Mediastinal A5: a novel artery variant of the pulmonary artery system: a case report

Mediastinal A5: a novel artery variant of the pulmonary artery system: a case report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Mediastinal A5: a novel artery variant of the pulmonary artery system: a case report Gang Li, Sheng Gong, Ning Wang, Yong Peng, Xiaojun Yao This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5378856/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 28 Mar, 2025 Read the published version in Journal of Cardiothoracic Surgery → Version 1 posted 14 You are reading this latest preprint version Abstract Background Variations in the pulmonary artery require increased attention from thoracic surgeons prior to or during lobectomy to avoid serious intraoperative bleeding. Patients with intrathoracic adhesions typically experience more intraoperative bleeding and therefore require conversion to open thoracotomy. The inability to recognize variant pulmonary arteries in the context of adhesions may have a fatal impact on the patient, especially for patients with adhesions caused by pulmonary tuberculosis. Case presentation A 52-year-old man who presented with adhesions caused by pulmonary tuberculosis in the right upper lobe underwent video-assisted thoracic lobectomy in our department. The precise identification of a mediastinal A5 artery variant (an artery entering the lateral segment of the right middle lobe) originating from the proximal pulmonary artery trunk and then traveling between the branches of the superior pulmonary vein parallel to the right middle pulmonary artery trunk ensured a safe surgery. Right upper lobe lobectomy was performed following isolation of the mediastinal A5 variant without serious intraoperative bleeding. Conclusion Exact identification of mediastinal A5 variants can help surgeons safely perform right upper lobectomy. Pulmonary artery Right middle lobe Vascular variation Figures Figure 1 Background Lobectomy or sub-lobar resection is routinely performed for patients with malignant pulmonary lesions or one of several benign diseases. Variations in the pulmonary vasculature require increased attention from thoracic surgeons during the operation to avoid serious intraoperative bleeding. Mediastinal lingual arteries of the left upper lobe have been reported in several studies and have been shown to increase the difficulty of left upper lobe lobectomy and segmentectomy. However, although it is similar to the mediastinal lingual artery, mediastinal A5 arteries of the right middle lobe have not been reported. Here, we describe a mediastinal A5 artery variant of the right middle lobe in a patient with adhesions caused by pulmonary tuberculosis. This is the first article reporting this rare variant pulmonary artery. Case Presentation A 52-year-old male presented to our department with a right upper lung lesion caused by tuberculosis. Chest computed tomography (CT) scans revealed a right upper lobe lesion with a diameter of 2.5 cm, and tuberculosis was diagnosed histopathologically. The patient suffered from cough and had undergone HRZE therapy for half a year; however, the lung lesion still persisted, and the patient’s clinical symptoms were not relieved. No other similarly affected individuals were reported in the patient’s family. Enhanced CT did not admitted for the economic issues. Lobectomy of the right upper lung was suggested by the multidisciplinary team (MDT). A variant mediastinal A5 artery of the right middle lobe was identified on the chest CT scans: the artery originated from the proximal right pulmonary trunk, parallel to the right middle pulmonary artery trunk, and then went between V1, V3 and the central vein into the right middle lobe. This variant could more clearly be observed on three-dimensional (3-D) computed tomographic bronchography and angiography (3D-CTBA) images. 3D reconstruction was performed with the free and open-source 3D Slicer software (Version 4.11, United States National Institutes of Health (NIH)). The patient was placed in the left lateral decubitus position, with the primary surgeon on the ventral side. Under general anesthesia and single-lung ventilation, the main utility incision and observation port were made in the third and seventh intercostal spaces, respectively, along the anterior axillary line. One assistant incision was made in the ninth intercostal space along the posterior axillary line. V1 and V3 were observed on the ventral surface of the right upper lung. Adequate exposure of the variant mediastinal A5 was obtained following separation of V1 and V3 with an endoscopic linear stapler, while the central vein located in the dorsal region (Fig. 1 ). Exploration of the central vein without damaging the variant mediastinal A5 was accomplished by traction conducted with a silk thread. Then, the central vein was separated from the variant artery via an endoscopic linear stapler. Following dissection of the tissues around the arteries and bronchus, A1 and A3 were separated via the endoscopic linear stapler, and