Rationale: 

Life-threatening airway obstructions caused by tumors demand prompt and effective intervention. Traditional surgical methods are often complicated by bleeding risks, especially with the use of anticoagulation during extracorporeal membrane oxygenation (ECMO). This report investigates the innovative application of heparin-free veno-venous ECMO (VV-ECMO) to minimize bleeding risks while maintaining effective oxygenation during airway obstruction surgeries, thereby offering a safer alternative in high-risk scenarios.

Patient concerns: 

A 44-year-old female with a history of recurrent synovial sarcoma presented with severe dyspnea, requiring a forced lateral position to breathe. A chest CT scan revealed a complete obstruction of the left mainstem bronchus by a tumor.

Diagnoses: 

The patient was diagnosed with airway obstruction secondary to metastatic synovial sarcoma.

Interventions: 

Preemptive heparin-free VV-ECMO was initiated before general anesthesia to maintain oxygenation. Surgical resection of the obstructing tumor was performed using rigid bronchoscopy and high-frequency electrocautery, followed by argon plasma coagulation to control bleeding.

Outcomes: 

Postoperatively, the patient showed significant improvement in respiratory status. VV-ECMO was successfully weaned off, and the patient was extubated shortly after surgery. She was discharged in stable condition 4 days later.

Lessons: 

Heparin-free VV-ECMO is an effective strategy for managing airway obstructions in patients at high-risk of bleeding. This case supports the use of ECMO without anticoagulation in airway surgeries, offering a balance between maintaining oxygenation and reducing bleeding complications.