Intraoperative Use of Veno-Arterial ECMO in Tracheal Surgery: Two Case Reports

Bambang Novianto Putro (Department of Anesthesiology and Intensive Care, Faculty of Medicine, Universitas Sebelas Maret / Dr. Moewardi General Hospital)
Eko Setijanto (Department of Anesthesiology and Intensive Care, Faculty of Medicine, Universitas Sebelas Maret / Dr. Moewardi General Hospital)
Elizabeth P. Yanti (Department of Anesthesiology and Intensive Care, Faculty of Medicine, Universitas Sebelas Maret / Dr. Moewardi General Hospital)

Jurnal Anestesiologi Indonesia
Publication In-Press

Introduction: Tracheal tumors and stenosis are rare but potentially life-threatening conditions due to severe airway obstruction. Anesthetic management during tracheal surgery is particularly challenging because of the high risk of hypoxia and ventilation failure during airway manipulation. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) has been used as a supportive strategy to maintain oxygenation and circulation during high-risk procedures, although clinical experience remains limited.Case: We report two cases of tracheal surgery performed with perioperative VA-ECMO support. The first case involved a 55-year-old man presenting with progressive dyspnea and cough for three months. Bronchoscopic examination revealed a tumor in the distal third of the trachea, and the patient underwent tumor resection with tracheal reconstruction. The second case was a 15-year-old male with hoarseness and respiratory symptoms following prolonged intubation. Bronchoscopy demonstrated cicatricial tracheal stenosis in the proximal third of the trachea, and the patient underwent endobronchial laser therapy followed by tracheal bougienage. In both patients, VA-ECMO with femorofemoral cannulation was established preemptively before anesthetic induction, with a single bolus of systemic heparinization (400 IU/kg). During airway manipulation, mechanical ventilation was suspended and oxygenation was maintained through ECMO. An episode of Harlequin syndrome was managed by increasing ECMO blood flow. Both procedures were completed without major perioperative complications.Discussion: These cases illustrate the complexity of anesthetic management in high-risk tracheal surgery. VA-ECMO facilitated airway manipulation by maintaining adequate oxygenation and hemodynamic stability during critical intraoperative periods, while requiring close monitoring for ECMO-related complications.Conclusion: VA-ECMO may be considered as a intraoperative support strategy in tracheal surgery with a high risk of airway obstruction. This case report highlights the potential role of VA-ECMO in increasing the safety margin of anesthetic management, although further evaluation is needed to define optimal indications and protocols.