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

Introduction

Central airway obstruction (CAO) can be caused by metastasis from various extrathoracic cancers, but it is most commonly caused by primary lung cancer, occurring in 13% of cases at the time of diagnosis and in 5% of cases during follow-up (1). Therapeutic bronchoscopy is a useful intervention that restores patency, thereby improving patients’ quality of life and enabling them to tolerate further therapies (2). Ventilation during interventional procedures for CAO can be challenging, especially in the presence of critical obstruction. Several ablative techniques such as laser coagulation, argon plasma coagulation (APC) or cryoprobe (depending on the energy delivered into the tissue, this will either be vaporised, coagulated or devitalised) are used during rigid bronchoscopy.

However, despite the use of different coagulation devices, the risk of bleeding from lesions in the airway may be so high that ventilation of the lung is not possible. Recent studies have shown that veno-venous extracorporeal membrane oxygenation (VV-ECMO) can provide adequate oxygenation during bronchoscopic procedures (3-5). Nevertheless, there is still limited data on reducing the heparin dose during CAO debulking with VV-ECMO, when the risk of bleeding is high.

In this report, we report our experience of using rigid bronchoscopic debulking for a bleeding lesion of the right main bronchus, with the aid of procedural heparin-free VV-ECMO. We present this article in accordance with the CARE reporting checklist (available at https://jovs.amegroups.com/article/view/10.21037/jovs-25-42/rc).

Case presentation

In January 2025, a 64-year-old male patient was admitted to the emergency department with haemoptysis and severe dyspnoea. In May 2023, he underwent a left pneumonectomy for large cell neuroendocrine lung cancer (T2N0M0). The resection margin of the left main bronchus was free from disease and there was no invasion of the carina. Fourteen hilar and mediastinal lymph nodes were also found to be disease-free. The patient did not receive adjuvant therapy based on tumour stage (6). At the age of 20 years [1979], the patient suffered a traumatic brain injury with cerebral hemorrhage, requiring a decompressive craniotomy. The trauma has resulted in post-traumatic epilepsy, treated and controlled with medical therapy, and in a mild cognitive impairment. From that date, the patient has been assigned a legal guardian (the sister). However, the patient was independent and able to perform normal daily activities. He had no other comorbidities. At the time of presentation at emergency department, the patient suffered from haemoptysis and severe dyspnoea with rhonchi of the right side at physical examination. Blood exams reported a hemoglobin (Hb) level of 10.2 md/dL, with normal coagulation activity. No other significant alteration was observed in blood exams, including liver and renal function tests. Chest computed tomography (CT) showed an endobronchial lesion in the right main bronchus, with normal ventilation of all right lung (Figure 1). Bronchoscopy confirmed the obstructing lesion originating from the posterior wall of the right main bronchus, with a residual lumen of 30%, while distal airway appeared free (Figure 2). After a multidisciplinary evaluation, that included oncologist, radiotherapist, endoscopist and anaesthesiologist, we decided to perform endoscopic debulking to obtain a histological diagnosis and to allow the patient to tolerate chemo-radiotherapy. Nevertheless, in this single-lung patient the risk of intraoperative complete airway obstruction, was considered extremely high. Thus, after a careful evaluation with our ECMO team, considering of the potential impossibility to ventilate the lung using conventional techniques, a procedural VV-ECMO was considered in order to ensure adequate blood oxygenation in event of complete bronchus occlusion. Additionally, based on the risk of major intraoperative bleeding related to disease characteristics, it was decided to perform a true procedural VV-ECMO, with short cannulation time (just for the bronchoscopic intervention duration) without heparin infusion.

Figure 1 CT imaging of the endobronchial lesion. The black arrow indicates the site of the endobronchial lesion in the right main bronchus. (A) CT scan for pulmonary parenchyma. (B) CT scan with contrast medium. CT, computed tomography.

Figure 2 Bronchoscopic view of the lesion, originating from the posterior wall, that suboccludes the lumen of right main bronchus.

All procedures performed in this study was in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient’s legal guardian for the publication of this study, accompanying images and the videos in an anonymous way. A copy of the written consent is available for review by the editorial office of this journal. However, the risks and benefits of the proposed procedure were explained also to the patient, who accepted it.

