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Long-Segment Tracheal Resection and Primary Reconstruction on Venovenous extracorporeal membrane oxygenation (ECMO)
Elorm J. Agra, Mani Daneshmand, Seth D. Force, Jeffrey Javidfar.
Emory University, Atlanta, GA, USA.

OBJECTIVE:
Demonstrate the feasibility of long-segment tracheal resection and primary reconstruction on veno-venous ECMO for intraoperative respiratory support.
METHODS:
A single-lumen 6.5 Endotracheal (ET) tube was used. Bilateral femoral veins were cannulated under ultrasound and fluoroscopic guidance. Veno-venous ECMO was established using a 25Fr multistage drainage cannula and 21Fr single stage inflow cannula. ACT was 180-200s with heparin. Flow was 3.5L/min. Serratus-sparing posterolateral thoracotomy was performed through the 5th interspace. After visualization of the stenosis, anesthesia was transitioned to intravenous, gas-exchange and oxygenation via ECMO with serial blood gases. 5 tracheal rings were resected and right hilar release performed. The posterior membranous trachea was anastomosed with 3-0 PDS running suture and the anterior cartilaginous ring completed in interrupted fashion. The patient was turned supine, ET tube upsized, airway cleared, and sweep gas trial performed. ACT normalized with subsequent decannulation and extubation.RESULTS:
Pre-op 3D CT tracheal reconstruction showed a 7.5cm-long segment of narrowing with distal tip 5cm above the carina. (Figure 1). Body surface area was 1.9m2. Total time on ECMO was 2.5 hrs. Intraoperative bronchoscopy confirmed a well-formed and patent distal trachea. Stridor, wheezing or hoarseness were absent postoperatively with normal speech and swallow evaluation. Follow-up bronchoscopy on POD 7, and via awake surveillance at 1,3,6 and 12 months confirmed a patent, well-formed anastomosis.CONCLUSIONS:
Veno-venous ECMO and intravenous anesthesia provides a unique platform to support patients undergoing major tracheal surgery avoiding prolonged periods of apnea or interruption of the surgical repair with cross-table ventilation.


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