{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,4,1]],"date-time":"2026-04-01T02:44:09Z","timestamp":1775011449572,"version":"3.50.1"},"reference-count":56,"publisher":"MDPI AG","issue":"1","license":[{"start":{"date-parts":[[2024,12,30]],"date-time":"2024-12-30T00:00:00Z","timestamp":1735516800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCM"],"abstract":"<jats:p>Background: Mediastinal mass syndrome represents a major threat to respiratory and cardiovascular integrity, with difficult evidence-based risk stratification for interdisciplinary management. Methods: We conducted a narrative review concerning risk stratification and difficult airway management of patients presenting with a large mediastinal mass. This is supplemented by a case report illustrating our individual approach for a patient presenting with a subtotal tracheal stenosis due to a large cyst of the thyroid gland. Results: We identified numerous risk stratification grading systems and only a few case reports of regional anesthesia techniques for extracorporeal membrane oxygenation patients. Clinical Case: After consultation with his general physician because of exertional dyspnea and stridor, a 78-year-old patient with no history of heart failure was advised to present to a cardiology department under the suspicion of decompensated heart failure. Computed tomography imaging showed a large mediastinal mass that most likely originated from the left thyroid lobe, with subtotal obstruction of the trachea. Prior medical history included the implantation of a dual-chamber pacemaker because of a complete heart block in 2022, non-insulin-dependent diabetes mellitus type II, preterminal chronic renal failure with normal diuresis, arterial hypertension, and low-grade aortic insufficiency. After referral to our hospital, an interdisciplinary consultation including experienced cardiac anesthesiologists, thoracic surgeons, general surgeons, and cardiac surgeons decided on completing the resection via median sternotomy after awake cannulation for veno-venous extracorporeal membrane oxygenation via the right internal jugular and the femoral vein under regional anesthesia. An intermediate cervical plexus block and a suprainguinal fascia iliaca compartment block were performed, followed by anesthesia induction with bronchoscopy-guided placement of the endotracheal tube over the stenosed part of the trachea. The resection was performed with minimal blood loss. After the resection, an exit blockade of the dual chamber pacemaker prompted emergency surgical revision. The veno-venous extracorporeal membrane oxygenation was explanted after the operation in the operating room. The postoperative course was uneventful, and the patient was released home in stable condition. Conclusions: Awake veno-venous extracorporeal membrane oxygenation placed under local anesthetic infiltration with regional anesthesia techniques is a feasible individualized approach for patients with high risk of airway collapse, especially if the mediastinal mass critically alters tracheal anatomy. Compressible cysts may represent a subgroup with easy passage of an endotracheal tube. Interdisciplinary collaboration during the planning stage is essential for maximum patient safety. Prospective data regarding risk stratification for veno-venous extracorporeal membrane oxygenation cannulation and effectiveness of regional anesthesia is needed.<\/jats:p>","DOI":"10.3390\/jcm14010165","type":"journal-article","created":{"date-parts":[[2024,12,31]],"date-time":"2024-12-31T07:34:19Z","timestamp":1735630459000},"page":"165","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":3,"title":["Local Anesthetic Infiltration, Awake Veno-Venous Extracorporeal Membrane Oxygenation, and Airway Management for Resection of a Giant Mediastinal Cyst: A Narrative Review and Case Report"],"prefix":"10.3390","volume":"14","author":[{"given":"Felix","family":"Berger","sequence":"first","affiliation":[{"name":"Anesthesiology and Operative Intensive Care, Faculty of Medicine, University of Augsburg, 86156 Augsburg, Germany"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Lennart","family":"Peters","sequence":"additional","affiliation":[{"name":"Anesthesiology and Operative Intensive Care, Faculty of Medicine, University of Augsburg, 86156 Augsburg, Germany"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Sebastian","family":"Reindl","sequence":"additional","affiliation":[{"name":"Department of Thoracic Surgery, Faculty of