Extracorporeal support in airway surgery

Introduction

Surgery involving the main airways requires optimal exposure and maintenance of adequate oxygenation and ventilation. For the vast majority of airway surgical cases, conventional cross-table ventilation with periodic apneic phases, is sufficient to provide excellent technical surgery with minimal morbidity. Jet ventilation is a reasonable alternative that is used predominately for high resections involving the larynx. For complex surgical cases and in patients with near total occlusion of the airways, extracorporeal life support (ECLS) is a good and safe option to support the patient’s respiratory functions during a complex resection. Today, a variety of ECLS devices and modes are available. The purpose of this review is to give an overview of the current application of ECLS in airway surgery. In addition, a practical guide on when and how ECLS should be implemented is also provided.

History

Cardiopulmonary bypass (CPB) was the first clinical application of extracorporeal support. It dates back to 1953 when John Gibbon was able to repair an atrial septal defect in an 18-year-old woman. During this case, the patient’s cardiopulmonary function was completely replaced for a short period of time. It was not until the early 1960s when the first reports on CPB in airway surgery were published. In 1961, Woods et al. successfully resected a recurrent adenoid cystic carcinoma (ACC) of the distal trachea (1). Two similar cases were consecutively published by Adkins et al. (2) and Nissen et al. (3). Interestingly, all those early cases were advanced stage ACC patients requiring a complete replacement of their cardiopulmonary function for a repair. A major problem during the early phase of CPB was the direct damage to blood cells caused by bubble oxygenators, which subsequently led to multi-organ dysfunction when used for more than a few hours. This problem was mitigated when small gas exchange membranes were interposed between the blood and the oxygen tank. The technology significantly evolved as new membranes were developed and evolved from silicone to polypropylene (PP) and eventually to new generation polymethylpentene (PMP). This development became known as extracorporeal membrane oxygenation (ECMO) and was slowly implemented in the 70s and 80s to treat acute respiratory failure in infants (4). The first described use of ECMO in airway surgery was published by Walker et al. in 1992 (5). They reported a case of a 2.5 kg infant suffering from a congenital distal airway stenosis. The child was successfully treated by a segmental resection and end-to-end anastomosis. Peripheral ECMO support was chosen over a traditional CPB because it did not require median sternotomy, required less heparin, and facilitated the anticipated postoperative ECLS prolongation. Shortly thereafter, the first series of cases using ECMO for intraoperative ventilatory support in pediatric airway patients was published by Connolly et al. (6). Since that time, ECMO has gradually found its way into the everyday clinical practice of large thoracic centers and is currently routinely applied in lung transplant and ARDS patients. In addition, it has also proven to be a powerful tool in the armamentarium of extended airway surgery (Table 1).

Table 1 Published experience of ECLS support in adult airway surgery and in pediatric airway surgery
Full table

Available ECLS configurations

Venous-venous (v-v) ECMO

Veno-venous (v-v) ECMO can be considered the gold standard if ECLS is needed during airway surgery. It can provide complete support of pulmonary function with effective CO₂ removal and oxygenation. The main advantage of v-v support over veno-arterial (v-a) ECMO is the lower risk of vascular complications that may be associated with arterial cannulation such as bleeding, arterial (pseudo-)aneurysms, limb ischemia and embolic events (41,42). The typical and simplest cannulation configuration is a femoral-jugular approach with two cannulas.

Single-cannula v-v ECMO

The development of double-lumen cannulas enabled single vessel access instead of a femoro-femoral or a femoro-jugular insertion. It is a good alternative to the standard two-cannula approach. With the growing experience of using these cannulas in ARDS and lung transplant patients, they have also been adopted in airway surgery (43,44). The placement of the cannula in the right atrium requires fluoroscopic (preferably) or TEE guidance (45). Its first successful use in airway surgery was published by the Toronto group in 2015. In their reported case, the cannula supplied stable respiratory support and facilitated tumor debridement of a near occluding tracheal squamous cell cancer (25).

