate pleural covering (2-4). Previously, digital subtraction angiography (DSA) was frequently regarded as the benchmark for diagnosing PS. However, with the advent of noninvasive imaging techniques, such as enhanced computed tomography (CT), computed tomography angiography (CTA), and magnetic resonance angiography (MRA), the role of DSA has gradually diminished (3,4). PS demonstrates nonspecific radiological manifestations on chest CT, frequently presenting as mass lesions, cystic or cavitary lesions, and pneumonic lesions (4-6). Clinical presentation spectrum ranges from incidental asymptomatic detection of cases to chronic respiratory manifestations including chronic cough, fever, and recurrent pneumonia. In rare cases, serious cardiovascular complications may occur, and even acute, life-threatening events such as massive hemoptysis may occur (2). Thus, the diagnostic challenge in PS stems from its heterogeneous clinical presentations and nonspecific radiological findings. A previous study found that 58.63% of cases, on average, were misdiagnosed prior to surgery (4).

Once a diagnosis of PS has been established, surgical resection emerges as the optimal treatment modality (7,8). This therapeutic recommendation also extends to pediatric populations. In patients with PS, the abnormal blood supply typically originates from the thoracic or abdominal aorta, and approximately 20% of cases involve multiple feeding arteries. The challenges and risks associated with this surgery arise from the necessity to carefully identify and sever the aberrant arteries, highlighting the importance of comprehensive preoperative evaluations to detect these anatomical variations (2,4,9-11).

Although aberrant arteries can occasionally be identified on preoperative imaging, the majority of PS cases, particularly those with recurrent infections, present with neovascularization and extensive adhesions. This condition causes the aberrant arteries to be concealed within these inflammatory tissues, making their identification more challenging (9,10). Conventional enhanced CT cannot adequately demonstrate the complex spatial relationships between aberrant vessels and adjacent bronchovascular structures.

As an alternative, the benefit of three-dimensional computed tomography bronchography and angiography (3D-CTBA) technology lies in its ability to accurately localize variant vessels, thereby mitigating the challenges and uncertainties associated with intraoperative searches for these arteries and minimizing collateral damage to healthy lung tissue and other normal structures (12,13). Therefore, the application of 3D-CTBA technology holds significant potential in the surgery of PS patients.

Today, a substantial body of evidence attests to the prevalence of 3D-CTBA technology in the context of preoperative planning and intraoperative guidance in the domain of thoracic surgery (12,14-16). However, the literature on the role of this procedure in the surgical planning of PS remains limited. This study focuses on the role of 3D-CTBA technology in 22 patients with PS. The objective of this study was to conduct a retrospective evaluation of the feasibility of 3D-CTBA technology in preoperative planning and intraoperative guidance for PS. We present this article in accordance with the STROBE reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-725/rc).

Methods

Patients selection

We retrospectively reviewed 22 consecutive patients with PS who underwent preoperative 3D-CTBA technology at the Department of Thoracic Surgery, The First Affiliated Hospital of Nanchang University, between January 2021 and October 2024.

Pregnant women and individuals with complex congenital abnormalities requiring simultaneous surgical intervention, such as diaphragmatic hernia, pectus excavatum, or bronchogenic cysts, were excluded.

Acquisition of 3D-CTBA models

We obtained chest-enhanced CT images (≤2 mm slices) by injecting an iodinated contrast medium and saved the digital imaging and communications in medicine (DICOM) data on a server. The DICOM data were then processed using Materialise Mimics^® (v21.0) to create 3D-CTBA models that focused on characterizing aberrant vasculature (origin, branching numbers), the spatial relationships between sequestration and the diaphragm, and lesion localization. Guided by these models, 22 consecutive cases successfully underwent uniportal video-assisted thoracic surgery (UVATS) by the same thoracic surgeon.

Operative procedure

Under general anesthesia, patients were positioned in lateral decubitus with double-lumen endotracheal intubation to establish single-lung ventilation. The surgical procedure began with a roughly 3-cm incision in the fourth or fifth intercostal space along the anterior axillary line. A 30-degree, 10-mm endoscope (Karl Storz, Tuttlingen, Germany) was utilized to provide the operative view. After conducting chest exploration, systematic adhesion lysis was prioritized.