Medicine, University of Augsburg, 86156 Augsburg, Germany"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8371-6463","authenticated-orcid":false,"given":"Felix","family":"Girrbach","sequence":"additional","affiliation":[{"name":"Anesthesiology and Operative Intensive Care, Faculty of Medicine, University of Augsburg, 86156 Augsburg, Germany"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2696-3254","authenticated-orcid":false,"given":"Philipp","family":"Simon","sequence":"additional","affiliation":[{"name":"Anesthesiology and Operative Intensive Care, Faculty of Medicine, University of Augsburg, 86156 Augsburg, Germany"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8028-0094","authenticated-orcid":false,"given":"Christian","family":"Dumps","sequence":"additional","affiliation":[{"name":"Anesthesiology and Operative Intensive Care, Faculty of Medicine, University of Augsburg, 86156 Augsburg, Germany"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1968","published-online":{"date-parts":[[2024,12,30]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"1090","DOI":"10.1111\/j.1460-9592.2007.02279.x","article-title":"Clinical and diagnostic imaging findings predict anesthetic complications in children presenting with malignant mediastinal masses","volume":"17","author":"Anghelescu","year":"2007","journal-title":"Paediatr. Anesth."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"826","DOI":"10.1097\/00000542-200404000-00012","article-title":"Perioperative cardiorespiratory complications in adults with mediastinal mass: Incidence and risk factors","volume":"100","author":"Bechard","year":"2004","journal-title":"Anesthesiology"},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"144","DOI":"10.1097\/00000542-198402000-00012","article-title":"The anesthetic management of the patient with an anterior mediastinal mass","volume":"60","author":"Neuman","year":"1984","journal-title":"Anesthesiology"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"4","DOI":"10.1111\/pan.14319","article-title":"Anesthesia for children with anterior mediastinal masses","volume":"32","author":"Tan","year":"2022","journal-title":"Paediatr. Anaesth."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"104","DOI":"10.1097\/ALN.0000000000004011","article-title":"Mediastinal Masses, Anesthetic Interventions, and Airway Compression in Adults: A Prospective Observational Study","volume":"136","author":"Hartigan","year":"2022","journal-title":"Anesthesiology"},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"2","DOI":"10.21037\/med-22-35","article-title":"The anesthetic management and the role of extracorporeal membrane oxygenation for giant mediastinal tumor surgery","volume":"7","author":"Bertini","year":"2023","journal-title":"Mediastinum"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"627","DOI":"10.1097\/EJA.0b013e328324b7f8","article-title":"Perioperative anaesthetic management of mediastinal mass in adults","volume":"26","author":"Erdos","year":"2009","journal-title":"Eur. J. Anaesthesiol."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"512","DOI":"10.1055\/s-2007-996794","article-title":"Mediastinal tumor and airway obstruction in general anesthesia. Case report and review of the literature","volume":"29","author":"Stamme","year":"1994","journal-title":"Anasthesiol. Intensivmed. Notfallmed. Schmerzther."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"1327","DOI":"10.2214\/ajr.172.5.10227511","article-title":"Helical CT phlebography of the superior vena cava: Diagnosis and evaluation of venous obstruction","volume":"172","author":"Qanadli","year":"1999","journal-title":"AJR Am. J. Roentgenol."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"259","DOI":"10.2214\/ajr.148.2.259","article-title":"Superior vena cava obstruction: A venographic classification","volume":"148","author":"Stanford","year":"1987","journal-title":"AJR Am. J. Roentgenol."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"811","DOI":"10.1097\/JTO.0b013e3181804791","article-title":"Superior vena cava syndrome--a proposed classification system and algorithm for management","volume":"3","author":"Yu","year":"2008","journal-title":"J. Thorac. Oncol."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"531","DOI":"10.1016\/0360-3016(87)90068-X","article-title":"Role of irradiation in the management of superior vena cava syndrome","volume":"13","author":"Armstrong","year":"1987","journal-title":"Int. J. Radiat. Oncol. Biol. Phys."