Elective Heparin-Free Veno-Venous Extracorporeal Membrane Oxygenation for High-Risk Airway Management in Advanced Laryngeal Tumor Obstruction: A Case Report

Background: Critical upper airway obstruction caused by advanced laryngeal malignancy poses an extreme risk of airway loss during induction of anesthesia and instrumental airway management. Veno-venous extracorporeal membrane oxygenation (VV-ECMO) has emerged as a strategy to enable safe performance of high-risk airway interventions. However, reports on heparin-free protocols in this setting remain scarce. Methods: A 46-year-old male with progressive dyspnea caused by a large laryngeal tumor reducing the residual glottic lumen to ~1 mm was admitted urgently. Safe endotracheal intubation was deemed impossible. Elective heparin-free VV-ECMO was established under local anesthesia via percutaneous femoro-femoral cannulation before induction of general anesthesia. Results: Under ECMO support, a technically demanding tracheostomy and tumor biopsy were performed without hypoxemic episodes. VV-ECMO was maintained postoperatively for 48 h without systemic anticoagulation and was weaned without hemorrhagic or thrombotic complications. Histopathology confirmed squamous cell carcinoma grade 2; the patient was discharged home after initiation of systemic immunotherapy. Conclusions: Elective heparin-free VV-ECMO can provide effective and safe respiratory support for patients with critical airway obstruction undergoing high-risk airway procedures. Pre-emptive cannulation under local anesthesia, femoro-femoral access in anatomically compromised necks, and short heparin-free circuit runs mitigate both airway and hemorrhagic risk. Prospective studies are needed to establish standardized patient selection criteria and anticoagulation protocols.