Drs. Kaley El-Arab and Brandon Friedman are Emergency Medicine Residents at Carolinas Medical Center and interested in medical education and Critical Care. They have teamed with Ms. Emily Lipitz a PA with the Sanger Heart & Vascular Institute. Along with the guidance of Dr. Michael Gibbs, a notable Professor of Emergency Medicine, and Dr. John Symanski, a cardiologist from the Sanger Heart & Vascular Institute, they aim to help augment our understanding of emergent imaging of implanted devices. Follow along with the EMGuideWire.com team as they post these educational, self-guided radiology slides. This set will cover: - Extracorporeal Membrane Oxygenation

1. Imaging Of Medical Devices
Extracorporeal Membrane Oxygenation
Brandon Friedman, MD1, Kaley El-Arab, MD1, Emily Lipitz, PA2
Departments of Emergency Medicine1 & Internal Medicine2
Carolinas Medical Center & Levine Children’s Hospital
John Symanski, MD, Guest Editor, Sanger Heart & Vascular Institute
Michael Gibbs, MD, Imaging Mastery Project Lead Editor
Medical Device Imaging Mastery Project
Presentation #4

2. Disclosures
 This ongoing imaging interpretation series is proudly sponsored by the
Emergency Medicine Residency Program at Carolinas Medical Center.
 Sanger Heart & Vascular clinicians provide expert Cardiology input.
 The goal is to promote widespread mastery of imaging interpretation.
 There is no personal health information [PHI] within, and all ages have
been changed to protect patient confidentiality.

3. Visit Our Website
www.EMGuidewire.com
For A Complete Archive Of Imaging Presentations And Much More!

4. Airway
Bones
Cardiac
Diaphragm
Effusion
Foreign body
Gastric
Hilum

5. It’s All About The Anatomy!

6. Extracorporeal Membrane Oxygenation
ECMO Basics

7. Extracorporeal Membrane Oxygenation (ECMO)
Definition: Extracorporeal mechanism for extended cardiac and pulmonary
support for individuals whose heart and lungs are unable to provide adequate
gas exchange or perfusion to sustain life.
Indication: Acute, severe reversible respiratory or cardiac failure with a high
risk of death that is refractory to conventional therapies.
Types of ECMO:
V-V = veno-venous
V-A = veno-arterial

8. ECMO Components
Air
O₂
Sweep
Gas
O₂
CO₂
CO₂
Pump
Oxygenator
Blood
Deoxygenated Blood
Oxygenated Blood
Blender
Figure 1: ECMO Components
The pump modulates flow in in L/min
by modifying pump speed in RPM. The
blender modifies the FiO₂ by mixing air
and oxygen. The oxygenator controls
the gas exchange by modifying the
sweep volume in L/min.

9. Extracorporeal Membrane Oxygenation
V-V ECMO

10. V-V ECMO
Support for severe pulmonary failure (w/o cardiac failure).
Clinical Conditions Appropriate For V-V ECMO
• Pneumonia
• ARDS
• Acute GVHD
• Pulmonary contusion
• Smoke inhalation
• Status asthmaticus
• Airway obstruction
• Aspiration
• Bridge to lung transplant
• Drowning

11. Figure 2: V-V ECMO
Central venous blood is drained and
oxygenated blood is returned to the
right atrium. This technique requires
adequate perfusion by the heart.

12. V-V ECMO – Femoro-Jugular Cannulation
Figure 3: Femoro-Jugular Cannulation
Dual cannula systems drains blood from
the IVC through femoral access and
returns oxygenated blood to the right
atrium via internal jugular access.

13. V-V ECMO – Femoro-Femoral Cannulation
Figure 3: Femoro-Femoral Cannulation
Dual cannula system drains blood from
the IVC through femoral access and
returns oxygenated blood to the right
atrium via the opposite femoral vein.

14. V-V ECMO – Single Lumen Cannulation
Figure 4: Single Cannula System
A single dual-lumen catheter drains
blood from the SVC and IVC through
small ports and returns blood to the
right atrium through a parallel port,
requiring a single point of access.

