Thoracoscopic Right S4 Segmentectomy for Pulmonary Arteriovenous Fistula Involving an Aberrant Bronchus: A Case Report.

INTRODUCTION: Although pulmonary arteriovenous fistulas (PAVFs) have often been treated with embolization, surgical approaches including segmentectomy might also play a curative role. Furthermore, a near-infrared fluorescent (NIF) imaging has been widely used as an assisting tool during surgery and has been useful for identifying the intersegmental plane during pulmonary segmentectomy. We describe a thoracoscopic right S4 segmentectomy for a PAVF case involving a rare aberrant bronchus in the middle lobe bronchus using NIF imaging to identify the intersegmental plane and target the segmental bronchus. CASE PRESENTATION: A 66-year-old woman presented with a PAVF consisting of dilated feeding and draining vessels (A4 and V4) in the right S4, the percutaneous oxygen saturation was 94%, and thoracoscopic right S4 segmentectomy was planned. Preoperatively, a bronchial CT simulation revealed a middle lobe bronchus involving a rare aberrant bronchus (B7a), and the target segmental bronchus (B4) was bronchoscopically marked with indocyanine green (ICG). Intraoperatively, the B4 was identified with NIF imaging and divided following division of the dilated vessels. The PAVF was completely removed with the dilated vessels, while the aberrant bronchus was preserved. CONCLUSIONS: Segmentectomy can contribute to a curative resection of PAVF, bronchial CT simulation helps to recognize the variant bronchus, and NIF imaging can identify not only the intersegmental plane but also the target segmental bronchus for division in PAVF cases with aberrant bronchus requiring thoracoscopic segmentectomy.