Korean J Radiol.  2014 Jun;15(3):322-329. 10.3348/kjr.2014.15.3.322.

Multislice CT Scans in Patients on Extracorporeal Membrane Oxygenation: Emphasis on Hemodynamic Changes and Imaging Pitfalls

• Liu KL
• Wang YF
• Chang YC
• Huang SC
• Chen SJ
• Tsang YM
• Chang CC

• KMID: 2078641
• DOI: http://doi.org/10.3348/kjr.2014.15.3.322

Abstract

This pictorial review provides the principles of extracorporeal membrane oxygenation (ECMO) support and associated CT imaging features with emphasis on the hemodynamic changes and possible imaging pitfalls encountered. It is important that radiologists in ECMO centers apply well-designed imaging protocols and familiarize themselves with post-contrast CT imaging findings in patients on ECMO.

Keyword

Extracorporeal membrane oxygenation; CT; Cardiopulmonary bypass

MeSH Terms

Adult
Aorta, Thoracic/physiopathology/radiography
Contrast Media/administration & dosage/pharmacokinetics
Extracorporeal Membrane Oxygenation/classification/*methods
Female
Heart-Assist Devices
Hemodynamics/*physiology
Humans
Intra-Aortic Balloon Pumping/instrumentation
Male
Middle Aged
*Multidetector Computed Tomography
Regional Blood Flow/physiology
Retrospective Studies
Ventricular Dysfunction, Left/physiopathology/radiography
Contrast Media

Figure

• 

  Fig. 1 Diagrammatic representation of (A) VA-ECMO and (B) VV-ECMO. A. In VA-ECMO, blood is withdrawn from IVC with cannulation via femoral vein (white arrow); after oxygenation, oxygenated blood returns to arterial side of circulation via femoral arterial cannula (black arrow). B. In VV-ECMO, blood is usually taken from SVC (white arrow), driven through oxygenator, and then returned to IVC (black arrow). ECMO = extracorporeal membrane oxygenation, IVC = inferior vena cava, SVC = superior vena cava, VA = veno-arterial, VV = veno-venous

• 

  Fig. 2 51-year-old male had acute onset of myocardial infarction during percutaneous coronary intervention under VA-ECMO support. Contrast-enhanced axial CT images in dynamic phases show contrast layering in descending aorta (white arrow) during arterial phase (A) and full opacification of descending aorta (black arrow) in venous phase (B). Left ventricular assisted device is also shown (arrowhead). VA-ECMO = veno-arterial extracorporeal membrane oxygenation

• 

  Fig. 3 54-year-old male underwent VA-ECMO due to cardiogenic shock. (A) In CT topogram, arterial cannula is labeled with black arrow and venous cannula is labeled with white arrow. Contrast medium was administrated via right jugular central venous line (short white arrow). Contrast-enhanced axial CT images in arterial phase (B) and venous phase (C) show pseudo-layering in ascending aorta (white arrows) in both phases and left ventricle appears slightly opacified in second phase. Emergency surgical treatment of suspected thrombi was performed, proving diagnosis of right coronary artery occlusion and myocardial infarction with absence of intimal flap or thrombus formation in ascending aorta. VA-ECMO = veno-arterial extracorporeal membrane oxygenation

• 

  Fig. 4 43-year-old male with acute myocarditis and VA-ECMO support whose ultrasound showed suspected LV and AV thrombus. (A) Bolus tracking with ROI at ascending aorta is used in order to avoid artifacts from intra-aortic balloon pump (white arrow). Enhancing curve is suggestive of rapid opacification of whole aorta. Contrast-enhanced axial CT images in arterial phase (B) and venous phase (C) show persistent non-enhancement of left ventricular chamber in both phases of scanning. Note full opacification of aortic sinus (white arrows). Further urgent surgical treatment revealed no evidence of intracardiac thrombus. AV = aortic valve, ECMO = extracorporeal membrane oxygenation, LV = left ventricle, ROI = region of interest, VA = veno-arterial

• 

  Fig. 5 56-year-old male with underlying congestive heart failure had acute myocardial infarction. After VA-ECMO was performed, left ventricle assisted device was inserted due to poor cardiac output. A. Post-contrast axial CT scanning during arterial phase shows complete opacification of left carotid artery and left subclavian artery but non-opacification of brachiocephalic artery (black arrow) and fluid layering within ascending aorta (white arrow). Left ventricle is fully opacified. B. During venous phase, filling defects in brachiocephalic artery (black arrow) and aortic root (arrowhead) are outlined by surrounding contrast medium. Fluid layering is persistent as shown at ascending aorta (white arrow). Transesophageal echocardiogram confirmed presence of thrombus at aortic valve and total occlusion of right common carotid artery. VA-ECMO = veno-arterial extracorporeal membrane oxygenation

• 

  Fig. 6 50-year-old female had sudden cardiac collapse during surgical treatment for brain metastasis from urothelial carcinoma. VA-ECMO was performed. (A) CT topogram shows arterial cannula at right common femoral artery (black arrow) and venous cannula at right common femoral vein (white arrow). During initial contrast medium injection via peripheral catheter in right arm (short white arrow in right arm), no enhancing flow is detected in bolus tracking with ROI at descending aorta (B). After confirmation of no local extravasation, marked beam-hardening streak artifacts are found due to dense contrast medium stasis in veins of right arm (C, black arrowhead). Upon repeating contrast enhanced scanning, bolus tracking is placed in descending aorta and contrast medium is administrated via central venous line (A, short black arrow in left external femoral vein). Anticipated enhancement curve in descending aorta is obtained (D). Pseudo-layering is also noted at ascending aorta in arterial phase (E, white arrow) as well as delayed opacification of left heart. In venous phase, ascending aorta and left heart are fully opacified by contrast agent (F). ROI = region of interest, VA-ECMO = veno-arterial extracorporeal membrane oxygenation

• 

  Fig. 7 35-year-old male had pneumonia complicated by acute respiratory distress syndrome and underwent VV-ECMO for oxygenating support. (A) In CT topogram, inflow cannula is labeled with black arrow and outflow cannula with white arrow. Contrast medium injection is performed via right jugular central venous line (short white arrow). After contrast injection, dynamic serial images are obtained using bolus tracking with ROI at descending aorta and heart chambers and major vessels are enhanced normally (B). ROI = region of interest, VV-ECMO = veno-venous extracorporeal membrane oxygenation

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