Anesthetic Management of Perioperative Extracorporeal Membrane Oxygenation (ECMO) for Thoracoscopic Bullectomy in a Single-Lung Patient: A Case Report.

Thoracic surgery in patients with severely limited pulmonary reserve may be unsafe or infeasible with conventional one-lung ventilation. In patients with previous pneumonectomy, surgical exclusion of the only functioning lung abolishes native ventilation, making conventional lung isolation impossible. Venovenous extracorporeal membrane oxygenation (VV-ECMO) may provide temporary respiratory support in carefully selected patients by maintaining oxygenation and carbon dioxide removal while allowing optimal surgical exposure. We report the case of a 79-year-old man with single-lung physiology following left pneumonectomy who presented with recurrent right pneumothorax and underwent uniportal video-assisted thoracoscopic surgery (VATS) bullectomy supported by perioperative VV-ECMO. Peripheral VV-ECMO was established using bilateral femoral venous cannulation, permitting alternating periods of controlled apnea and protective mechanical ventilation while maintaining adequate gas exchange. Following surgery, ECMO support was electively continued during the early postoperative period because of the patient's severely limited respiratory reserve and was successfully weaned 36 hours after surgery. The postoperative course was complicated by bilateral femoral deep venous thrombosis after decannulation, requiring therapeutic anticoagulation. This case illustrates that perioperative VV-ECMO may represent a feasible strategy for carefully selected high-risk thoracic surgical patients in whom conventional lung isolation is not possible. It also highlights the importance of meticulous multidisciplinary planning, individualized anticoagulation strategies, and routine surveillance for cannula-related thrombotic complications.