(A631) Severe, Complex Tracheal Stenosis Requiring Tracheal Resection with Primary Re-anastomosis Under Extracorporeal Membrane Oxygenation (ECMO)

Introduction: Tracheal resection with primary re-anastomosis is a definitive management for tracheal stenosis unresponsive to conservative endotracheal treatment, such as balloon dilation and laser scar excision. Endotracheal intubation may be difficult in cases of severe tracheal stenosis.

Methods: This is a case report of a 47 year old man with history of intubation for three weeks two years prior who presented with progressive dyspnea and hoarseness. CT neck showed a complex circumferential upper tracheal stenosis with 50% narrowing of the transverse diameter. Bronchoscopy was attempted but aborted due to a complex, circumferential 2 cm stenotic segment 2.5 cm inferior to the true vocal folds.

Results: The complexity of the stenosis precluded endotracheal intubation, therefore Extracorporeal Membrane Oxygenation (ECMO) was initiated. Once the larynx was mobilized and trachea skeletonized, intubation was attempted to minimize ECMO time. Video endoscopy using a Hopkins rod telescope was used to visualize the intraluminal trachea, noting the severe, complex stenosis. The transmitted light was used to mark the proximal and distal extent of resection. An attempt to intubate with the Hopkins rod was made, however the endotracheal tube (ETT) would not pass. A 5-0 ETT over a flexible bronchoscope was used to intubate. Tracheal incisions were made, and the stenotic segment resected, with completion of the primary anastomosis. A Grillo suture was placed to maintain neck flexion and the patient extubated. The Grillo suture was removed on POD 8 with discharge home on POD 9. There was significant improvement in dyspnea at one-month follow-up.

Conclusions: Tracheal resection with primary re-anastomosis is a definitive management for tracheal stenosis unresponsive to conservative treatment or not amenable to endotracheal intervention. The present case is a patient with complex, circumferential tracheal stenosis for whom endotracheal intervention and intubation was not possible. ECMO provided an opportunity for successful tracheal resection without endotracheal intubation.