A2 was double ligated via silk thread and then separated. The bronchus of the right upper lobe was separated with the endoscopic linear stapler. Two catheters with a diameter of 16 mm were utilized to achieve sufficient postoperative drainage of the thoracic cavity. Owing to the identified unmalignant diagnosis, lymph node dissection and intraoperative frozen examination were not performed. The operation lasted 2 h, and the amount of blood loss was less than 50 ml. The postoperative recovery of the patient was uneventful, and so the patient was discharged from the hospital 5 days after the surgery. Six months after the operation, the patient had recovered from the surgery and the pulmonary tuberculosis. Written informed consent was obtained from the patient. This reported was approved by the ethics committee of the Public Health Clinical Center of Chengdu. Discussion and conclusions The anatomies and variants of arteries derived from the trunk of the pulmonary artery and that enter into the right middle lobe have been well documented by numerous authors, including Wragg, L E [ 1 ], Warren, W. H. and F. J. Milloy[ 2 ] and Kandathil, A[ 3 ]. Unlike the more frequently observed lingual artery, which supplies the lingual segment of the left lobe [ 4 , 5 ], the mediastinal A5 variant has not been reported by surgeons or radiologists. Almost all the variants of the right pulmonary arteries include two branches or a single branch, and few have three branches. In this case, two branches of the right pulmonary artery, accounting for nearly half of the variants of the pulmonary middle lobe artery, could be observed. Although variants of the pulmonary artery have been well documented, those with an origin at the middle lobe artery mostly consisted of truncus arteriosus of the pulmonary artery. The superior pulmonary vein (SPV) is located anteriorly and superior to the origin of the pulmonary artery. Although the enhanced CT scan did not reveal abnormal liver function, 3D-CTBA reconstruction according to the plain scan illustrated the structures of the right pulmonary bronchus and vessels. In this case, the A5 variant originated in the superior region of the central vein and then coursed through the fissure of V1 + 3 and the central vein, parallel to the right middle pulmonary artery trunk, into S5 (the lateral segment of the right middle lobe), unlike any anomalous middle lobe arteries previously reported. Therefore, we named this new A5 variant the mediastinal A5 artery. Similar to the mediastinal lingual artery, the mediastinal A5 artery coursed posterior to V1 + 3, anterior to the truncus arteriosus of the pulmonary artery, superior to the central vein, into S5. This anomalous A5 can be injured during dissection of the anatomy of the hilum to expose the SPV, which consists of V1 + 3 and the central vein. Inadvertent electrical injury or avulsion can lead to severe intraoperative bleeding, which is a considerable challenge for the surgeon to manage. Although uniport video-assisted thoracic surgery (VATS) can be complex because of the mediastinal lingual artery[ 4 ], three-port VATS was still performed to ensure a safe lobectomy in this case. The V1 + 3 and the central vein were separated with an endoscopic linear stapler while protecting the mediastinal A5. Separation of a pulmonary artery may cause a postoperative cavitating pulmonary infarction[ 6 ]. Mediastinal A5 is a rare variant of the pulmonary artery that needs greater attention during right upper lobectomy. To identify the pulmonary vessels, especially anomalous pulmonary vessels, 3D-reconstruction techniques should be introduced. With the help of 3D-reconstruction technologies, radiologists and surgeons can dissect variant vessels easily while anticipating their structures. Abbreviations A5 Artery entering the lateral segment of the right middle lobe CT Computer tomography MDT multidisciplinary team 3-D Three-dimensional CTBA Computed tomographic bronchography and angiography NIH National Institutes of Health S5 Lateral segment of the right middle lobe Declarations Acknowledgements: The authors are grateful for the assistance provided by LiangShuang Jiang and other staff at Public Health Clinical Center of Chengdu in preparing this manuscript. Author contributions G.L wrote the manuscript and participated in the surgery. S.G participated in the surgery and collected the data of this patient. N.W conducted the 3D-reconstruction of the vessels. Y.P modified the grammar and did a major contribution in writing the manuscript. XJ.Y performed the surgical procedure and analyzed the patient data. All authors read and approved the final manuscript. Founding None. Data availability No datasets were generated or analysed during the current study Ethics approval and consent to participate Not applicable. Consent for publication Written informed consent for publication of this individual clinical details and images was obtained from the patient. Competing interests The authors declare no competing interests. References Wragg LE, Milloy FJ and Anson BJ. Surgical aspects of the pulmonary arterial supply to the middle and lower lobes of the lungs. Surg Gynecol Obstet. 