title: Intraoperative veno-venous extracorporeal lung support in thoracic surgery: a single-centre experience.
abstract: OBJECTIVE
  Intraoperative extracorporeal lung support (ECLS) during thoracic surgical procedures is a modern concept that is gaining increasing acceptance. So far, cardiopulmonary bypass (CPB), veno-arterial extracorporeal membrane oxygenation (v-a-ECMO) or pumpless arterio-venous interventional lung assist (iLA) were utilized for intraoperative support. Only a few case reports have described the use of veno-venous ECMO for intraoperative ECLS. Here, we report our experience with intraoperative ECLS using different veno-venous low-flow and high-flow settings adapted to the individual patient requirements.
  
  
  METHODS
  Between April 2014 and April 2015, 9 patients underwent pulmonary resections under ECLS. In 6 patients, a twin-port double-lumen cannula was inserted percutaneously into the right femoral vein for low-flow ECLS. In 3 patients, high-flow ECLS was achieved either by femoro-atrial (n = 1) or femoro-jugular cannulation.
  
  
  RESULTS
  Indications for ECLS were severely impaired lung function (n = 3), previous pulmonary resections including contralateral pneumonectomy (n = 4), previous single-lung transplantation (sLTX) (n = 1) and extended carinal pneumonectomy (n = 1). Procedures included segmentectomy (n = 3), extended lobectomy with bronchial and vascular anastomoses (n = 1), VATS lobectomy (n = 2), extended left-sided carinal pneumonectomy (n = 1) as well as extended metastasectomy (n = 2). Low-flow ECLS allowed for apnoea up to 45 min in patients with previous pneumonectomy (n = 3) and facilitated protective single-lung ventilation in patients (n = 3) with severely impaired pulmonary function. During trans-sternal carinal pneumonectomy (n = 1), high-flow ECLS achieved by femoro-atrial cannulation allowed for apnoea for 40 min, avoiding cross-field ventilation. In 2 patients requiring extended metastasectomy after previous lobectomy of the contralateral lower lobe (n = 1) or pulmonary metastases in the graft after sLTX for end-stage fibrosis (n = 1), high-flow ECLS by percutaneous femoro-jugular cannulation allowed for extensive metastasectomy under optimal atelectasis of the lung.
  
  
  CONCLUSIONS
  For intraoperative ECLS, different modes may be applied depending on the intended procedures and required mechanical ventilation. In our experience, different settings of veno-venous ECLS provide sufficient partial or complete lung support, avoiding possible complications associated with other forms of extracorporeal support such as CPB or v-a-ECMO.
authors.affiliation: Department of Thoracic Surgery and Lung Support, Ibbenbueren General Hospital, Ibbenbueren, Germany.
authors.forename: Bassam
authors.initials: B
authors.lastname: Redwan
authors.affiliation: Department of Anesthesiology and Intensive Care Medicine, Ibbenbueren General Hospital, Ibbenbueren, Germany.
authors.forename: Stephan
authors.initials: S
authors.lastname: Ziegeler
authors.affiliation: Department of Thoracic Surgery and Lung Support, Ibbenbueren General Hospital, Ibbenbueren, Germany.
authors.forename: Stefan
authors.initials: S
authors.lastname: Freermann
authors.affiliation: Department of Anesthesiology and Intensive Care Medicine, Ibbenbueren General Hospital, Ibbenbueren, Germany.
authors.forename: Liane
authors.initials: L
authors.lastname: Nique
authors.affiliation: Department of Thoracic Surgery and Lung Support, Ibbenbueren General Hospital, Ibbenbueren, Germany.
authors.forename: Michael
authors.initials: M
authors.lastname: Semik
authors.affiliation: Department of Respiratory Medicine and Thoracic Oncology, Ibbenbueren General Hospital, Ibbenbueren, Germany.
authors.forename: Mahyar
authors.initials: M
authors.lastname: Lavae-Mokhtari
authors.affiliation: Department of Anesthesiology and Intensive Care Medicine, Ibbenbueren General Hospital, Ibbenbueren, Germany.
authors.forename: Thomas
authors.initials: T
authors.lastname: Meemann
authors.affiliation: Department of Respiratory Medicine and Thoracic Oncology, Ibbenbueren General Hospital, Ibbenbueren, Germany.
authors.forename: Nicolas
authors.initials: N
authors.lastname: Dickgreber
authors.affiliation: Department of Thoracic Surgery and Lung Support, Ibbenbueren General Hospital, Ibbenbueren, Germany s.fischer@klinikum-ibbenbueren.de.
authors.forename: Stefan
authors.initials: S
authors.lastname: Fischer
mesh_terms: D000368:Aged; D015199:Extracorporeal Membrane Oxygenation / Q000379:methods*; D005260:Female; D005268:Femoral Vein / Q000601:surgery*; D006801:Humans; D007601:Jugular Veins / Q000601:surgery*; D008175:Lung Neoplasms / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D011013:Pneumonectomy; D029424:Pulmonary Disease, Chronic Obstructive / Q000601:surgery; D011656:Pulmonary Emphysema / Q000601:surgery
keywords: ECLS; ECMO; Lung resection; Thoracic surgery