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"1114","DOI":"10.1164\/ajrccm\/141.5_Pt_1.1114","article-title":"Superior vena cava syndrome. The myth\u2014the facts","volume":"141","author":"Yellin","year":"1990","journal-title":"Am. Rev. Respir. Dis."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"1169","DOI":"10.1016\/0002-9343(81)90823-8","article-title":"Superior vena caval obstruction. Is it a medical emergency?","volume":"70","author":"Schraufnagel","year":"1981","journal-title":"Am. J. Med."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"207","DOI":"10.1016\/S0002-9610(05)80308-3","article-title":"A contemporary perspective on superior vena cava syndrome","volume":"160","author":"Chen","year":"1990","journal-title":"Am. J. Surg."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"299","DOI":"10.1111\/j.1440-1843.2006.00841.x","article-title":"Prevalence and characteristics of pleural effusions in superior vena cava syndrome","volume":"11","author":"Rice","year":"2006","journal-title":"Respirology"},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"209","DOI":"10.1016\/S0169-5002(03)00361-1","article-title":"Treatment of malignant superior vena cava syndrome by endovascular stent insertion. Experience on 52 patients with lung cancer","volume":"43","author":"Urruticoechea","year":"2004","journal-title":"Lung Cancer"},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"1777","DOI":"10.1053\/j.jvca.2021.08.033","article-title":"The Role of Extracorporeal Membrane Oxygenation in the Anesthetic Management of Superior Vena Cava Syndrome: Is it Time to Use a Scoring System?","volume":"36","author":"Potere","year":"2022","journal-title":"J. Cardiothorac. Vasc. Anesth."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"531","DOI":"10.1148\/radiology.189.2.8210386","article-title":"Self-expandable metallic stent therapy for superior vena cava syndrome: Clinical observations","volume":"189","author":"Kishi","year":"1993","journal-title":"Radiology"},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"450","DOI":"10.1007\/s10047-021-01264-6","article-title":"Rescue extracorporeal membrane oxygenation for massive anterior mediastinal masses","volume":"24","author":"Leow","year":"2021","journal-title":"J. Artif. Organs."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"338","DOI":"10.1007\/s12055-020-01077-x","article-title":"ECMO and adult mediastinal masses","volume":"37","author":"Ramanathan","year":"2021","journal-title":"Indian J. Thorac. Cardiovasc. Surg."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"E175","DOI":"10.21037\/jtd.2016.02.55","article-title":"Management of large mediastinal masses: Surgical and anesthesiological considerations","volume":"8","author":"Li","year":"2016","journal-title":"J. Thorac. Dis."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"659","DOI":"10.1016\/j.athoracsur.2008.12.073","article-title":"Extracorporeal membrane oxygenation-assisted resection of goiter causing severe extrinsic airway compression","volume":"88","author":"Shao","year":"2009","journal-title":"Ann. Thorac. Surg."},{"key":"ref_24","first-page":"e21799","article-title":"Airway Emergencies Due to Anterior Mediastinal T-Lymphoblastic Lymphoma Managed With Planned Extracorporeal Membrane Oxygenation and Endotracheal Stent: A Case Report and Literature Review","volume":"14","author":"Oyake","year":"2022","journal-title":"Cureus"},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"1719","DOI":"10.1007\/s00277-016-2734-7","article-title":"Successful use of extracorporeal membrane oxygenation during induction chemotherapy in a patient with mediastinal tumor mass of a T lymphoblastic lymphoma","volume":"95","author":"Lueck","year":"2016","journal-title":"Ann. Hematol."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"465","DOI":"10.1053\/j.jvca.2011.02.013","article-title":"Use of venovenous extracorporeal membrane oxygenation under regional anesthesia for a high-risk rigid bronchoscopy","volume":"26","author":"Gourdin","year":"2012","journal-title":"J. Cardiothorac. Vasc. Anesth."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"869","DOI":"10.29271\/jcpsp.2024.08.869","article-title":"Comparison of Intermediate and Superficial Cervical Plexus Blocks for Central Venous Catheterisation","volume":"34","author":"Sevim","year":"2024","journal-title":"J. Coll. Physicians. Surg. Pak."