Avoiding Preemptive Extracorporeal Membrane Oxygenation in Near-Occlusive Tracheal Chondrosarcoma: An Awake Airway Strategy

Primary tracheal chondrosarcoma is an exceptionally rare malignancy. When it presents with near-occlusive airway obstruction, it creates substantial anesthetic challenges, particularly regarding safe airway control and potential reliance on extracorporeal support. In the setting of significant tracheal narrowing, some clinicians consider preemptive venovenous extracorporeal membrane oxygenation (VV-ECMO) because induction of anesthesia may precipitate complete airway obstruction. We report a case of a 57-year-old man with >95% tracheal occlusion from a proximal tracheal chondrosarcoma; tumor vascularity and inferior extension made tracheostomy unsafe and prevented advancement of a standard adult bronchoscope. To avoid the risks associated with preemptive ECMO, spontaneous ventilation was maintained under monitored anesthesia care (MAC) with VV-ECMO on standby. A modified awake fiberoptic intubation technique was performed using video laryngoscopy, a microlaryngoscopy tube, and a Cook airway exchange catheter to secure the airway without precipitating obstruction. After successful intubation, general anesthesia was induced, and rigid bronchoscopic debulking proceeded without complications. This case demonstrates that in select patients with near-total tracheal obstruction, a structured hybrid approach combining preserved spontaneous ventilation, topical anesthesia, and low-profile intubation adjuncts can achieve secure airway control while avoiding the risks of preemptive ECMO. This strategy represents a practical alternative when conventional awake fiberoptic intubation is not feasible, underscoring important considerations for tailoring airway management in rare tracheal pathology.