Based on preoperative 3D-CTBA models, the posterior mediastinal pleura was sequentially opened, the lower pulmonary ligament was released, and the aberrant blood vessels were carefully dissected. Following the division of the aberrant arteries using a vascular endostapler (Ethicon Endo-Surgery, Inc., New Jersey, USA), the lung resection was performed. Finally, the arterial stump was sealed with fibrin glue, and a 24-Fr chest tube was placed via the single incision to drain the pleural space.

Postoperative management and follow-up

After the operation, the patient was moved to the normal surgical ward and monitored overnight via electrocardiogram (ECG). The urinary catheter and ECG leads were discontinued early to encourage mobility, support lung expansion, and improve pleural effusion drainage—key elements of the enhanced recovery protocol. The chest tube was withdrawn once no air leak was observed and drainage was under 200 mL over a 24-hour period. Patients were typically discharged on the day following chest tube removal and scheduled for a follow-up outpatient visit. During follow-up, they were evaluated for signs of respiratory infection, including cough, fever, or hemoptysis.

Statistical analysis

The accuracy evaluation of 3D-CTBA technology was evaluated by the surgical team. Safety was assessed based on the incidence of damage to the aberrant arteries and adjacent vital tissues or organs.

Statistical analyses were conducted using the Statistical Package for the Social Sciences (SPSS) version 21.0 (SPSS Inc., Chicago, IL, USA). Continuous data were presented as mean ± standard deviation, while categorical variables were presented as counts.

Ethical statement

This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Ethics Committee of The First Affiliated Hospital of Nanchang University (No. 2024058). Written informed consent was obtained from patients and/or their immediate family members.

Results

Patient characteristics

Table 1 displays the characteristics of 22 patients with PS including 12 females and 10 males with the mean age of 43.7±13.6 (range, 23–64) years old. This study included 10 asymptomatic cases (45.5%) that were identified incidentally during routine health screenings, along with 12 symptomatic cases (54.5%). Clinical manifestations included cough with sputum production (40.9%, 9/22), fever (22.7%, 5/22), chest pain (22.7%, 5/22), and intermittent hemoptysis associated with dyspnea (4.5%, 1/22). All lesions were confined in the lower lobes, with a predominance in the left lower lobe (63.6%, 14/22) compared to the right (36.4%, 8/22). Cystic masses were the most common morphological type, accounting for 63.6% (14/22), followed by multiloculated cystic lesions at 27.3% (6/22) and mass lesions at 13.6% (3/22).

Accuracy of 3D-CTBA models

Table 2 shows the accuracy of preoperative 3D-CTBA models in characterizing aberrant arteries compared to CT data. Regarding the origin of aberrant arteries, preoperative CT data revealed that 15 cases originated from the thoracic aorta, four cases originated from the abdominal aorta, and no cases originated from other locations. In contrast, the preoperative 3D-CTBA model revealed that 15 cases originated from the thoracic aorta, four cases originated from the abdominal aorta, and three cases originated from other systemic blood vessels. Concerning the number of aberrant arteries, preoperative CT data indicated that 19 cases involved single arteries, one case involved double arteries, and no cases involved triple arteries. The preoperative 3D-CTBA model indicated that 19 cases had one artery, two cases had two arteries, and one case had three arteries.

Two cases that originated from other arteries were not detected in the CT data, and one patient, who had three arteries originated from the thoracic aorta, was incorrectly identified as having a single artery variant. The 3D-CTBA model is completely consistent with the actual surgical findings (Figure 1).

Figure 1 Posterior view of the 3D-CTBA model showing three aberrant arteries (red), pulmonary arteries (blue), veins (pink), bronchi (green), and the diseased area (yellow). 3D-CTBA, three-dimensional computed tomography bronchography and angiography.

Perioperative results

Table 3 displays the perioperative outcomes of the patients. Among the 22 surgical procedures, lobectomy was performed in 17 cases (77.3%) and sublobar resection in five cases (22.7%). No accidental injuries (aberrant arteries or surrounding structures) or perioperative deaths occurred. The mean operative duration was 133.3±42.5 minutes (range, 95–225 minutes), with a blood loss of 110.6±56.5 mL (range, 50–200 mL). The duration of chest drainage and postoperative hospital stay averaged 4.0±1.5 days (range, 3–6 days) and 6.1±2.5 days (range, 3–11 days), respectively. Postoperative complications occurred in 10 patients (45.5%), including pleural effusion (22.7%, 5/22), pneumothorax (18.2%, 4/22), subcutaneous emphysema (13.6%, 3/22), and infection (9.1%, 2/22). The remaining 12 patients (54.5%) had no complications. These outcomes reflect favorable surgical safety associated with the use of 3D-CTBA models.