Veno-arterial (v-a) ECMO

The main advantage of a v-a over a v-v ECMO is the hemodynamic support that can be provided. This is especially important during emergency settings, when an airway occlusion has already led to severe hemodynamic compromise. In addition, it results in a more stable support during complex airway reconstructions, most notably when the heart needs to be retracted to improve visualization. It is considered more invasive than v-v ECMO and is associated with a higher incidence of neurologic events (infarction, microemboli, hemorrhage) as well as peripheral vascular complications (dissection, limb ischemia, aneurysm). Moreover, femoro-femoral v-a ECMO sometimes fails to provide adequate central oxygenation, especially in patients with a high cardiac output (46).

Cardiopulmonary bypass

Although some centers still use conventional CPB for support during airway surgery, several disadvantages limit its use. In contrast to v-a ECMO, which also provides hemodynamic stability, CPB requires higher levels of anticoagulation and uses a venous reservoir with an air-blood interface. This is thought to contribute to the higher incidence of coagulopathy and systemic inflammatory reactions, especially during longer pump runs (47). However, CPB has the advantage of using a cardiotomy suction, which enables the rescue of large blood volumes during major bleeding, although this is a rare situation in airway surgery.

Novalung assist

Pumpless lung assistance devices like the Novalung are based on the development of low transmembrane pressure gradient oxygenators. These devices are interposed between the femoral artery and vein and can effectively remove CO₂. However, they have a lower capacity to oxygenate compared to ECMO devices. Novalung membranes alone cannot provide hemodynamic support without a pump, and their gas exchange capacity is dependent on a stable cardiac output (9). To the best of our knowledge, there is only one published case on the use of a Novalung during airway surgery. Walles et al. used the system during a repair of a TEF with a bioartificial patch (48).

Awake induction

In the 1970s, the risk of fatal airway obstruction and cardiopulmonary arrest during induction of anesthesia was first recognized in patients with large anterior mediastinal masses (49). Initiation of ECLS under local anesthesia prior to induction of general anesthesia can be performed safely and may prevent this grave complication in such patients. Awake induction and initiation of ECLS has been described for different ECLS configurations [v-v ECMO (27), v-a ECMO (50), CPB (51)] predominately in patients with a near occlusion of the cervical trachea from primary tracheal neoplasms or with tumorous infiltrations of the trachea from thyroid carcinomas (25,27,52). Once ECLS is initiated, general anesthesia can be fully administered and airway tumor debridement or resection can be performed under more safe and controlled conditions.

Extracorporeal support in adult airway surgery

ECLS in oncological surgery

The first reported use of ECLS for airway surgery was published in 1961 in a patient with ACC. While CPB was used in these earlier reported cases, ECMO technology has considerably evolved over the past few decades and has become the preferred support option for ECLS in most institutions that perform airway surgery today. Complex tracheobronchial resections require optimal surgical exposure and adequate control of the patient’s ventilation. The traditional approach of cross-table ventilation with intermittent apnea phases or jet ventilation is sufficient for most oncological airway surgery cases, but presents challenges in extended resections and complex reconstructions.

The use of ECMO poses several advantages in these cases. Firstly, it provides a clear, un-obstructed (tubeless) operative field (especially if peripheral cannulation is used), facilitating precise dissection and reconstruction. If veno-arterial support is used, this additionally provides hemodynamic stability during the surgery if required. The risk of bleeding can be minimized by only partial heparinization with activated clotting times (ACTs) targets between 160–180 seconds. The theoretical spread of tumor cells is neglectable, since ECMO is a closed system and suctioned blood can be discarded (53). There are several institutional reports on the use of ECLS for extended, oncological airway procedures including carinal resections/reconstructions (8,17,28) and extended (crico-)tracheal resections (20,26,54,55).

ECLS during airway surgery in non-malignant cases

There are only few case reports on the use of ECLS in patients with benign airway stenosis. V-v ECMO support has been advocated for endoscopic removal of extensive tracheal papillomata (36). ECLS was also successfully used during the repair of a complex TEF (23,48) and catastrophic airway trauma (transection of the trachea and life-threatening hemoptysis) (22,56).

