Complete resection of central tumors invading the main pulmonary artery (PA) requires arterial reconstruction to avoid pneumonectomy. Oncologic equivalence with pneumonectomy has been suggested. We review clinical selection and outcome for these uncommon procedures in the context of candidacy for pneumonectomy. From 2000 to 2018, 9 different surgeons performed 34 pulmonary arterial resections for primary or metastatic pulmonary malignancy, with independent determination of pneumonectomy candidacy and arterioplasty technique. Patients undergoing limited lateral stapled PA resection (n = 3) or resection for metastasis (n = 3) were excluded from survival analysis. The PA was resected as a sleeve with primary anastomosis (14.7%) or noncircumferentially with primary (61.8%), stapled (8.8%), or patch (14.7%) closure. Arterial resections represented between 2.5% and 43% of each surgeon's pneumonectomy volume. Sixteen (47%) patients were candidates for pneumonectomy. There was no operative mortality and 1 death at 47 days. Postoperative complications occurred in 21 (61.8%) patients. No patient required completion pneumonectomy. Overall 5-year survival was 33% (95% confidence interval [CI], 12-53). Compared with pulmonary arterioplasty alone, patients undergoing bronchial sleeve resection and pulmonary arterioplasty had better disease-free 5-year survival (50% [95% CI, 18-82] vs 19% [95% CI, 5-43]; P = .04), higher complete resection rate (100% [95% CI, 83-100] vs 80% [95% CI, 56-94]; P = .23) and lower disease recurrence (8% [n = 1 of 13] vs 47% [n = 7 of 15]; P = .04); 80% of disease recurrence was distant. Resection and reconstruction of the PA for malignant lung disease may be safely performed. In candidates for pneumonectomy, arterial resection offers low operative risk. Long-term survival is impaired by distant, not local, recurrence emphasizing the importance of systemic therapy.