The patient’s height was 180 cm and he weighed 77 kg. Preoperative parameters showed a sinus rhythm with a heart rate of 96 bpm, arterial blood pressure of 130/90 mmHg, and an oxygen saturation of 97% on 4 L/min nasal oxygen. Two 19-Fr femoral ECMO cannulae were placed under local anaesthesia without heparin infusion. After ECMO started and blood gas analysis values showed stable, intravenous anaesthesia started and maintained throughout the procedure with propofol (2 mg/kg/h) and remifentanil infusion (0.05 mcg/kg/min). The ECMO flow was maintained at 4.0 L/min with a FiO₂ of 60% and a fresh gas flow of 4 L/min. The patient underwent laser-assisted neodymium-doped yttrium aluminium garnet (Nd:YAG) mechanical debulking via rigid bronchoscopy (Video 1). The vegetation was removed using the beveled tip of the bronchoscope directly (coring out), after laser coagulation and the airway lumen was restored (Figure 3). The oxygenation level remained stable during the procedure (oxygen saturation never <90%). Hemodynamic stability was observed during the whole procedure (blood pressure ranging between 90/62 and 112/86 mmHg, cardiac frequency ranging between 60 and 82 bpm). The ECMO circuit and oxygenator were continuously checked for clot formation, during the whole procedure. At the end of the procedure, after rigid bronchoscopy removal, the sedation was stopped, and the patient regained consciousness and effective spontaneous ventilation rapidly. Then the VV-ECMO assistance was removed. The total operative time was of 60 minutes, while ECMO was maintained for a total of 100 minutes. No perioperative complications occurred. The patient reported a significant improvement in dyspnea, requiring no oxygen support and no significant haemoptysis occurred. The patient was discharged home 2 days after the operation. Definitive histology confirmed large cell neuroendocrine lung tumour: the patient underwent radiotherapy (60 Gy in 30 days; 2 Gy/fx), one week after the endoscopic procedure (January 2025) (Figure 4; Video 1). Then, the patient underwent 3 cycles of chemotherapy (cisplatin 75 mg/m² and etoposide 100 mg/m²) that was well tolerated, with no significant complications. During follow-up period, on August 2025, the patient underwent CT scan (Video 2) that showed bronchial patency of the right main bronchus (Video 3). At the time of last follow-up (December 2025), by phone interview, the patient was alive in good clinical condition, and he did not report haemoptysis nor dyspnoea.

Figure 3 Postoperative bronchoscopic view of the right main bronchus.

Figure 4 Postoperative CT imaging that shows a right main bronchus free from endobronchial lesions (black arrow). CT, computed tomography.

Discussion

The management of severe airways obstructions caused by neoplastic lesions is a complex issue (7,8). Therapeutic bronchoscopy aims to restore airway patency and make the patient able to tolerate further medical therapies such as chemo or radiotherapy. It is generally achieved with rigid bronchoscopy that simultaneously allows ventilation via side port and insertion of several devices for debulking. Tissue can be removed by mechanical extraction using forceps, the tip of the barrel, the microdebrider or the cryoprobe while thermal energy can be applied in the form of laser, electrocautery or APC (2,4). However, in spite of these coagulation devices used during debulking manoeuvres, the risk of massive haemorrhage can lead to complete airway obstruction, making it impossible to ventilate the lung. Therefore, in this single-lung patient with an active bleeding lesion of the right main bronchus, VV-ECMO was considered a valid option.

During the last decade, some authors reported ECMO application for endoscopic procedures, as a means of maintaining oxygenation (3,8,9). In 2015, Kim et al. reported the endoscopic treatment of a malignant tracheal mass with the use of VV-ECMO (140 minutes) with heparin bolus. They used a flexible bronchoscopy passed through an endotracheal tube, placed just above the tracheal mass, that was maintained for mechanical ventilation till the day after (4). In 2024, Fiorelli et al. reported a case similar to ours. They performed rigid bronchoscopy in a single-lung patient with a tracheal lesion with the aid of procedural ECMO (55 minutes) with no mention of heparin infusion. As a protection from sudden bleeding, they left in place an 8.0-mm endotracheal tube until the next day (10). An analogous result was reported by Biolo et al. in a 17-year-old patient with a carcinoid tumour at the level of the carina that was removed using a rigid bronchoscope. In this case report, the authors did not specify the amount of heparin used for VV-ECMO, which lasted 12 hours after the procedure ended. However, they emphasised the importance of minimising anticoagulation for extracorporeal circulation on a risk-benefit basis due to active bleeding from the lesion (11). Martinod et al. reported the successful use of VV-ECMO for high-risk rigid bronchoscopy debulking (including stenting and Y-stenting) in five cases. They used a heparin bolus (5,000 IU) in all 5 cases, and VV-ECMO was removed at the end of the procedure in three cases. However, it was prolonged for 22 and 24 hours due to respiratory failure in two cases. No other complications were reported in this study (5).