ECLS as a support for endoscopic interventions

Rigid bronchoscopic interventions (e.g., tumor debridement and stent placement) are well-established therapies for malignant obstructions of the airways (57). At times, such cases can be very challenging. In patients with high-grade stenosis, surgeons are sometimes reluctant to re-canalize a patient, because of the considerable risk of peri-procedural asphyxia. The published experience is extensive for the use of ECLS support during complex endoscopic airway interventions. Although the use of CPB with full heparinization has been anecdotally reported, ECMO should be used as the device of choice (50,58). V-a ECMO is favored in the acute setting of a patient who is hemodynamically unstable (16), but for all other interventions v-v ECMO is preferred (7,25,27). The largest reported series of ECLS during endoscopic airway intervention comes from the Asian Medical Center in Korea reporting 18 patients with different primary and secondary tracheal malignancies (18). Their results were excellent with a successful weaning from ECMO in all but one case. Most of their patients were anticoagulated with a single heparin bolus dose and despite extensive endoscopic tumor debulking, significant bleeding was only observed in two cases.

In children as well as adults, massive foreign body aspiration might also require ECLS. Case reports of sand, cement or massive food aspiration requiring ECMO have been published (12,19,59).

ECLS in emergency settings

An important indication for ECLS in airway surgery is acute situations when conventional ventilation strategies fail. In patients with traumatic airway injuries, conventional ventilation is sometimes impossible. In the situation of a ruptured airway, an orotracheal tube must be advanced across the site of injury. Failing to bridge the defect can result in severe pneumomediastinum, tension pneumothorax and death (60). For extensive distal-tracheal injuries, bridging usually leads to a unilateral intubation, often poorly tolerated by the patients. These situations are considered an acute indication for ECLS (61). Once oxygenation has been restored and maintained, the rupture can be safely repaired (56).

Extracorporeal support in pediatric airway surgery

ECLS plays an important role in pediatric airway surgery. There are several features of the pediatric airway, which make children more vulnerable to airway compromise than adults. Firstly, the pediatric airway is smaller, measuring only a few millimeters in diameter. This is especially important with regard to the subglottic airway. In infants, the maximal diameter of the subglottis is 5–6 mm with a cross-sectional area of 28 mm². Following Hagen-Pouiselle’s law, only a millimeter of mucosal edema results in a 50% reduction of the cross-sectional area (62). Furthermore, children have less cartilaginous stability in their airways, increased chest wall compliance and increased metabolic requirements. For example, the typical oxygen consumption at rest is 6–8 mL/kg/min in a child but only 3–4 mL/kg/min in adults (63). All these factors contribute to the fact that children are more prone to airway compromise than adults.

ECLS for foreign body removal

Aspiration of a foreign body can be lethal in children. Although aspiration can be seen at any age, the majority of reported cases occur within the first 3 years of age (64). The reason for this is that young children often explore their environment by mouth. There are several factors making infants prone to aspiration such as their edentulous oral cavities, a potential for aspiration of food during crying or yelling and immaturity of the neuromuscular structures that control swallowing (65). ECMO is the mode of choice when an aspirated foreign body leads to respiratory failure and the child is too unstable to undergo bronchoscopy. Sometimes extraction of the foreign body can be challenging because of tight impaction and an intermittent complete occlusion of the airway by the manipulating instruments within the small airway lumen. Usually a veno-venous mode is sufficient to provide temporary respiratory support and safe bronchoscopic extraction. However, if respiration is severely impaired and the child is persistently acidotic, a veno-arterial support mode should be chosen. Published evidence is limited to two case reports and a retrospective multi-institutional review of a case series (32,34,39). Aspirated foreign bodies requiring ECMO support were beans (n=2), an almond, a peanut, and a grape (n=1), respectively.

