VV-ECMO-Assisted High-Risk Endobronchial Stenting as Rescue for Asphyxiating Mediastinal Mass

Extracorporeal membrane oxygenation bridging for chemotherapy in obstructing mediastinal mass after cardiopulmonary arrest

BACKGROUND

In a sedated patient, airway compression by a large mediastinal mass can cause acute fatal cardiopulmonary arrest. Extracorporeal membrane oxygenation (ECMO) has been investigated to protect the airway and provided cardiopulmonary stability. The use of ECMO in the management of mediastinal masses was reported, however, the management complicated by cardiopulmonary arrest is poorly documented.

CASE PRESENTATION

32-year-old female presented with acute onset of left arm swelling and subacute onset of dry cough. Further investigation showed a deep venous thrombosis in left upper extremity as well as a large mediastinal mass. She underwent mediastinoscopy with biopsy of the mass which was complicated by cardiopulmonary arrest secondary to airway obstruction by the mediastinal mass. Venoarterial ECMO was initiated, while concurrently treating with a chemotherapy. The mediastinal mass responded to the chemotherapy and reduced in size during 2 days of ECMO support. She was extubated successfully and decannulated after 2 days of ECMO and discharged later.

CONCLUSIONS

Extracorporeal membrane oxygenation can serve as a viable strategy to facilitate cardiopulmonary support while concurrently treating the tumor with chemotherapy, ultimately allowing for the recovery of cardiopulmonary function, and achieving satisfactory outcomes.

Extracorporeal membrane oxygenation (ECMO) assisted huge mediastinal tumor resection combined with superior vena cava replacement: A case report and literature review

As to huge solid mediastinal tumor which direct compression or invasion of the superior/inferior vena cava (SVC/IVC), surgical resection remains the main lifesaving treatment. However, it would present formidable anesthetic challenges due to the extremely high risks of cardiorespiratory compromise, drastic hemodynamic fluctuations and death at all perioperative stages. Here, we report a case of huge anterior mediastinal tumor resection combined with SVC replacement under the assistance of venoarterial extracorporeal membrane oxygenation (VA ECMO), and stable hemodynamics were maintained as well as high internal jugular vein pressure being avoided during the operation procedure. He was weaned off ECMO successfully just after surgery and eventually discharged. No signs of postoperatively neurological complications occurred. Therefore, the use of ECMO assistance in huge mediastinal tumor resection combined with SVC replacement is feasible and safe, which may provide the possibility of surgical treatment for such patients and improve outcomes.

Use of veno-venous extracorporeal membrane oxygenation for stabilization prior to redo sternotomy for aortic pseudoaneurysm repair

Background: Aortic pseudoaneurysms are particularly dangerous because of the risk of rupture and compression of mediastinal structures, including the trachea, and resultant respiratory distress. If respiratory distress progresses to respiratory failure, extracorporeal membrane oxygenation may be used to provide oxygenation prior to or during pseudoaneurysm repair. Case presentation: A 62-year-old male with a history of emergent aortic ascending and arch replacement for Stanford Type A dissection 10 months prior presented to his primary care physician with dyspnea. Chest radiography revealed a widened mediastinum, and subsequent computed tomography angiogram revealed a pseudoaneurysm at the distal suture line of the aortic arch replacement. Due to the location of the pseudoaneurysm, the patient's trachea was compressed, and he was emergently placed on veno-venous (VV) extracorporeal membrane oxygenation (ECMO) following unsuccessful intubation for respiratory distress. Two days later, the patient underwent a redo sternotomy and repair of a 2-3 mm defect in the anterior aspect of the distal suture line of the prior aortic arch replacement. The patient progressed well and was discharged on postoperative day 13. What we learned: Using a combination of peripheral bypass, hypothermic circulatory arrest, delayed closure, and respiratory support, this case demonstrates how even complex patients can be successfully treated with multiple strategies.

Extracorporeal membrane oxygenation in critical airway interventional therapy: A review

Introduction

Extracorporeal membrane oxygenation (ECMO) is widely used during refractory cardiac or respiratory failure, and some case reports described ECMO utilization in critical airway interventional therapy.