In a larger series, Hong et al. treated 18 patients for severe airway stenosis using rigid bronchoscopy (including malignant mass removal, tracheal stent insertion and, tracheal stent removal) with the aid of VV-ECMO (median time 20.9 hours, range, 2.2–113.4 hours) (3). They reported an initial intravenous injection of heparin during vascular cannulation for ECMO, and in some cases, a continuous infusion of nafamostat mesilate. However, one of the most significant complications in this study was bleeding, including massive bleeding after removing the tracheal stent and intracranial, gastrointestinal and pulmonary haemorrhage (3). Actually, bleeding is one of the most common complications of ECMO. In fact, with the aim of minimising bleeding, Fung et al. reported the use of 50 mg of protamine before starting an endoscopic debulking procedure for a malignant subtotal obstruction of the distal trachea after VV-ECMO application with a 5,000 IU heparin bolus (12). After a multidisciplinary discussion, we decided to use a true procedural VV-ECMO, with the understanding that it would be removed at the end of the bronchoscopic procedure. On a risk-benefit basis, taking into account the active bleeding from the lesion and the desirable short cannulation time, the multidisciplinary team decided to avoid the heparin bolus.

Since 2015, several case reports described the application of heparin-free ECMO in different fields with the aim of reducing bleeding tendency. It has been used in patients with diffuse alveolar haemorrhage and acute respiratory distress syndrome (ARDS) (13), as well as in trauma patients with severe pulmonary contusion (14,15). More recently, Araki et al. described the use of venoarterial ECMO without initial anticoagulation for five days in a female patient with an amniotic fluid embolism (16).

In our case, heparin-free VV-ECMO was run for 100 minutes, no thrombotic events occurred, and the patient’s oxygenation remained stable throughout the procedure. Recently, Sun et al. described the case of a 44-year-old patient with airway obstruction secondary to metastatic synovial sarcoma, that underwent endoscopic debulking using rigid bronchoscopy, with heparin-free VV-ECMO, where a 7-Fr endotracheal tube was left inserted after adequate local hemostasis (17). They emphasized that heparin-free VV-ECMO is an effective strategy for managing airway obstructions in patients at high-risk of bleeding. This case supports the use of ECMO without anticoagulation during airway surgery, striking a balance between maintaining oxygenation and reducing bleeding complications.

In our case, the disease onset (haemoptysis) and the site of the lesion, that lied on the only remaining main bronchus, moved the multidisciplinary decision towards a laser-assisted bronchoscopic disruption with a true procedural VV-ECMO, with short cannulation time (ECMO was removed at the end of the procedure) and no heparin infusion. However, the absence of anticoagulation did not result in any thrombotic complications, which may be partly due to the short cannulation time. Our results support the recent review of Lin et al. that emphasized that short-term ECMO cannulation and heparin-free approach can be pursued during bronchoscopic treatment of CAO, with limited morbidity, when there is a concern for bleeding (9). From the oncological point of view, we have to underline two aspects. Firstly, there was the necessity to obtain a diagnosis in order to plan medical therapies. Secondly, recent papers empathized the role of adjuvant chemo- and radiotherapy in large cell neuroendocrine lung tumor even if the optimal sequence of these treatments and the feasibility of combinations have not yet been defined. In addition, numerous new targeted agents are currently being evaluated in clinical trials for well-differentiated neuroendocrine tumors, and useful findings regarding large cell neuroendocrine lung tumors may emerge in the near future (18).

However, our paper has some limitations. Firstly, as it is a case report, our results cannot be generalized and we cannot draw any definitive cause-effect conclusions. Secondly, there is a selection bias: the favourable outcome of the patient case may have influenced our decision to propose this case report.

Conclusions

This challenging case highlighted the necessity to balance an effective respiratory support and the bleeding risk during bronchoscopic laser-assisted debulking of severe airway obstruction. Heparin-free VV-ECMO, with short cannulation time, may have a role in achieving this equilibrium in life-threatening airway stenosis for this kind of patients. This procedure gave the patient the opportunity to obtain a diagnosis and, consequently, to undergo further medical treatments. However, a multidisciplinary discussion, case by case, on all possible therapeutic options from the oncological, endoscopic and anesthesiological points of view, is still essential in order to front challenging situations. This paper may provide practical insights to guide the management of similar high-risk cases. Additionally, we hope that our anecdotal case could promote communication between practicing clinicians and academic researchers and will serve as a starting point for further studies.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://jovs.amegroups.com/article/view/10.21037/jovs-25-42/rc

Peer Review File: Available at https://jovs.amegroups.com/article/view/10.21037/jovs-25-42/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jovs.amegroups.com/article/view/10.21037/jovs-25-42/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study was in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient’s legal guardian for the publication of this study, accompanying images and the videos in an anonymous way. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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