Veno-venous extracorporeal membrane oxygenation-supported rigid bronchoscopy for airway obstruction in a post-pneumonectomy patient with recurrent neuroendocrine lung cancer: a case report.

Background: Life-threatening airway obstructions caused by tumors require immediate and effective intervention. However, the management of severe airway obstruction during therapeutic bronchoscopy is challenging, particularly when there is a potential inability to ventilate the lungs using conventional techniques, due to extensive tracheobronchial lesions or the risk of major intraoperative bleeding related to disease characteristics. For these reasons, the multidisciplinary team opted for an endoscopic debulking with the aid of a procedural veno-venous extracorporeal membrane oxygenation (VV-ECMO). Additionally, on the basis of bleeding risk, no heparin bolus was administrated. This report investigates the innovative use of heparin-free VV-ECMO to minimise bleeding risks while maintaining effective oxygenation during rigid bronchoscopy for central airway obstruction (CAO), offering a safer alternative in high-risk scenarios. Case Description: A single lung 64-year-old male patient, previously undergone left pneumonectomy for large cell neuroendocrine lung cancer (T2N0M0), was brought to our attention with haemoptysis and severe dyspnoea. Diagnostic investigations revealed a lesion obstructing the right main bronchus. A bronchoscopic debulking procedure was deemed necessary in order to obtain a histological diagnosis and give the patient the possibility of further therapies. In this case, after a multidisciplinary discussion, we decided to perform bronchoscopic debulking with the aid of a procedural VV-ECMO, without heparin infusion trying to minimize the bleeding risk. The patient remained haemodynamically stable throughout the procedure, with oxygen saturation never dropping below 90% (range, 90-97%). The procedure was uneventfully, successfully completed and the patient was weaned off the VV-ECMO at the end of the bronchoscopic procedure. Histological examination result was large cell neuroendocrine lung carcinoma. Postoperatively, the patient underwent radiotherapy and chemotherapy. The computed tomography (CT) scan performed 4 months after intervention showed resolution of the lesion. Conclusions: Heparin-free VV-ECMO may be an effective strategy for managing airway obstructions in patients at high-risk of bleeding. This case supports the use of ECMO without anticoagulation in airway debulking, offering a balance between maintaining blood oxygenation and bleeding complications. However, a multidisciplinary discussion involving oncologist and radiotherapist, and endoscopist with ECMO team anesthesiologist, is mandatory for a correct diagnostic and therapeutic assessment.