Intraoperative management of locally advanced mediastinal masses: options and role of extracorporeal cardio-respiratory support through a case-series evaluation

Background: Mediastinal masses are a heterogeneous group of disorders that often require a radical surgical treatment. However, especially for large masses involving or compressing airways and/or vascular structures, surgery may be complicated by a variety of cardiorespiratory complications possibly occurring during patient positioning, oro-tracheal intubation, induction, surgical manipulation and extubation. In some situations, an extracorporeal cardio-respiratory support (C-R support) may be necessary to safely perform surgery. The choice of the most appropriate extracorporeal C-R support is a complex indication, depending on patients’ conditions, position and characteristics of the mediastinal mass. Up to date, there are no specific guidelines on the extracorporeal C-R support management in those patients. We aim to propose a schematic approach to the different extracorporeal C-R support strategies through a series of exemplifying cases. Case Description: Four representative cases of advanced mediastinal mass undergoing surgical treatment with different extracorporeal C-R support systems have been collected: one required central cardiopulmonary bypass (CPB) for hemodynamic instability; one had an emergency peripheral CPB for aortic injury; one an elective extra corporeal membrane oxygenation (ECMO) for respiratory failure during pneumonectomy. In our experience, if a hemodynamic impairment occurs, CPB or veno-arterial ECMO should be preferred over veno-venous ECMO that should be reserved to pure respiratory impairment. CPB is mandatory if a bloodless surgical field is needed or if a severe bleeding required a massive hemodynamic support. Finally, the mass position and great vessels involvement could affect the choice of a peripheral approach over a central cannulation. Conclusions: The use of C-R support systems may be mandatory in case of large mediastinal masses in order to perform a safe surgery. We developed a schematic flowchart to guide the choice of the most adequate C-R support depending on patient status and mass characteristics.