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"e01429","DOI":"10.1213\/XAA.0000000000001429","article-title":"Superficial Cervical Plexus Block for Awake Large-Bore Central Line Placement in Parturients: A Case Series","volume":"15","author":"Sheikh","year":"2021","journal-title":"A A Pract."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"700","DOI":"10.1111\/hdi.12164","article-title":"A minimally painful, comfortable, and safe technique for hemodialysis catheter placement in children: Superficial cervical plexus block","volume":"18","author":"Ciftci","year":"2014","journal-title":"Hemodial. Int."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"638","DOI":"10.1097\/ACO.0b013e328308bb70","article-title":"Regional anesthesia for carotid surgery","volume":"21","author":"Guay","year":"2008","journal-title":"Curr. Opin. Anaesthesiol."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"1619","DOI":"10.2147\/JPR.S138222","article-title":"Ultrasound-guided bilateral superficial cervical plexus block is more effective than landmark technique for reducing pain from thyroidectomy","volume":"10","author":"Senapathi","year":"2017","journal-title":"J. Pain Res."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"539","DOI":"10.1097\/AAP.0b013e3181faa11c","article-title":"A randomized comparison between ultrasound-guided and landmark-based superficial cervical plexus block","volume":"35","author":"Tran","year":"2010","journal-title":"Reg. Anesth. Pain Med."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"370","DOI":"10.1213\/00000539-197505000-00030","article-title":"Interscalene cervical plexus block: A single-injection technic","volume":"54","author":"Winnie","year":"1975","journal-title":"Anesth. Analg."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"775","DOI":"10.1093\/bja\/aeh550","article-title":"Correct nomenclature of superficial cervical plexus blocks","volume":"92","author":"Telford","year":"2004","journal-title":"Br. J. Anaesth."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"733","DOI":"10.1093\/bja\/aeg250","article-title":"Spread of injectate with superficial cervical plexus block in humans: An anatomical study","volume":"91","author":"Pandit","year":"2003","journal-title":"Br. J. Anaesth."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"274","DOI":"10.4097\/kja.d.18.00143","article-title":"Cervical plexus block","volume":"71","author":"Kim","year":"2018","journal-title":"Korean J. Anesthesiol."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"417","DOI":"10.1016\/j.accpm.2016.03.005","article-title":"Prilocaine spinal anesthesia for ambulatory surgery: A review of the available studies","volume":"35","author":"Boublik","year":"2016","journal-title":"Anaesth. Crit. Care Pain Med."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"99","DOI":"10.1016\/j.ijoa.2018.02.009","article-title":"Regional anaesthesia with extracorporeal membrane oxygenation backup for caesarean section in a parturient with neck and mediastinal masses","volume":"35","author":"Mahmood","year":"2018","journal-title":"Int. J. Obstet. Anesth."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"28","DOI":"10.1186\/s40981-017-0098-1","article-title":"Anesthetic management of cesarean section in a patient with a large anterior mediastinal mass: A case report","volume":"3","author":"Kusajima","year":"2017","journal-title":"JA Clin. Rep."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"2458","DOI":"10.1053\/j.jvca.2020.08.023","article-title":"Continuous Ilioinguinal Nerve Block for Treatment of Femoral Extracorporeal Membrane Oxygenation Cannula Site Pain","volume":"35","author":"Graber","year":"2021","journal-title":"J. Cardiothorac. Vasc. Anesth."},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"S94","DOI":"10.1053\/j.jvca.2018.08.173","article-title":"Use of peripheral nerve blocks for femoral artery repair in critically ill patient: A case report","volume":"32","author":"Italiano","year":"2018","journal-title":"J. Cardiothorac. Vasc. Anesth."},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"300","DOI":"10.1111\/j.1365-2044.2011.06628.x","article-title":"Ultrasound-guided supra-inguinal fascia iliaca block: A cadaveric evaluation of a novel approach","volume":"66","author":"Hebbard","year":"2011","journal-title":"Anaesthesia"},{"key":"ref_43","first-page":"526","article-title":"Ultrasound guided fascia iliaca block: A comparison with the loss of resistance technique","volume":"33","author":"Dolan","year":"2008","journal-title":"Reg. Anesth. Pain Med."