1968;127(3)531-537 Warren WH and Milloy FJ. Pulmonary vascular system and pulmonary hilum. Thorac Surg Clin. 2007;17(4):601-17 Kandathil A and Chamarthy M. Pulmonary vascular anatomy & anatomical variants. Cardiovasc Diagn Ther. 2018;8(3):201-07[ Zhang XN, Lin G and Li J. How far will minimally invasive thoracic surgery go? Uniportal Video-assisted thoracoscopic lingulectomy with 1 cm incision complicated by a mediastinal lingual artery: A case report. Thoracic Cancer. 2021;12(5):703-706 Sugiura Y, Fujimoto H, Naruke M, Hashizume T, Kaseda S, Nemoto E. The first rib hypoplasia and the aberrant pulmonary artery branch detected by three-dimensional computed tomography in a surgical case with apical lung cancer, a case report. BMC Surg. 2017;17(1):4 Brown WJH, Masani V, Batchelor T, Rodrigues JCL. Postoperative cavitating infarction following lobectomy: the importance of variant pulmonary anatomy. BMJ Case Rep.2020;13(12). e238138 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 28 Mar, 2025 Read the published version in Journal of Cardiothoracic Surgery → Version 1 posted Editorial decision: Revision requested 18 Jan, 2025 Reviewers agreed at journal 06 Dec, 2024 Reviews received at journal 02 Dec, 2024 Reviewers agreed at journal 02 Dec, 2024 Reviews received at journal 25 Nov, 2024 Reviewers agreed at journal 25 Nov, 2024 Reviews received at journal 24 Nov, 2024 Reviews received at journal 19 Nov, 2024 Reviewers agreed at journal 19 Nov, 2024 Reviewers agreed at journal 18 Nov, 2024 Reviewers invited by journal 18 Nov, 2024 Editor assigned by journal 04 Nov, 2024 Submission checks completed at journal 04 Nov, 2024 First submitted to journal 02 Nov, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5378856","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":373908940,"identity":"fd7c198e-fa27-44d0-b950-8017fdf46b8b","order_by":0,"name":"Gang Li","email":"","orcid":"","institution":"Public Health Clinical Center of Chengdu","correspondingAuthor":false,"prefix":"","firstName":"Gang","middleName":"","lastName":"Li","suffix":""},{"id":373908941,"identity":"5fb8bbdc-a5e3-4bd5-a40d-57976c41818a","order_by":1,"name":"Sheng Gong","email":"","orcid":"","institution":"Public Health Clinical Center of Chengdu","correspondingAuthor":false,"prefix":"","firstName":"Sheng","middleName":"","lastName":"Gong","suffix":""},{"id":373908942,"identity":"3ab4687c-38a6-4317-a0cf-210d7ed3d49f","order_by":2,"name":"Ning Wang","email":"","orcid":"","institution":"Public Health Clinical Center of Chengdu","correspondingAuthor":false,"prefix":"","firstName":"Ning","middleName":"","lastName":"Wang","suffix":""},{"id":373908943,"identity":"fe779855-297d-4e64-9bc9-45c17f1b1209","order_by":3,"name":"Yong Peng","email":"","orcid":"","institution":"West China Hospital of Sichuan University","correspondingAuthor":false,"prefix":"","firstName":"Yong","middleName":"","lastName":"Peng","suffix":""},{"id":373908944,"identity":"026d092f-d711-41a8-9f04-397bda039bb9","order_by":4,"name":"Xiaojun Yao","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAy0lEQVRIiWNgGAWjYBAC9nYGhgMQVmPjww/EaOE5DNPCc7jZWIJYLRAgkd4mwEOUFmYew8MFvw7L80s+bGOQYLCT020grMXg8My+w4YzZye2PShgSDY2O0BAiz1IC2/PYcYNtxPbDSQYDiRuI6SFB6rFfsPNg20SPERr4flxOHHDDUaitbAVHOZtSE+e2ZMIDGQDIvzCw968+TPPH2vbfvbjDx9+qLCTI6iFgYHDgIGxrRnKMSCoHATYHzAw/KkjSukoGAWjYBSMUAAAeKZDq7L+gYgAAAAASUVORK5CYII=","orcid":"","institution":"Public Health Clinical Center of Chengdu","correspondingAuthor":true,"prefix":"","firstName":"Xiaojun","middleName":"","lastName":"Yao","suffix":""}],"badges":[],"createdAt":"2024-11-02 15:08:19","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5378856/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5378856/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s13019-025-03399-6","type":"published","date":"2025-03-28T15:57:04+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":70402061,"identity":"322aa224-d9e7-4fd1-934a-e4836ffc05c8","added_by":"auto","created_at":"2024-12-02 22:28:57","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":3425670,"visible":true,"origin":"","legend":"\u003cp\u003eA:Three-dimensional reconstruction shows that the Mediastinal A5 located behand the SPV and V1+3. B: Three dimensional shows that the Mediastinal A5 located between the V1+3 and the Central Vein. C: The pulmonary vessels reconstruction shows that the Mediastinal A5 originates proximal to the pulmonary artery and goes between the V1+3 and Central vein into the S5. D: intraoperative view shows the location of the Mediastinal A5: When the V\u003csup\u003e1+3\u003c/sup\u003e were divided and the stump of the V1+3 were ligated to the cephalic side, the Mediastinal A5 located in the ventral of the Central vein. SPV: supper pulmonary vein.\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-5378856/v1/a9ac4b34016ff4748644c9cc.png"},{"id":79604792,"identity":"6c2739c2-55e0-42d8-8aab-c1b0e8d1d393","added_by":"auto","created_at":"2025-03-31 16:05:31","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1874444,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5378856/v1/1d1540fc-ebd2-4710-a0ae-6c6bcaacd27a.