Discussion

Historically, PS was predominantly managed via posterolateral thoracotomy (PLT), a technique associated with considerable tissue trauma and prolonged postoperative recovery. With the advancement of minimally invasive thoracic surgery, UVATS has emerged as a superior alternative. Recent studies have shown that UVATS offers improved visualization of the interface between normal lung parenchyma and inflamed sequestrated tissue while providing a wider operative field compared to both multiport VATS and conventional thoracotomy. These technical advantages allow for more precise dissection of aberrant vessels and dense inflammatory adhesions, particularly in anatomically complex cases. As a result, UVATS has become the preferred surgical approach for PS (10,11,17,18). However, the widespread adoption of UVATS in PS remains challenged by technical difficulties, particularly in adhesiolysis and in the identification of aberrant arteries embedded within inflamed or fibrotic tissue (10,19). Conventional two-dimensional (2D) imaging, limited by inadequate spatial resolution and depth perception, often fails to accurately delineate such complex anatomical relationships, underscoring the need for more advanced preoperative assessment. 3D-CTBA effectively addresses these limitations by offering detailed visualization of vascular trajectories and adhesion patterns (12,14). Nonetheless, there is a paucity of data evaluating the effectiveness of 3D-CTBA technology in PS surgery. This study is the first cohort study to assess the feasibility of 3D-CTBA technology in PS surgery and to determine whether it enhances surgical accuracy and safety.

Under the guidance of 3D imaging, all 22 patients in this study successfully underwent UVATS without requiring conversion to PLT or open thoracotomy. This indicates that preoperative 3D-CTBA can serve as an effective decision-support technology for surgical planning in PS by enabling accurate anatomical assessment and individualized resection strategies. While traditional management recommends lobectomy for intralobar PS and diseased lung resection for extralobar PS, recent evidence supports sublobar resection in intralobar PS cases if the boundaries of sequestration are clearly demarcated (20,21). In this study, as the surgical team’s proficiency with 3D reconstructions increased, this heightened confidence enabled sublobar resection in five consecutive intralobar PS cases (22.7%, 5/22), without complications or recurrences (Figures 2,3). This evolving surgical paradigm emphasizes maximal preservation of functional lung tissue without compromising surgical efficacy (12,13). Concurrently, the surgical team’s growing proficiency in 3D-CTBA technology has enhanced confidence in managing complex PS cases and has facilitated a strategic shift from empirical lobectomy toward precision-guided sublobar resection.

Figure 2 Chest enhanced CT and 3D-CTBA model of a patient. (A) Mass lesion (yellow arrow) in LS10 on lung window. (B) Aberrant artery (yellow arrow) originating from the thoracic aorta on mediastinal window. (C) Anterior view of the 3D-CTBA model displaying the aberrant artery (red, yellow arrow), lesion area (yellow), pulmonary arteries (blue), veins (pink), bronchi (green), and diaphragm (deep pink). (D) Posterior view of the 3D-CTBA model displaying the aberrant artery (yellow arrow). 3D-CTBA, three-dimensional computed tomography bronchography and angiography; CT, computed tomography; LS10, the posterior basal segment of lower lobe of left lung.

Figure 3 Intraoperative and postoperative images of a patient who underwent UVATS left posterior basal segmentectomy. (A) The aberrant artery (yellow arrow) looped. (B) The arterial stump (yellow arrow) after division with an endostapler. (C) The pulmonary stump (yellow arrow) remaining after the UVATS left posterior basal segmentectomy. (D) Resected pulmonary specimen with the diseased area (yellow arrow). UVATS, uniportal video-assisted thoracic surgery.