ECLS for endoluminal masses

As in adults, endotracheal masses and their management can easily result in a critical airway. There are few reports when ECLS was required to stabilize a child and alleviate obstruction from an endoluminal mass. Malignant endotracheal tumors are rare in the pediatric population and only two cases utilizing ECMO for tracheal tumors can be found in the literature. Shiraishi et al. reported a case of a tracheal fibrosarcoma in a child, which was successfully treated by segmental resection and end-to-end anastomosis with femoro-femoral v-a ECMO (30). Another interesting case published by otolaryngologists and thoracic surgeons from the University of Michigan, described the use of v-v ECMO during vaporization of tracheal papillomatosis (37). This approach has advantages since ECLS facilitates a meticulous and thorough surgical procedure and there is a decreased risk of airway fire when using the laser since supplemental oxygen is not flowing through the surgical field.

ECLS for congenital stenosis

Congenital stenosis is the main indication for ECLS utilization in pediatric airway surgery. One of the challenges in treating these often long-segment stenoses is the maintenance of adequate intraoperative and postoperative ventilation. Cross-table ventilation after opening the airway distal to the stenosis can obscure the operative site, especially in children, where the operative field and airway lumen are small. In distal airway stenosis requiring a resection at the level of the carina, cross-table intubation and ventilation of both lungs might be technically impossible. In order to avoid mechanical ventilation, CPB or ECMO can be utilized. Traditionally, surgical corrections of the airways (e.g., slide tracheoplasties) have been performed using a heart-lung machine and full heparinization (66,67). The reason for this might be explained by the high percentage of concomitant defects of the heart and great vessels, which are often corrected in the same operation as the slide tracheoplasty (68). The drawback to CPB is that it generally requires a median sternotomy in children and therefore limits the surgical approaches to the trachea. Furthermore, the need for full heparinization also increases the risk for hemorrhagic complications. V-a ECMO cannulation can be performed using the internal jugular vein and the carotid artery creating an ideal surgical field free of cannulas. If needed, ECMO support can be continued postoperatively to avoid aggressive mechanical ventilation. This may be beneficial for the healing of a newly reconstructed airway (35). The use of ECMO during repair of congenital airway stenosis has been highlighted by several case series (6,31,33,35).

Practical considerations on ECLS in airway surgery

ECLS should be considered pre-emptively in all patients with critical intrathoracic airway stenosis, in patients requiring a complex lower tracheal/carinal reconstruction and in cases where a temporary complete airway occlusion is anticipated. In patients with a near-occlusion of the intrathoracic airways by a significant mediastinal mass, ECMO should be initiated under local anesthesia and light sedation, since the risk of total airway collapse after paralysis is not insignificant.

We consider v-v ECMO as the configuration of choice since it can fully support the patients’ respiratory function. Traditionally, v-v ECMO is achieved via a two-cannula configuration, however, with the growing experience of single dual-lumen cannulas in other clinical settings (ARDS, lung transplantation), these cannulas present an interesting less-invasive alternative (25) when the accompanying resources are available (TEE or fluoroscopy). For complex carinal reconstructions, a central v-a approach is preferred if extensive manipulation of the heart and great vessels is anticipated (28).

Peripheral v-v ECLS configurations are usually inserted using a percutaneous Seldinger technique. For v-a ECMO, Seldinger or cut-down are acceptable approaches. Heparin coated tubing should be used in order to reduce systemic heparin doses. For adults, v-v ECMO cannula sizes of 21–25 Fr (drainage) and 17–21 Fr (inflow) are sufficient to provide adequate oxygenation and CO2 removal. Single dual-lumen cannulas of 27 or 31 Fr are usually used depending on patient size. For v-a ECMO, a 17-21Fr arterial cannula and a 21–25 Fr venous cannula are recommended. Central v-a cannulations can be performed when the type of airway surgery requires a sternotomy or a right sided thoracotomy. This has the advantage of sparing the peripheral vessels.

Before inserting the cannulas, a single administration of intravenous unfractionated heparin (60 units/kg) is administered. Target ACTs should be between 160 and 180 seconds. ACT is measured every 15 to 30 minutes during the procedure. At the end of the operation, ECMO flow should be gradually reduced while oxygen saturation and hemodynamic parameters are closely monitored. If the patient is stable, cannulas may be clamped and the patient may be disconnected from the ECMO circuit.

