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Cannulation strategies for intraoperative mechanical cardio- respiratory support in general thoracic surgery

In general thoracic surgery, extracorporeal mechanical cardio-respiratory support (EMCS) techniques are performed intraoperatively mainly for respiratory but also for cardiocirculatory support. The increasing panel of EMCS technologies available in thoracic surgery is the result of a century of clinical practices, engineering progress, and improvements of physiological knowledge. Complex procedures of tumor resection, traqueal and main airway surgery or lung transplantation are the scenarios where these techniques should be considered if needed. The aim of this review is to describe different modalities of EMCS used in general thoracic surgery with a particular attention to the cannulation techniques. Venovenous extracorporeal membrane oxygenation (VV-ECMO) is the most common EMCS modality and represents the most efficient in supporting lung function. Venoarterial ECMO (VA-ECMO) may be achieved in both central and peripheral cannulation. Central VA-ECMO is the main modality for intraoperative emergent support, which brought a decrease in popularity of classic cardiopulmonary bypass (CPB) due to lower risk of complications. Peripheral VA-ECMO is traditionally performed in a femorofemoral configuration. Extracorporeal CO2 removal (ECCO2R) and Novalung are marginal alternatives for intraoperative support during general thoracic surgery. Although rarely used, ECMS techniques should be part of every general thoracic surgeon armamentarium and should be brought to mind in complex cases or in