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Mediastinal A5: a novel artery variant of the pulmonary artery system: a case report","fulltext":[{"header":"Background","content":"\u003cp\u003eLobectomy or sub-lobar resection is routinely performed for patients with malignant pulmonary lesions or one of several benign diseases. Variations in the pulmonary vasculature require increased attention from thoracic surgeons during the operation to avoid serious intraoperative bleeding. Mediastinal lingual arteries of the left upper lobe have been reported in several studies and have been shown to increase the difficulty of left upper lobe lobectomy and segmentectomy. However, although it is similar to the mediastinal lingual artery, mediastinal A5 arteries of the right middle lobe have not been reported. Here, we describe a mediastinal A5 artery variant of the right middle lobe in a patient with adhesions caused by pulmonary tuberculosis. This is the first article reporting this rare variant pulmonary artery.\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003eA 52-year-old male presented to our department with a right upper lung lesion caused by tuberculosis. Chest computed tomography (CT) scans revealed a right upper lobe lesion with a diameter of 2.5 cm, and tuberculosis was diagnosed histopathologically. The patient suffered from cough and had undergone HRZE therapy for half a year; however, the lung lesion still persisted, and the patient’s clinical symptoms were not relieved. No other similarly affected individuals were reported in the patient’s family. Enhanced CT did not admitted for the economic issues. Lobectomy of the right upper lung was suggested by the multidisciplinary team (MDT). A variant mediastinal A5 artery of the right middle lobe was identified on the chest CT scans: the artery originated from the proximal right pulmonary trunk, parallel to the right middle pulmonary artery trunk, and then went between V1, V3 and the central vein into the right middle lobe. This variant could more clearly be observed on three-dimensional (3-D) computed tomographic bronchography and angiography (3D-CTBA) images. 3D reconstruction was performed with the free and open-source 3D Slicer software (Version 4.11, United States National Institutes of Health (NIH)).\u003c/p\u003e \u003cp\u003eThe patient was placed in the left lateral decubitus position, with the primary surgeon on the ventral side. Under general anesthesia and single-lung ventilation, the main utility incision and observation port were made in the third and seventh intercostal spaces, respectively, along the anterior axillary line. One assistant incision was made in the ninth intercostal space along the posterior axillary line.\u003c/p\u003e \u003cp\u003eV1 and V3 were observed on the ventral surface of the right upper lung. Adequate exposure of the variant mediastinal A5 was obtained following separation of V1 and V3 with an endoscopic linear stapler, while the central vein located in the dorsal region (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Exploration of the central vein without damaging the variant mediastinal A5 was accomplished by traction conducted with a silk thread. Then, the central vein was separated from the variant artery via an endoscopic linear stapler. Following dissection of the tissues around the arteries and bronchus, A1 and A3 were separated via the endoscopic linear stapler, and A2 was double ligated via silk thread and then separated. The bronchus of the right upper lobe was separated with the endoscopic linear stapler. Two catheters with a diameter of 16 mm were utilized to achieve sufficient postoperative drainage of the thoracic cavity. Owing to the identified unmalignant diagnosis, lymph node dissection and intraoperative frozen examination were not performed. The operation lasted 2 h, and the amount of blood loss was less than 50 ml. The postoperative recovery of the patient was uneventful, and so the patient was discharged from the hospital 5 days after the surgery. Six months after the operation, the patient had recovered from the surgery and the pulmonary tuberculosis. Written informed consent was obtained from the patient. This reported was approved by the ethics committee of the Public Health Clinical Center of Chengdu.