Carinal resection and reconstruction with extracorporeal membrane oxygenation support

Abstract

: Resection of the main carina is one of the most complex procedures of airway resection and reconstruction. It is defined as the resection of the tracheo-bronchial bifurcation and can be accomplished with or without pulmonary resection. Carinal pneumonectomy is defined as the removal of the whole lung together with the main carina; it is usually performed on the right side while it is quite uncommon on the opposite side, although feasible in selected cases. The most frequent indication for carinal pneumonectomy (CP) is primary lung cancer with involvement of the carina or the distal trachea. Isolated carinal resection (CR) without pulmonary resection is rarer and it is performed in patients with primary tumors of the distal tract of the trachea or the carinal bifurcation. Cross-field ventilation (CFV) usually provides adequate support to guarantee tissue oxygenation after tracheal transection; however, airway reconstruction can sometimes be very difficult because of the presence of the ventilation tube in the bronchus to be anastomosed. Extracorporeal membrane oxygenation (ECMO) is a cardio-pulmonary system providing cardiac, pulmonary and circulatory support in the case of cardiac and/or respiratory failure. It can temporarily support cardiac and pulmonary functions until they are restored or—in more advanced cases of pulmonary failure—until lung transplant. The veno-venous ECMO (VV ECMO) is an effective alternative to CFV, allowing tissue oxygenation and CO2 extraction without the need for tubes in the surgical field. Care should be taken when cannulating vessels as well as managing the ECMO flow during the procedure, in order to prevent major complications. In this paper we focus on the more common techniques of CR and the role of the VV ECMO during the procedure.