},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"57","DOI":"10.1016\/j.bpa.2019.03.004","article-title":"Fascia iliaca compartment blocks: Different techniques and review of the literature","volume":"33","author":"Desmet","year":"2019","journal-title":"Best Pract. Res. Clin. Anaesthesiol."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"327","DOI":"10.1097\/AAP.0000000000000543","article-title":"A Longitudinal Supra-Inguinal Fascia Iliaca Compartment Block Reduces Morphine Consumption After Total Hip Arthroplasty","volume":"42","author":"Desmet","year":"2017","journal-title":"Reg. Anesth. Pain Med."},{"key":"ref_46","unstructured":"(2024, November 01). American Society of Anesthesiologist: Statement on ASA Physical Status Classification System. Available online: https:\/\/www.asahq.org\/standards-and-practice-parameters\/statement-on-asa-physical-status-classification-system."},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"1066","DOI":"10.1345\/aph.19381","article-title":"The origin of the \"ideal\" body weight equations","volume":"34","author":"Pai","year":"2000","journal-title":"Ann. Pharmacother."},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"1523","DOI":"10.1053\/j.jvca.2023.05.013","article-title":"Norepinephrine Dose Should Be Reported as Base Equivalence in Clinical Research Manuscripts","volume":"37","author":"Kotani","year":"2023","journal-title":"J. Cardiothorac. Vasc. Anesth."},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"521","DOI":"10.1097\/CCM.0000000000006176","article-title":"Position Paper on the Reporting of Norepinephrine Formulations in Critical Care from the Society of Critical Care Medicine and European Society of Intensive Care Medicine Joint Task Force","volume":"52","author":"Wieruszewski","year":"2024","journal-title":"Crit. Care Med."},{"key":"ref_50","doi-asserted-by":"crossref","first-page":"150","DOI":"10.1186\/s13054-016-1329-y","article-title":"\u201cAwake\u201d extracorporeal membrane oxygenation (ECMO): Pathophysiology, technical considerations, and clinical pioneering","volume":"20","author":"Langer","year":"2016","journal-title":"Crit. Care"},{"key":"ref_51","doi-asserted-by":"crossref","unstructured":"Wu, H., Zhuo, K., and Cheng, D. (2023). Extracorporeal membrane oxygenation in critical airway interventional therapy: A review. Front. Oncol., 13.","DOI":"10.3389\/fonc.2023.1098594"},{"key":"ref_52","doi-asserted-by":"crossref","first-page":"S931","DOI":"10.21037\/jtd.2018.03.116","article-title":"Principles and indications of extracorporeal life support in general thoracic surgery","volume":"10","author":"McRae","year":"2018","journal-title":"J. Thorac. Dis."},{"key":"ref_53","doi-asserted-by":"crossref","first-page":"1137","DOI":"10.1016\/j.jtcvs.2011.07.042","article-title":"Long-term survival after lung resection for non-small cell lung cancer with circulatory bypass: A systematic review","volume":"142","author":"Muralidaran","year":"2011","journal-title":"J. Thorac. Cardiovasc. Surg."},{"key":"ref_54","doi-asserted-by":"crossref","unstructured":"Aburahma, K., de Manna, N.D., Kuehn, C., Salman, J., Greer, M., and Ius, F. (2024). Pushing the Survival Bar Higher: Two Decades of Innovation in Lung Transplantation. J. Clin. Med., 13.","DOI":"10.3390\/jcm13185516"},{"key":"ref_55","doi-asserted-by":"crossref","first-page":"38","DOI":"10.1007\/s11748-017-0836-3","article-title":"Extracorporeal membrane oxygenation versus cardiopulmonary bypass during lung transplantation: A meta-analysis","volume":"66","author":"Magouliotis","year":"2018","journal-title":"Gen. Thorac. Cardiovasc. Surg."},{"key":"ref_56","doi-asserted-by":"crossref","first-page":"5075","DOI":"10.21037\/jtd.2017.10.142","article-title":"Outcomes of perioperative extracorporeal membrane oxygenation use in patients undergoing lung transplantation","volume":"9","author":"Song","year":"2017","journal-title":"J. Thorac. Dis."}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/14\/1\/165\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,10]],"date-time":"2025-10-10T16:57:14Z","timestamp":1760115434000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/14\/1\/165"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2024,12,30]]},"references-count":56,"journal-issue":{"issue":"1","published-online":{"date-parts":[[2025,1]]}},"alternative-id":["jcm14010165"],"URL":"https:\/\/doi.org\/10.3390\/jcm14010165","relation":{},"ISSN":["2077-0383"],"issn-type":[{"value":"2077-0383","type":"electronic"}],"subject":[],"published":{"date-parts":[[2024,12,30]]}}}