Methods

Eligible reports about patients receiving airway interventional therapy under ECMO were retrieved from Web of Science, Embase, Medline, and Cochrane databases up to 1 August 2022.

Results

Forty-eight publications including 107 patients who underwent ECMO for critical airway problems met the inclusion criteria. The critical airway problem that was reported the most was tumor-associated airway obstruction (n = 66, 61.7%). The second most reported etiology was postoperative airway collapse or stenosis (n = 19, 17.8%). The main interventional therapies applied were airway stent placement or removal (n = 61, 57.0%), mass removal (n = 22, 20.6%), and endotracheal intubation (n = 12, 11.2%) by bronchoscopy. The median ECMO duration was 39.5 hours. Eleven patients had ECMO-associated complications, including seven cases of airway hemorrhage, one case of arteriovenous fistula, one case of vein rupture and hematoma, one case of foot ischemia, and one case of neuropraxia of the cannulation site. In total, 91.6% of the patients survived and were discharged from the hospital.

Conclusion

ECMO appears to be a viable form of life support for patients undergoing interventional therapy for critical airway problems.

Anesthetic management of patients undergoing mediastinal mass operation

Objectives

To summarize the anesthetic management of patients undergoing mediastinal mass operation.

Methods

Electronic databases were searched to identify all case reports of patients undergoing mediastinal mass operation. Information such as clinical characteristics, perioperative management and patients’ outcomes were abstracted and analyzed.

Results

Seventy-seven case reports with 85 patients aging from 34 days to 81 years were included. Mediastinal masses were located in anterior (n = 48), superior (n = 15), middle (n = 9) and posterior (n = 9) mediastinum, respectively. Clinical manifestations included dyspnea (n = 45), cough (n = 29), chest or radiating pain (n = 12), swelling (n = 8), fever (n = 7) and chest distress (n = 4). Most patients (n = 75) had signs of compression or invasion of vital structures. General anesthesia (n = 76) was the most commonly used method of anesthesia. Muscle relaxants were administered in 35 patients during anesthesia induction and spontaneous respiration was maintained in 37 patients. Mediastinal mass syndrome (MMS) occurred in 39 cases. Extracorporeal circulation was utilized in 20 patients intraoperatively. Three patients experienced cardiac arrest after ventilation failure and two patients died intraoperatively and one postoperatively.

Conclusions

Peri-operative management of patients undergoing mediastinal mass operation could be challenging. Pre-operative multi-disciplinary discussion, well-planned anesthetic management and pre-determined protocols for emergency situations are all vital to patient safety.

Airway Emergencies Due to Anterior Mediastinal T-Lymphoblastic Lymphoma Managed With Planned Extracorporeal Membrane Oxygenation and Endotracheal Stent: A Case Report and Literature Review

Anterior mediastinal tumors can occasionally cause acute respiratory failure by compressing the trachea and bronchi. In such cases, sedative muscle relaxants during tracheal intubation can cause fatal complete tracheal obstruction. We encountered a 15-year-old male patient with T-lymphoblastic lymphoma (T-LBL) of the anterior mediastinum. For his airway emergency due to the stenosis extended from the lower part of the trachea to the tracheal bifurcation, venovenous (VV) extracorporeal membrane oxygenation (ECMO) was introduced from the femoral vein under local anesthesia. After a short period of tracheal intubation management, an endotracheal stent (ES) was immediately placed in the lower trachea. We performed a needle biopsy, and he was diagnosed with T-LBL. Following the diagnosis, chemotherapy was introduced. The ES was able to secure sufficient tracheal diameter, and ECMO and ventilation were promptly discontinued. In the case of tracheal stenosis from the lower part of the trachea due to anterior mediastinal tumor, depending on the degree of stenosis, VV ECMO can be considered. Moreover, ES can lead to early weaning from VV ECMO and a ventilator.