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e "},{"header":"Discussion and conclusions","content":"\u003cp\u003eThe anatomies and variants of arteries derived from the trunk of the pulmonary artery and that enter into the right middle lobe have been well documented by numerous authors, including Wragg, L E [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e], Warren, W. H. and F. J. Milloy[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] and Kandathil, A[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Unlike the more frequently observed lingual artery, which supplies the lingual segment of the left lobe [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], the mediastinal A5 variant has not been reported by surgeons or radiologists. Almost all the variants of the right pulmonary arteries include two branches or a single branch, and few have three branches. In this case, two branches of the right pulmonary artery, accounting for nearly half of the variants of the pulmonary middle lobe artery, could be observed. Although variants of the pulmonary artery have been well documented, those with an origin at the middle lobe artery mostly consisted of truncus arteriosus of the pulmonary artery. The superior pulmonary vein (SPV) is located anteriorly and superior to the origin of the pulmonary artery. Although the enhanced CT scan did not reveal abnormal liver function, 3D-CTBA reconstruction according to the plain scan illustrated the structures of the right pulmonary bronchus and vessels. In this case, the A5 variant originated in the superior region of the central vein and then coursed through the fissure of V1 + 3 and the central vein, parallel to the right middle pulmonary artery trunk, into S5 (the lateral segment of the right middle lobe), unlike any anomalous middle lobe arteries previously reported. Therefore, we named this new A5 variant the mediastinal A5 artery.\u003c/p\u003e\u003cp\u003eSimilar to the mediastinal lingual artery, the mediastinal A5 artery coursed posterior to V1 + 3, anterior to the truncus arteriosus of the pulmonary artery, superior to the central vein, into S5. This anomalous A5 can be injured during dissection of the anatomy of the hilum to expose the SPV, which consists of V1 + 3 and the central vein. Inadvertent electrical injury or avulsion can lead to severe intraoperative bleeding, which is a considerable challenge for the surgeon to manage. Although uniport video-assisted thoracic surgery (VATS) can be complex because of the mediastinal lingual artery[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], three-port VATS was still performed to ensure a safe lobectomy in this case. The V1 + 3 and the central vein were separated with an endoscopic linear stapler while protecting the mediastinal A5. Separation of a pulmonary artery may cause a postoperative cavitating pulmonary infarction[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eMediastinal A5 is a rare variant of the pulmonary artery that needs greater attention during right upper lobectomy. To identify the pulmonary vessels, especially anomalous pulmonary vessels, 3D-reconstruction techniques should be introduced. With the help of 3D-reconstruction technologies, radiologists and surgeons can dissect variant vessels easily while anticipating their structures.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eA5 Artery entering the lateral segment of the right middle lobe\u003c/p\u003e\n\u003cp\u003eCT Computer tomography\u003c/p\u003e\n\u003cp\u003eMDT multidisciplinary team\u003c/p\u003e\n\u003cp\u003e3-D Three-dimensional\u003c/p\u003e\n\u003cp\u003eCTBA Computed tomographic bronchography and angiography\u003c/p\u003e\n\u003cp\u003eNIH National Institutes of Health\u003c/p\u003e\n\u003cp\u003eS5 Lateral segment of the right middle lobe\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors are grateful for the assistance provided by LiangShuang Jiang and other\u0026nbsp;staff at Public Health Clinical Center of Chengdu in preparing this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eG.L wrote the manuscript and participated in the surgery. S.G participated in the surgery and collected the data of this patient. N.W conducted the 3D-reconstruction of the vessels. Y.P modified the grammar and did a major contribution in writing the manuscript. XJ.Y performed the surgical procedure and analyzed the patient data. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFounding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo datasets were generated or analysed during the current study\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent for publication of this individual clinical details and images was obtained from the patient.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWragg LE, Milloy FJ and Anson BJ. Surgical aspects of the pulmonary arterial supply to the middle and lower lobes of the lungs. Surg Gynecol Obstet. 1968;127(3)531-537\u003c/li\u003e\n\u003cli\u003eWarren WH and Milloy FJ. Pulmonary vascular system and pulmonary hilum. Thorac Surg Clin. 2007;17(4):601-17\u003c/li\u003e\n\u003cli\u003eKandathil A and Chamarthy M. Pulmonary vascular anatomy \u0026amp; anatomical variants. Cardiovasc Diagn Ther. 2018;8(3):201-07[\u003c/li\u003e\n\u003cli\u003eZhang XN, Lin G and Li J. How far will minimally invasive thoracic surgery go? Uniportal Video-assisted thoracoscopic lingulectomy with 1 cm incision complicated by a mediastinal lingual artery: A case report. Thoracic Cancer. 