Single-stage virtual-assisted lung mapping with mobile cone-beam CT confirmation followed by thoracoscopic sublobar...

Virtual-assisted lung mapping (VAL-MAP) is a multispot dye marking technique that requires real-time fluoroscopic guidance and post-mapping confirmation. This study aimed to evaluate the feasibility of lung mapping performed under endotracheal tube intubation and general anesthesia (ETGA), followed by post-mapping mobile cone-beam computed tomography (CBCT) confirmation and thoracoscopic sublobar lung resection.

We retrospectively enrolled 25 patients who underwent VAL-MAP, followed by video-assisted thoracoscopic lung resection between August 2024 and July 2025. Transbronchial markings were created using indigo carmine dye under ETGA with an ultrathin bronchoscope and a virtual bronchoscopy system. Post-VAL-MAP confirmation scans were performed using a mobile C-arm CBCT to visualize the actual markings. Clinical, procedural, and outcome data were retrospectively collected.

During the study period, 25 consecutive patients with 28 lung lesions underwent single-stage VAL-MAP followed by thoracoscopic resection. The mean lesion size was 7.94 ± 2.51 mm, with a median depth-to-size ratio of 1.82 (IQR, 1.26-2.67). The mean total localization time was 28.48 ± 14.64 min, and the median radiation exposure was 139.56 ± 48.98 mGy. Overall, 24 wedge resections and one segmentectomy were performed. Seven patients underwent the procedure in the supine position, whereas 18 were treated in the lateral position. Lung collapse occurred in three patients in the supine position but in none of those in the lateral position, representing a significant difference (p = 0.015).

Single-stage VAL-MAP with post-mapping mobile CBCT confirmation under general anesthesia, followed by thoracoscopic surgery, is feasible and safe. Performing bronchoscopic VAL-MAP markings in the lateral position may help prevent lung collapse and improve marking quality.