Not Your Average Mediastinal Mass: A Case of a Large Mediastinal Teratoma in a Patient With a History of Polio Disease

Mediastinal masses can be challenging to the surgical team and anesthetic considerations vary according to the location, pathology, surgical approach, and patient comorbidities. We report the case of a 21 cm symptomatic intrathoracic teratoma in a postpartum patient with a history of poliomyelitis. Significant challenges were presented for anesthetic induction, potential extracorporeal membrane oxygenation, and the use of neuraxial pain techniques and neuromuscular blockade. This case report demonstrates techniques to safely manage a patient with a large symptomatic mediastinal mass and potential neuromuscular disease.

Contraindications to the Initiation of Veno-Venous ECMO for Severe Acute Respiratory Failure in Adults: A Systematic Review and Practical Approach Based on the Current Literature

(1) Background: Extracorporeal membrane oxygenation (ECMO) is increasingly used for acute respiratory failure with few absolute but many relative contraindications. The provider in charge often has a difficult time weighing indications and contraindications to anticipate if the patient will benefit from this treatment, a decision that often decides life and death for the patient. To assist in this process in coming to a good evidence-based decision, we reviewed the available literature. (2) Methods: We performed a systematic review through a literature search of the MEDLINE database of former and current absolute and relative contraindications to the initiation of ECMO treatment. (3) Results: The following relative and absolute contraindications were identified in the literature: absolute-refusal of the use of extracorporeal techniques by the patient, advanced stage of cancer, fatal intracerebral hemorrhage/cerebral herniation/intractable intracranial hypertension, irreversible destruction of the lung parenchyma without the possibility of transplantation, and contraindications to lung transplantation; relative-advanced age, immunosuppressed patients/pharmacological immunosuppression, injurious ventilator settings > 7 days, right-heart failure, hematologic malignancies, especially bone marrow transplantation and graft-versus-host disease, SAPS II score ≥ 60 points, SOFA score > 12 points, PRESERVE score ≥ 5 points, RESP score ≤ -2 points, PRESET score ≥ 6 points, and "do not attempt resuscitation" order (DN(A)R status). (4) Conclusions: We provide a simple-to-follow algorithm that incorporates absolute and relative contraindications to the initiation of ECMO treatment. This algorithm attempts to weigh pros and cons regarding the benefit for an individual patient and hopefully assists caregivers to make better, informed decisions.

Rescue extracorporeal membrane oxygenation for massive anterior mediastinal masses

The management of massive anterior mediastinal masses (AMM) is challenging. With the burgeoning role of extracorporeal membrane oxygenation support (ECMO) beyond the confines of salvage therapy, more trained clinicians are adopting it as a bridge for high-risk procedures or situations where temporary respiratory or cardiac support is required. We report our experience with using ECMO in the management of massive AMM in this case series of three patients sharing their clinical details and the lessons learned from them.

ECMO and adult mediastinal masses

The role of extracorporeal membrane oxygenation (ECMO) is expanding as surgeons look at its utility beyond rescue treatment and have started adopting it for high-risk procedures to provide temporary airway and hemodynamic stabilization. ECMO needs to be deliberated in all patients with mediastinal masses who have compromised airways as well as in those with compression of heart and great vessels. There is a dearth of literature highlighting the definitive role of ECMO in patients with mediastinal masses. This article reviews the available adult literature and highlights the possible situations where the use of ECMO would be supportive in the management of patients with mediastinal masses.

VV-ECMO for surgical cure of a critical central airway obstruction

Extracorporeal membrane oxygenation (ECMO) is a form of prolonged cardiopulmonary bypass that has extensively been used in critically ill patients in an intensive care setting. Both veno-venous (VV-) and veno-arterial (VA-) ECMO have been described as a perioperative rescue or replacement of endotracheal intubation in the setting of extrinsic airway compression due to a mediastinal mass. In this paper, we will outline the utility of ECMO in the context of extrinsic airway compression and will use an illustrative case to examine how ECMO can be useful during severe airway obstruction. Our patient successfully underwent surgical resection of the mass while on VV-ECMO. His symptoms resolved quickly and is now back to his baseline quality of life.