Apneic Tracheal Stenting Using Femorofemoral Venoarterial Extracorporeal Membrane Oxygenation in a Coronavirus Disease 2019 (COVID-19) Patient With Critical Airway Obstruction: A Case Report

Palliative tracheal stenting for severe central airway obstruction in patients with coronavirus disease 2019 (COVID-19) presents a dual challenge: the imminent risk of acute asphyxia during anesthetic induction and the risk of viral transmission to healthcare professionals via aerosols. While extracorporeal membrane oxygenation (ECMO) can serve as a safety bridge to facilitate apneic interventions, conventional venovenous ECMO may not be feasible in patients with superior vena cava (SVC) compression. Femorofemoral venoarterial ECMO (VA-ECMO) is an alternative; however, it carries a substantial risk of differential hypoxia, particularly in patients with poor native lung function. We report a case of a 41-year-old woman with COVID-19 pneumonia and critical tracheal stenosis (luminal diameter 2 mm) caused by mediastinal lymphadenopathy. Given the prohibitive risk of airway collapse and the need for aerosol containment, she underwent successful apneic tracheal stent placement under femorofemoral VA-ECMO support. This approach was employed because SVC compression precluded upper body cannulation, and differential hypoxia was managed using a multifaceted physiological strategy without circuit modification. A combination of high-flow ECMO, deep anesthesia, pharmacologic cardiac output suppression, and anemia correction effectively mitigated the risk of differential hypoxia. This case demonstrates that femorofemoral VA-ECMO is a safe and effective option for facilitating apneic high-risk airway procedures, simultaneously ensuring airway security and infection control when conventional strategies are insufficient. Further case accumulation is needed to determine the validity and generalizability of these findings.