Case Reports Of Veno-venous Extracorporeal Membrane Oxygenation To Facilitate Removal Of Carinal Tumors
Bryan Miles, BA, Lucian A. Durham, MD, PhD, Jonathan Kurman, MD, Lyle D. Joyce, MD, PhD, David W. Johnstone, MD, Uzair Ghori, MD, Paul J. Pearson, MD, PhD
Medical College of Wisconsin, Wauwatosa, WI, USA
Extracorporeal membrane oxygenation (ECMO) is a useful adjunct during thoracic procedures, as demonstrated by these two cases in which V-V ECMO was utilized to remove bronchial tumors. In one case, a 52 year-old male presented to an outside hospital with respiratory failure, necessitating intubation. Computed tomography showed a right mass completely obstructing the main stem bronchus. Suctioning allowed for removal of clot, but further assessment revealed a solid mass which could not be removed with conventional techniques. The patient was percutaneously placed on V-V ECMO for debulking. Optimal placement in the retrohepatic cava was confirmed by fluoroscopy and transesophageal echocardiography (TEE). Following placement on V-V ECMO, the tumor was successfully debulked and ECMO was weaned. Pathology revealed poorly differentiated large cell carcinoma. Postoperatively, the patient received adjuvant chemoradiation with carboplatin and paclitaxel, followed by darvalumab. The second case involves a 66-year-old male former smoker who presented to the emergency department for dyspnea after failing several courses of antibiotics and steroids for presumed pneumonia and COPD exacerbation. Computed tomography scan demonstrated a endotracheal mass at the carina which completely obstructed the right mainstem bronchus and partially encroached on the left mainstem bronchus. His condition rapidly deteriorated, despite emergent radiation, and he was urgently placed on peripheral V-V ECMO. Using fluoroscopic guidance, the patient was percutaneously femorally cannulated, which was advanced into the right atrium under TEE guidance. The contralateral femoral vein was cannulated for return from the ECMO circuit. A Perclose suture device was utilized so the vein could be percutaneously secured at the end of the procedure. Debulking was performed using rigid bronchoscopy. ECMO was weaned in the operating room. Pathology revealed invasive, moderately differentiated squamous cell carcinoma. Post-operatively, the patient received adjuvant chemoradiation with radiation and cisplatin. Three month followup broncoscopy was negative for malignancy. Without V-V ECMO, these cases would have utilized much more invasive cardiopulmonary bypass. Instead, V-V ECMO allowed for apnea and lung deflation. These cases complement the only handful of similar published examples of ECMO to facilitate complex thoracic surgery, raising the exciting possibility of expanding ECMO to facilitate otherwise prohibitive life-saving procedures.
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