Conclusions

In the vast majority of cases, airway surgery can be safely performed by experienced teams without the need for ECLS. However, there are instances where airway control is predictably very difficult or near impossible, or where loss of airway control can suddenly occur. ECLS is an important tool in the armamentarium of the thoracic surgeon to facilitate extended airway surgery or endoscopic airway manipulation in critical obstructions.

Acknowledgements

None.

Footnote

Conflicts of Interest: The authors have no conflicts of interest to declare.

References

1. Woods FM, Neptune WB, Palatchi A. Resection of the carina and main-stem bronchi with the use of extracorporeal circulation. N Engl J Med 1961;264:492-4. [Crossref] [PubMed]
2. Adkins PC, Izawa EM. Resection of Tracheal Cylindroma Using Cardiopulmonary Bypass. Arch Surg 1964;88:405-9. [Crossref] [PubMed]
3. Nissen R. Extracorporeal circulation for prolonged (30 minutes) respiratory interruption in surgery of tracheal tumors in the area of the bifurcation. Schweiz Med Wochenschr 1961;91:957-64. [PubMed]
4. Newland PE. Extracorporeal membrane oxygenation in the treatment of respiratory failure--a review. Anaesth Intensive Care 1977;5:99-112. [PubMed]
5. Walker LK, Wetzel RC, Haller JA Jr. Extracorporeal membrane oxygenation for perioperative support during congenital tracheal stenosis repair. Anesth Analg 1992;75:825-9. [Crossref] [PubMed]
6. Connolly KM, McGuirt WF Jr. Elective extracorporeal membrane oxygenation: an improved perioperative technique in the treatment of tracheal obstruction. Ann Otol Rhinol Laryngol 2001;110:205-9. [Crossref] [PubMed]
7. Ishikawa S, Yoshida I, Otani Y, et al. Intratracheal stent intubation under extracorporeal lung assist. Surg Today 1995;25:995-7. [Crossref] [PubMed]
8. Horita K, Itoh T, Furukawa K, et al. Carinal reconstruction under veno-venous bypass using a percutaneous cardiopulmonary bypass system. Thorac Cardiovasc Surg 1996;44:46-9. [Crossref] [PubMed]
9. Walles T. Clinical experience with the iLA Membrane Ventilator pumpless extracorporeal lung-assist device. Expert Rev Med Devices 2007;4:297-305. [Crossref] [PubMed]
10. Chen A. ECMO-assisted Rigid Bronchoscopy for Tracheal Obstruction. J Bronchology Interv Pulmonol 2009;16:296-7. [Crossref] [PubMed]
11. Lei J, Su K, Li XF, et al. ECMO-assisted carinal resection and reconstruction after left pneumonectomy. J Cardiothorac Surg 2010;5:89. [Crossref] [PubMed]
12. Holliday T, Jackson A. Emergency use of extracorporeal membrane oxygenation for a foreign body obstructing the airway. Crit Care Resusc 2010;12:273-5. [PubMed]
13. Gourdin M, Dransart C, Delaunois L, et al. Use of venovenous extracorporeal membrane oxygenation under regional anesthesia for a high-risk rigid bronchoscopy. J Cardiothorac Vasc Anesth 2012;26:465-7. [Crossref] [PubMed]
14. Thung AK, Hayes D Jr, Preston TJ, et al. Respiratory support including emergent extracorporeal membrane oxygenation as a bridge to airway dilatation following perioperative bronchial occlusion. Middle East J Anaesthesiol 2012;21:879-88. [PubMed]
15. George TJ, Knudsen KP, Sodha NR, et al. Respiratory support with venovenous extracorporeal membrane oxygenation during stenting of tracheobronchomalacia. Ann Thorac Surg 2012;94:1736-7. [Crossref] [PubMed]
16. Willms DC, Mendez R, Norman V, et al. Emergency bedside extracorporeal membrane oxygenation for rescue of acute tracheal obstruction. Respir Care 2012;57:646-9. [Crossref] [PubMed]
