In complex airway surgery and high-risk rigid bronchoscopy, conventional ventilation may be unsafe or impossible. We report our experience using veno-venous extracorporeal membrane oxygenation (VV-ECMO) as respiratory support.

We retrospectively reviewed patients managed with planned VV-ECMO for airway surgery or high-risk rigid bronchoscopy (May 2012 to February 2025). Indications were anticipated inability to ventilate due to extensive lesions or a high risk of major bleeding. Data included patients’ and procedures’ details, ECMO configuration, and 30-day outcomes.

Twenty-four patients (15 women, 9 men; mean age 49 years, range 20-66) underwent 28 procedures under VV-ECMO: 11 rigid bronchoscopies and 17 surgeries, including 15 airway replacements with a stented cryopreserved aortic allograft, 1 tracheal repair after injury, and 1 tracheal resection with end-to-end anastomosis. Cannulation was mainly femoro-jugular (93%). Decannulation occurred in the operating theatre in 22 cases after a mean run of 3.8 h; it was delayed 1-22 days in 4 cases, and 2 patients died while still on ECMO. Major 30-day morbidity occurred in 10 patients and minor in 13; ECMO-specific complications occurred in 4 cases (deep-vein thrombosis, n = 3; vasoplegic syndrome, n = 1), all resolving medically. Thirty-day mortality was 5/24 patients (21%): 3 surgical and 2 endoscopic. In 2 deaths, a contribution of VV-ECMO could not be excluded. At the last follow-up, 16 patients were alive.

Planned VV-ECMO may be considered a useful adjunct for complex airway surgery and high-risk rigid bronchoscopy when ventilation is precarious or major bleeding is anticipated, enabling safer, more controlled interventions in selected patients.