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.