17. Keeyapaj W, Alfirevic A. Carinal resection using an airway exchange catheter-assisted venovenous ECMO technique. Can J Anaesth 2012;59:1075-6. [Crossref] [PubMed]
18. Hong Y, Jo KW, Lyu J, et al. Use of venovenous extracorporeal membrane oxygenation in central airway obstruction to facilitate interventions leading to definitive airway security. J Crit Care 2013;28:669-74. [Crossref] [PubMed]
19. Metcalf KB, Michaels AJ, Edlich RF, et al. Extracorporeal membrane oxygenation can provide cardiopulmonary support during bronchoscopic clearance of airways after sand aspiration. J Emerg Med 2013;45:380-3. [Crossref] [PubMed]
20. Liou JY, Chow LH, Chan KH, et al. Successful anesthetic management of a patient with thyroid carcinoma invading the trachea with tracheal obstruction, scheduled for total thyroidectomy. J Chin Med Assoc 2014;77:496-9. [Crossref] [PubMed]
21. Chang X, Zhang X, Li X, et al. Use of extracorporeal membrane oxygenation in tracheal surgery: a case series. Perfusion 2014;29:159-62. [Crossref] [PubMed]
22. Park JM, Kim CW, Cho HM, et al. Induced airway obstruction under extracorporeal membrane oxygenation during treatment of life-threatening massive hemoptysis due to severe blunt chest trauma. J Thorac Dis 2014;6:E255-8. [PubMed]
23. Wang L, Xu XP, Zhan H, et al. Application of ECMO to the treatment of benign double tracheoesophageal fistula: report of a case. Ann Thorac Cardiovasc Surg 2014;20 Suppl:423-6. [Crossref] [PubMed]
24. Park SY, Lee HB, Kim MH, et al. Concrete airway. Am J Respir Crit Care Med 2014;189:e1-3. [PubMed]
25. Ko M, dos Santos PR, Machuca TN, et al. Use of single-cannula venous-venous extracorporeal life support in the management of life-threatening airway obstruction. Ann Thorac Surg 2015;99:e63-5. [Crossref] [PubMed]
26. Kim CW, Kim DH, Son BS, et al. The Feasibility of Extracorporeal Membrane Oxygenation in the Variant Airway Problems. Ann Thorac Cardiovasc Surg 2015;21:517-22. [Crossref] [PubMed]
27. Kim JJ, Moon SW, Kim YH, et al. Flexible bronchoscopic excision of a tracheal mass under extracorporeal membrane oxygenation. J Thorac Dis 2015;7:E54-7. [PubMed]
28. Lang G, Ghanim B, Hotzenecker K, et al. Extracorporeal membrane oxygenation support for complex tracheo-bronchial proceduresdagger. Eur J Cardiothorac Surg 2015;47:250-5; discussion 256. [Crossref] [PubMed]
29. Goldman AP, Macrae DJ, Tasker RC, et al. Extracorporeal membrane oxygenation as a bridge to definitive tracheal surgery in children. J Pediatr 1996;128:386-8. [Crossref] [PubMed]
30. Shiraishi T, Kawahara K, Shirakusa T, et al. Primary tracheal fibrosarcoma in a child: a case of tracheal resection under ECMO support. Thorac Cardiovasc Surg 1997;45:252-4. [Crossref] [PubMed]
31. Angel C, Murillo C, Zwischenberger J, et al. Perioperative extracorporeal membrane oxygenation for tracheal reconstruction in congenital tracheal stenosis. Pediatr Surg Int 2000;16:98-101. [Crossref] [PubMed]
32. Brown KL, Shefler A, Cohen G, et al. Near-fatal grape aspiration with complicating acute lung injury successfully treated with extracorporeal membrane oxygenation. Pediatr Crit Care Med 2003;4:243-5. [Crossref] [PubMed]
33. Hines MH, Hansell DR. Elective extracorporeal support for complex tracheal reconstruction in neonates. Ann Thorac Surg 2003;76:175-8; discussion 179. [Crossref] [PubMed]
