Prevention and management of pulmonary vascular complications in anatomic lung resections: a narrative review

Background and Objective: Pulmonary artery (PA) injury during anatomic lung resection remains a rare but potentially catastrophic complication. With the increasing adoption of robotic-assisted thoracoscopic surgery (RATS), the absence of tactile feedback and the growing use of neoadjuvant therapies introduce unique challenges. This review aims to summarize the epidemiology, risk factors, prevention strategies, and intraoperative management of vascular injuries in the era of minimally invasive thoracic surgery. Methods: A narrative review of the literature was performed, with inclusion of English-language studies between 2005 and 2026 focusing on studies evaluating intraoperative vascular complications during video-assisted thoracoscopic surgery (VATS) and RATS lung resections. Emphasis was placed on reported incidence, risk factors, perioperative outcomes, and technical strategies for prevention and management. Exclusion criteria included preprints and studies without mention of vascular injury or anatomic lung resection. Key Content and Findings: The incidence of PA injury during minimally invasive lung resection remains low, with reported rates ranging from 1.5-2.9% for VATS and 0.5-2.6% for RATS. Identified risk factors include upper lobe resections, left-sided tumors, bulky or calcified lymphadenopathy, prior thoracic surgery, pleural adhesions, advanced tumor stage, squamous histology, and use of neoadjuvant therapy. Preventative strategies include detailed preoperative planning with three-dimensional computed tomography and careful dissection informed by bronchovascular anatomy. Intraoperative management is multifactorial and relies on adherence to the "four P's": poise, pressure, preparedness, and proximal control. While many injuries can be managed minimally invasively, prompt conversion to thoracotomy remains critical when hemostasis cannot be achieved safely. Conclusions: PA injuries during lung resection require a high level of surgical awareness, preparation, and technical proficiency. As the use of RATS and induction therapies continues to expand, structured strategies for prevention and management are essential to maintain patient safety and optimize outcomes.