Abstract Introduction Iatrogenic tracheal tears with concurrent esophageal injury and mediastinal sepsis are rare and technically challenging. We report definitive tracheal reconstruction performed under veno-venous extracorporeal membrane oxygenation (VV-ECMO), emphasizing how ECMO altered perioperative physiology to protect the repair. Case Description A previously healthy 29-year-old woman developed a 3.5 cm longitudinal tracheal defect approximately 3 cm above the carina after rigid esophagoscopy for an impacted bone, complicated by cervical esophageal perforation, retropharyngeal and mediastinal infection, and acute hypoxemic respiratory failure. At our center, femoro-femoral VV-ECMO (flows 3.5-4.0 L/min; sweep titrated) enabled ultra-low-pressure ventilation and prolonged apneic windows for operative exposure. Through a right posterolateral thoracotomy, a 5 × 2 cm intrathoracic tracheal defect within inflamed and phlegmonous tissue was closed using a composite autologous pericardial and acellular dermal matrix patch, buttressed by a pedicled latissimus dorsi flap. A Bivona size 7 adjustable tracheostomy was positioned 1 cm above the carina. Postoperatively, the patient remained on VV-ECMO while sedation was lightened and ventilator pressures minimized. She underwent daily bronchoscopy for pulmonary toilet and direct inspection of the repair. She was decannulated from ECMO on postoperative day 23, weaned to room air, advanced to oral diet after a negative esophagram, and discharged to rehabilitation. Follow-up showed normal voice, good airway patency, and full recovery. A cannulation-related iliocaval deep vein thrombosis was managed successfully with anticoagulation. Discussion ECMO provided a physiological bridge that optimized both surgical and postoperative management. By maintaining ultra-low airway pressures, it created an ideal environment for flap maturation and graft integration. Offloading mechanical stress from the tracheal wall promoted early perfusion and capillary ingrowth, essential for the stability of the repair in infected and friable tissue. ECMO also allowed oxygenation independent of airway mechanics, permitting precise tube positioning with minimal cuff pressure and preventing mainstem intubation or suture-line tension. Daily planned bronchoscopies, feasible under ECMO support, ensured pulmonary clearance, confirmed flap viability, and guided ventilator adjustments. These strategies minimized barotrauma, preserved airway hygiene, and supported early healing. Anticoagulation was carefully balanced to maintain circuit patency while minimizing bleeding risk. Decannulation was guided by physiologic stability and direct endoscopic confirmation rather than fixed timing. Conclusion In complex tracheal reconstruction within infected and unstable airways, veno-venous extracorporeal membrane oxygenation serves as more than rescue therapy. It provides a low-pressure environment that supports flap maturation, precise airway control, and daily bronchoscopic care, resulting in durable repair and favorable recovery. This abstract is funded by: NA
Zyara et al. (2026) studied this question.