34. Ignacio RC Jr, Falcone RA Jr, Brown RL. A case report of severe tracheal obstruction requiring extracorporeal membrane oxygenation. J Pediatr Surg 2006;41:E1-4. [Crossref] [PubMed]
35. Kunisaki SM, Fauza DO, Craig N, et al. Extracorporeal membrane oxygenation as a bridge to definitive tracheal reconstruction in neonates. J Pediatr Surg 2008;43:800-4. [Crossref] [PubMed]
36. Smith IJ, Sidebotham DA, McGeorge AD, et al. Use of extracorporeal membrane oxygenation during resection of tracheal papillomatosis. Anesthesiology 2009;110:427-9. [PubMed]
37. Collar RM, Taylor JC, Hogikyan ND, et al. Awake extracorporeal membrane oxygenation for management of critical distal tracheal obstruction. Otolaryngol Head Neck Surg 2010;142:618-20. [Crossref] [PubMed]
38. Fuzaylov G, Cauley BD. Spontaneous ventilation via facemask and laryngeal mask airway as bridge to extracorporeal membrane oxygenation during long-segment tracheal stenosis repair. Paediatr Anaesth 2012;22:1226-8. [Crossref] [PubMed]
39. Park AH, Tunkel DE, Park E, et al. Management of complicated airway foreign body aspiration using extracorporeal membrane oxygenation (ECMO). Int J Pediatr Otorhinolaryngol 2014;78:2319-21. [Crossref] [PubMed]
40. Liston DE, Richards MJ. Venoarterial extracorporeal membrane oxygenation (VA ECMO) to facilitate combined pneumonectomy and tracheoesophageal fistula repair. J Cardiothorac Vasc Anesth 2014;28:1021-3. [Crossref] [PubMed]
41. Lorusso R, Barili F, Mauro MD, et al. In-Hospital Neurologic Complications in Adult Patients Undergoing Venoarterial Extracorporeal Membrane Oxygenation: Results From the Extracorporeal Life Support Organization Registry. Crit Care Med 2016;44:e964-72. [Crossref] [PubMed]
42. Jacobs JP, Goldman AP, Cullen S, et al. Carotid artery pseudoaneurysm as a complication of ECMO. Ann Vasc Surg 1997;11:630-3. [Crossref] [PubMed]
43. Reeb J, Falcoz PE, Santelmo N, et al. Double lumen bi-cava cannula for veno-venous extracorporeal membrane oxygenation as bridge to lung transplantation in non-intubated patient. Interact Cardiovasc Thorac Surg 2012;14:125-7. [Crossref] [PubMed]
44. Gothner M, Buchwald D, Strauch JT, et al. The use of double lumen cannula for veno-venous ECMO in trauma patients with ARDS. Scand J Trauma Resusc Emerg Med 2015;23:30. [Crossref] [PubMed]
45. Johnson SM, Itoga N, Garnett GM, et al. Increased risk of cardiovascular perforation during ECMO with a bicaval, wire-reinforced cannula. J Pediatr Surg 2014;49:46-9; discussion 9-50. [Crossref] [PubMed]
46. Marasco SF, Lukas G, McDonald M, et al. Review of ECMO (extra corporeal membrane oxygenation) support in critically ill adult patients. Heart Lung Circ 2008;17 Suppl 4:S41-7. [Crossref] [PubMed]
47. Pillai JB, Suri RM. Coronary artery surgery and extracorporeal circulation: the search for a new standard. J Cardiothorac Vasc Anesth 2008;22:594-610. [Crossref] [PubMed]
48. Walles T, Steger V, Wurst H, et al. Pumpless extracorporeal gas exchange aiding central airway surgery. J Thorac Cardiovasc Surg 2008;136:1372-4. [Crossref] [PubMed]
49. Bittar D. Respiratory obstruction associated with induction of general anesthesia in a patient with mediastinal Hodgkin's disease. Anesth Analg 1975;54:399-403. [PubMed]
50. Jensen V, Milne B, Salerno T. Femoral-femoral cardiopulmonary bypass prior to induction of anaesthesia in the management of upper airway obstruction. Can Anaesth Soc J 1983;30:270-2. [Crossref] [PubMed]