2021;12(5):703-706\u003c/li\u003e\n\u003cli\u003eSugiura Y, Fujimoto H, Naruke M, Hashizume T, Kaseda S, Nemoto E. The first rib hypoplasia and the aberrant pulmonary artery branch detected by three-dimensional computed tomography in a surgical case with apical lung cancer, a case report. BMC Surg. 2017;17(1):4\u003c/li\u003e\n\u003cli\u003eBrown WJH, Masani V, Batchelor T, Rodrigues JCL. Postoperative cavitating infarction following lobectomy: the importance of variant pulmonary anatomy. BMJ Case Rep.2020;13(12). e238138\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-cardiothoracic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jcts","sideBox":"Learn more about [Journal of Cardiothoracic Surgery](http://cardiothoracicsurgery.biomedcentral.com)","snPcode":"13019","submissionUrl":"https://submission.nature.com/new-submission/13019/3","title":"Journal of Cardiothoracic Surgery","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Pulmonary artery, Right middle lobe, Vascular variation","lastPublishedDoi":"10.21203/rs.3.rs-5378856/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5378856/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eVariations in the pulmonary artery require increased attention from thoracic surgeons prior to or during lobectomy to avoid serious intraoperative bleeding. Patients with intrathoracic adhesions typically experience more intraoperative bleeding and therefore require conversion to open thoracotomy. The inability to recognize variant pulmonary arteries in the context of adhesions may have a fatal impact on the patient, especially for patients with adhesions caused by pulmonary tuberculosis.\u003c/p\u003e\u003ch2\u003eCase presentation\u003c/h2\u003e \u003cp\u003eA 52-year-old man who presented with adhesions caused by pulmonary tuberculosis in the right upper lobe underwent video-assisted thoracic lobectomy in our department. The precise identification of a mediastinal A5 artery variant (an artery entering the lateral segment of the right middle lobe) originating from the proximal pulmonary artery trunk and then traveling between the branches of the superior pulmonary vein parallel to the right middle pulmonary artery trunk ensured a safe surgery. Right upper lobe lobectomy was performed following isolation of the mediastinal A5 variant without serious intraoperative bleeding.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eExact identification of mediastinal A5 variants can help surgeons safely perform right upper lobectomy.\u003c/p\u003e","manuscriptTitle":"Mediastinal A5: a novel artery variant of the pulmonary artery system: a case report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-12-02 22:28:52","doi":"10.21203/rs.3.rs-5378856/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-01-18T07:15:48+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"103409762885284771056691518008500205475","date":"2024-12-06T06:20:12+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-12-02T13:33:30+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"214988159698361339058606575089491835960","date":"2024-12-02T12:00:12+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-11-25T15:02:36+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"123845601079859087557611591962702676049","date":"2024-11-25T14:15:33+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-11-24T17:46:36+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-11-19T20:31:28+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"50614845842098404027936437810408393982","date":"2024-11-19T20:20:21+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"294916161101187746034658987031561888267","date":"2024-11-18T19:53:41+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-11-18T18:10:21+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-11-04T14:12:41+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-11-04T14:06:39+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Cardiothoracic Surgery","date":"2024-11-02T15:04:41+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-cardiothoracic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jcts","sideBox":"Learn more about [Journal of Cardiothoracic Surgery](http://cardiothoracicsurgery.biomedcentral.com)","snPcode":"13019","submissionUrl":"https://submission.nature.com/new-submission/13019/3","title":"Journal of Cardiothoracic Surgery","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"0a058850-b5b1-403a-a5b5-731842960dd7","owner":[],"postedDate":"December 2nd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-03-31T15:58:59+00:00","versionOfRecord":{"articleIdentity":"rs-5378856","link":"https://doi.org/10.1186/s13019-025-03399-6","journal":{"identity":"journal-of-cardiothoracic-surgery","isVorOnly":false,"title":"Journal of Cardiothoracic Surgery"},"publishedOn":"2025-03-28 15:57:04","publishedOnDateReadable":"March 28th, 2025"},"versionCreatedAt":"2024-12-02 22:28:52","video":"","vorDoi":"10.1186/s13019-025-03399-6","vorDoiUrl":"https://doi.org/10.1186/s13019-025-03399-6","workflowStages":[]},"version":"v1","identity":"rs-5378856","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5378856","identity":"rs-5378856","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}