Delayed Hemorrhage Following Needle Aspiration for a Mediastinal Cyst: The Significance of Confronting Upside-Down Video-Assisted Thoracic Surgery Under Two-Lung Ventilation.

Introduction: Surgical resection remains the gold standard for managing mediastinal cysts, including bronchogenic cysts, whereas needle aspiration serves as an alternative option that can facilitate preoperative volume reduction or, in certain selected cases, serve as a definitive treatment. However, it may lead to rare but potentially life-threatening complications such as mediastinitis; therefore, its indication should be carefully considered. This report details a case of a delayed intracystic hemorrhage 3 days after an endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA), requiring emergency surgery with venoarterial extracorporeal membrane oxygenation (V-A ECMO) on standby, which was successfully managed using a confronting upside-down video-assisted thoracoscopic surgery (VATS) approach.

Case presentation: A 64-year-old woman with exertional dyspnea was diagnosed with a superior mediastinal cyst compressing the trachea and esophagus. Preoperative EUS-FNA was performed to reduce the cyst volume and any mitigate potential complications during anesthesia induction. Three days later, she developed dyspnea due to a delayed intracystic hemorrhage, necessitating emergency surgery. VATS with a confronting upside-down monitor setup was performed under standby V-A ECMO. Despite a limited surgical field under 2-lung ventilation, a confronting upside-down VATS approach allowed sufficient visualization and maneuverability. The patient had an uneventful recovery, with no recurrence at 3 months.

Conclusions: A delayed intracystic hemorrhage is a potential risk following an EUS-FNA for mediastinal cysts. A confronting upside-down VATS approach provides sufficient maneuverability even for superior mediastinal tumors, despite a limited surgical field due to inadequate 1-lung ventilation. Placement of the camera port in the higher intercostal space was deemed particularly crucial.