51. Tyagi I, Goyal A, Syal R, et al. Emergency cardiopulmonary bypass for impassable airway. J Laryngol Otol 2006;120:687-90. [Crossref] [PubMed]
52. Goyal A, Tyagi I, Tewari P, et al. Management of difficult airway in intratracheal tumor surgery. BMC Ear Nose Throat Disord 2005;5:4. [Crossref] [PubMed]
53. Hasegawa S, Otake Y, Bando T, et al. Pulmonary dissemination of tumor cells after extended resection of thyroid carcinoma with cardiopulmonary bypass. J Thorac Cardiovasc Surg 2002;124:635-6. [Crossref] [PubMed]
54. Nakamura H, Taniguchi Y, Miwa K, et al. Primary adenocarcinoma of the trachea resected using percutaneous cardiopulmonary support (PCPS). Ann Thorac Cardiovasc Surg 2007;13:338-40. [PubMed]
55. Jeon HK, So YK, Yang JH, et al. Extracorporeal oxygenation support for curative surgery in a patient with papillary thyroid carcinoma invading the trachea. J Laryngol Otol 2009;123:807-10. [Crossref] [PubMed]
56. Guillamondegui OD, Nance ML, Gaynor JW, et al. Successful management of concommitant blunt injury to the trachea, esophagus, and cervical spine in a 6-year-old girl. J Pediatr Surg 2004;39:1130-2. [Crossref] [PubMed]
57. Jeon K, Kim H, Yu CM, et al. Rigid bronchoscopic intervention in patients with respiratory failure caused by malignant central airway obstruction. J Thorac Oncol 2006;1:319-23. [Crossref] [PubMed]
58. Yang R, Yu X, Ma L, et al. Emergency management of a patient with severe airway obstruction resulting from poorly differentiated thyroid carcinoma: A case report. Oncol Lett 2012;4:771-4. [PubMed]
59. Mellema JD, Bratton SL, Inglis A Jr, et al. Use of cardiopulmonary bypass during bronchoscopy following sand aspiration. A case report. Chest 1995;108:1176-7. [Crossref] [PubMed]
60. Gries CJ, Pierson DJ. Tracheal rupture resulting in life-threatening subcutaneous emphysema. Respir Care 2007;52:191-5. [PubMed]
61. Gómez-Hernández MT, Rodríguez-Pérez M, Varela-Simó G. Acute respiratory distress due to post-tracheostomy tracheal rupture treated with venovenous extracorporeal membrane oxygenation and endotracheal prosthesis. Arch Bronconeumol 2016;52:337-8. [Crossref] [PubMed]
62. Monnier P. Pediatric airway surgery management of laryngotracheal stenosis in infants and children. Heidelberg: Springer, 2011.
63. Webster PA, King SE, Torres A Jr. An in vitro validation of a commercially available metabolic cart using pediatric ventilator volumes. Pediatr Pulmonol 1998;26:405-11. [Crossref] [PubMed]
64. Oncel M, Sunam GS, Ceran S. Tracheobronchial aspiration of foreign bodies and rigid bronchoscopy in children. Pediatr Int 2012;54:532-5. [Crossref] [PubMed]
65. Higo R, Matsumoto Y, Ichimura K, et al. Foreign bodies in the aerodigestive tract in pediatric patients. Auris Nasus Larynx 2003;30:397-401. [Crossref] [PubMed]
66. Butler CR, Speggiorin S, Rijnberg FM, et al. Outcomes of slide tracheoplasty in 101 children: a 17-year single-center experience. J Thorac Cardiovasc Surg 2014;147:1783-9. [Crossref] [PubMed]
67. Beierlein W, Elliott MJ. Variations in the technique of slide tracheoplasty to repair complex forms of long-segment congenital tracheal stenoses. Ann Thorac Surg 2006;82:1540-2. [Crossref] [PubMed]
68. Manning PB, Rutter MJ, Lisec A, et al. One slide fits all: the versatility of slide tracheoplasty with cardiopulmonary bypass support for airway reconstruction in children. J Thorac Cardiovasc Surg 2011;141:155-61. [Crossref] [PubMed]