A 75-year-old woman experienced a myocardial infarction (MI) treated with percutaneous coronary angioplasty 3 months before her lung cancer surgery; therefore, dual antiplatelet therapy was started. Chest computed tomography (CT) performed while treating her for MI revealed a nodule in the upper lobe of the right lung. The interlobar LN (#11s) was surrounded by the posterior ascending PA (A2) and posterior bronchus (Fig. 1A, B) on one side and the superior PA (A6) and intermediate bronchial truncus on the other side (Fig. 1C, D), showing an unclear boundary with the PA. Therefore, inflammatory infiltration was suspected. Positron emission tomography–CT showed a maximum standardized uptake value of 2.20, indicating 2-deoxy-2-[18F]-fluorodeoxyglucose accumulation in the nodule of the right lung upper lobe without any significant accumulation in the hilar or mediastinal LNs. A right upper lobe lung cancer cT1bN0M0, stage IA2, was suspected. A preoperative evaluation of respiratory function was performed, which revealed no abnormalities. The stress electrocardiogram demonstrated a slight ST segment depression in the II, aVf, V5, and V6 leads. Echocardiography showed a normal left ventricular ejection fraction but abnormal wall motion in the septum, anterior wall, and apex region.

Chest contrast-enhanced computed tomography showing inflammatory lymph node infiltration of the hilar lymph node. A, B show the coronal views. C, D show the sagittal view. B is in the same range as the red square in (A). D is in the same range as the yellow square in (C). E Postoperative chest contrast-enhanced computed tomography showing no aneurysm in the A2 treated area

The wedge resection for the nodule in the right upper lobe was performed by video-assisted thoracic surgery, and samples were submitted for intraoperative frozen section diagnosis. The patient was diagnosed with adenocarcinoma. Subsequently, a right upper lobectomy was performed. The upper lobe PV and superior arterial trunk were isolated using an auto-stapler. Moreover, there was widespread inflammatory LN infiltration around A2, which led us to suspect that detachment was impossible; thus, we converted to thoracotomy. After oblique fissure and minor fissure isolation, we attempted to detach the LNs around A2, but it seemed improbable; therefore, the main trunk of the PA was taped (Fig. 2A, B).

Intraoperative findings. A, B There was widespread inflammatory lymph node infiltration around the A2. C, D The A2 lesion coupled with the bronchus was treated using an auto-stapler (black; 4.2-mm cartridge). E The schema of treatment for A2 and the upper lobe bronchus. F No cancerous tissue was found at the bronchial stump, and a lymph node with silicotic nodules was found between the pulmonary artery and bronchus. Scale bar: 500 μm. LN, lymph node; ULB, upper lobe bronchus; Tr-sup, superior arterial trunk; MLB, middle lobe bronchus

One of the hilar LNs (#10) was excised, and an intraoperative frozen section confirmed there was no LN metastasis. Blockade of blood circulation at the peripheral A2 was difficult due to inflammatory LN infiltration; therefore, pulmonary arterioplasty with PV clamping was considered. However, since this procedure would have been excessively invasive after MI, the A2 lesion coupled with the upper lobe bronchus (ULB) was secured using an auto-stapler (black; 4.2-mm cartridge) (Fig. 2C, D; see Additional file 1). The schema is shown in Fig. 2E. The bronchial stump (BS) was covered with free pericardial adipose tissue. The surgery required 183 min, and the estimated blood loss was 70 mL.

The postoperative course was uneventful; the chest tube was removed on the second postoperative day, and the patient was discharged on the ninth postoperative day. Histopathologically, the adenocarcinoma was diagnosed as pT1bN0M0, stage IA2. No cancerous tissue was found at the ULB stump, and an LN with silicotic nodules was found between the PA and bronchus (Fig. 2F). Chest contrast-enhanced CT performed 2 months postoperatively showed no aneurysm in the A2 area (Fig. 1E). Thereafter, the patient was maintained on regular follow-up through an outpatient clinic. No recurrence has been observed to date. Written informed consent was obtained from the patient for the publication of this report and its accompanying images.