Case Presentation:
A 29-year-old female presented to the thoracic surgery clinic for surgical evaluation of an incidental finding of cystic mediastinal mass in April 2017. She was scheduled for an elective mass resection in August 2017; however she was lost to follow-up. She re-presented in March 2020 with significant dyspnea at rest with occasional stridor, dysphagia, and chest pain that began a few days prior to presentation. Computed tomography (CT) scan demonstrated complex, heterogeneous 8 cm x 10 cm x 7.4 cm mass on right middle mediastinum, abutting the medial right lung apex, causing significant extrinsic compression the distal trachea (Figure 1a and 1b). Interventional radiology was consulted to drain the mass to reduce the tracheal narrowing to allow for safer intubation. This was not possible as most of the mass was filled with hyperdense material representing blood clots and little free fluid to be drained. Given the critical extrinsic compression of the intrathoracic trachea, there was a significant risk of losing airway control by standard endotracheal intubation. Therefore, the ECMO team was requested to electively place the patient on VV ECMO intra-operatively prior to intubation and thoracotomy. Bilateral femoral veins were cannulated with the Seldinger technique with local anesthesia and ketamine infusion and veno-venous ECMO flow was instituted at 4 L/minute. The patient then underwent general anesthesia and was successfully intubated with a 38F double-lumen endotracheal tube under bronchoscopic guidance. She subsequently was placed in left lateral decubitus and the flow was decreased to 2 L/minute. The paratracheal mass was successfully resected via a right muscle-sparing thoracotomy and standard single left lung ventilation with right lung deflation. Large amount of clots were evacuated from the mass to decompress it for safe resection. The VV ECMO canulae were removed at the end of the operation. Her postoperative course was uneventful. The final pathology report revealed the paratracheal mass to be a benign mediastinal hemangioma (Figures 2) with intracavitary hemorrhage as indicated by the intraoperative large amount of clot discovered.