This study rigorously validated the clinical accuracy of 3D-CTBA through direct surgical assessment in 22 cases of PS. This study revealed limitations in preoperative CT for identifying the origin and number of aberrant arteries in PS patients. Specifically, one case of an aberrant artery originating from the abdominal aorta and two cases originating from the celiac trunk were not detected by CT. Additionally, one patient with three aberrant arteries was misidentified as having only one. Furthermore, three aberrant vessels across two patients went completely undetected. However, 3D-CTBA models successfully identified all these arteries, with findings entirely concordant with the intraoperative arteries’ anatomy, as confirmed by the surgical team. These results are consistent with Oizumi et al., whose series of 52 3D-guided thoracoscopic segmentectomies achieved 98% anatomical accuracy (15). Based on these findings, we conclude that preoperative 3D-CTBA models provide precise anatomical information about aberrant arteries. The origin and number of arteries detected by this technology are completely consistent with intraoperative observations, providing great assistance to the surgeon.

The safety of PS surgery is also an important indicator. The current surgical consensus highlights that successful PS resection depends on the precise identification and secure ligation of aberrant arteries (2,4,9-11). However, this task is complicated by their frequent concealment within inflammatory tissues and their variable anatomical courses (9,10). In a study conducted by Savic et al., seven patients experienced postoperative mortality. Among them, five patients died due to massive hemorrhage following accidental severance of the aberrant artery (22). Similarly, Li et al. reported cases of life-threatening hemorrhagic shock that occurred when undiagnosed PS led to intraoperative vascular injury (7). Both studies emphasize the urgent need for precise preoperative diagnosis and real-time anatomical navigation in PS surgery.

Thus, to validate the safety benefits of 3D-CTBA technology in PS surgery, we systematically analyzed intraoperative injury rates to aberrant arteries and adjacent structures (e.g., esophagus, diaphragm, vagus nerve) across all 22 patients. Notably, preoperative 3D-CTBA achieved comprehensive preoperative identification of aberrant artery origins, numbers, and their spatial relationships with critical neighboring tissues in every case, with perfect alignment to intraoperative findings. This precision allowed for meticulous dissection of aberrant arteries while avoiding inadvertent damage to surrounding structures, as evidenced by the complete absence of accidental injuries (0%). Even in the presence of dense pleural adhesions in certain patients, there were no injuries observed to aberrant arteries or nearby critical structures. These outcomes underscore 3D-CTBA’s unmatched ability to enhance surgical safety by addressing the limitations of conventional imaging. By offering high-fidelity 3D-CTBA models of vascular anatomy, it eliminates diagnostic uncertainties, reduces intraoperative surprises, and empowers surgeons to solve complex anatomical variations with confidence.

There are several limitations in this study. First, due to the rarity of PS and the limited number of surgical cases, the sample size was insufficient for comparisons with 2D surgical planning. Therefore, only a small-sample, single-center cohort study was conducted. Second, the single-surgeon assessment may limit the generalizability of the findings, as the evaluation is inherently subjective and influenced by the surgeon’s proficiency in both 3D image interpretation and surgical anatomy. Additionally, even with 3D-CTBA guidance, the safety and efficacy of managing aberrant arteries remain dependent on operative experience. Finally, the learning curve associated with integrating 3D-CTBA into preoperative planning and intraoperative navigation was not assessed in this study.

In our further study, we would increase the sample size and further investigate the clinical outcomes to confirm the safety and feasibility of UVATS technique for anatomical lung resection of PS. Additionally, to further enhance young doctors’ understanding of 3D-CTBA technology and promote its application in isolation surgery, we will actively conduct teaching activities, including preoperative interpretation of 3D models and real-time synchronization of surgical procedures using computer technology.

Conclusions

In conclusion, this study preliminarily demonstrates that preoperative 3D-CTBA is a feasible and reliable tool in PS surgery, delivering high anatomical accuracy and enhancing intraoperative safety by overcoming key technical challenges, especially for complicated patients (e.g., those with arteries originating from rare systemic arterial circulation or having multiple aberrant arteries). Additionally, through 3D-CTBA technology, surgeons can provide personalized surgical approaches for PS patients, further enhancing confidence in managing complex cases. Further large-scale, multicenter, prospective studies are required to further confirm our findings.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-725/rc

Data Sharing Statement: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-725/dss

Peer Review File: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-725/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-725/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Ethics Committee of The First Affiliated Hospital of Nanchang University (No. 2024058). Written informed consent was obtained from patients and/or their immediate family members.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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