15. Extracorporeal Membrane Oxygenation
V-A ECMO

16. V-A ECMO
Support for cardiac failure (+/- pulmonary failure).
Clinical Conditions Appropriate For V-A ECMO
• Graft failure post heart or heart
lung transplant
• Non-ischemic cardiogenic shock
• Failure to wean post
cardiopulmonary bypass
• Bridge to LVAD
• Drug overdose
• Sepsis
• Pulmonary embolus
• Cardiac or major vessel trauma
• Massive pulmonary hemorrhage
• Pulmonary trauma
• Acute anaphylaxis

17. Figure 5: V-A ECMO
Central venous blood is drained and
oxygenated blood is returned to the
arterial system.

18. Extracorporeal Membrane Oxygenation
Cases From Carolinas Medical Center

19. Case 1: 50-yo in
Cardiogenic
Shock

20. Tip Of Venous
ECMO Cannula
V-A ECMO
Case 1: 50-yo in
Cardiogenic
Shock

21. Case 2: 55-yo
with a Large
Tracheal
Laceration

22. Tip of Reinjection
Cannula
V-V ECMO
Case 2: 55-yo
with a Large
Tracheal
Laceration

23. Case 3: 28-yo
with a Severe
Asthma
Exacerbation

24. Case 3: 28-yo
with a Severe
Asthma
Exacerbation
Dual-Lumen RIJ
ECMO Cannula
V-V ECMO
Suction
Port
Reinjection
Port

25. Case 4: 47-yo in
Cardiogenic
Shock

26. Tip Of Venous
ECMO Cannula
V-A ECMO
Case 4: 47-yo in
Cardiogenic
Shock

27. Test yourself!
Cases From Carolinas Medical Center

28. Case 5: 59-yo In
Cardiogenic
Shock

29. Tip of Venous
ECMO Cannula
V-A ECMO
Case 5: 59-yo In
Cardiogenic
Shock

30. Case 6: 30-yo
with Necrotizing
Pneumonia after
Trauma

31. Case 6: 30-yo
with Necrotizing
Pneumonia after
Trauma
Tip of RIJ Dual-Lumen
ECMO Cannula
V-V ECMO
Suction
Port
Reinjection
Port
Suction
Port

32. Case 7: 64-yo in
Cardiogenic
Shock

33. V-A ECMO
Tip Of Venous
ECMO Cannula
Case 7: 64-yo in
Cardiogenic
Shock

34. Case 8: 70-yo
with a Massive
PE s/p tPA

35. V-A ECMO
Case 8: 70-yo
with a Massive
PE s/p tPA
Tip Of Venous
ECMO Cannula

36. Case 9: 49-yo
with Post-Op
Pulmonary
Edema

37. Case 9: 49-yo
with Post-Op
Pulmonary
Edema
Tip of Reinjection
Cannula
V-V ECMO

38. Case 9: 49-yo
with Post-Op
Pulmonary
Edema
Abdominal View

39. Case 9: 49-yo
with Post-Op
Pulmonary
Edema
Tip of Suction
Cannula
V-V ECMO
Abdominal View
Right Femoral Vein Access

40. Case 10: 37-yo
with Pulmonary
Contusions after
an MVC

41. Case 10: 37-yo
with Pulmonary
Contusions after
an MVC
V-V ECMO
Tip of RIJ Dual-Lumen
ECMO Cannula
Suction
Port
Reinjection
Port
Suction
Port

42. Case 11: 48-yo
with a Saddle PE
s/p tPA

43. Case 11: 48-yo
with a Saddle PE
s/p tPA
V-A ECMO
Tip Of Venous
ECMO Cannula

44. Case 11: 48-yo
with a Saddle PE
s/p tPA
Abdominal View
V-A ECMO

45. Case 11: 48-yo
with a Saddle PE
s/p tPA
Abdominal View
Left Femoral Vein Access
V-A ECMO
Tip Of Venous
ECMO Cannula

46. Case 12: 25-yo
with Traumatic
Pulmonary
Hemorrhage

47. Case 12: 25-yo
with Traumatic
Pulmonary
Hemorrhage
V-V ECMO
RIJ Dual-Lumen
ECMO Cannula Suction
Port
Reinjection
Port
Suction
Port

48. Case 12: 25-yo
with Traumatic
Pulmonary
Hemorrhage
Abdominal View

49. Case 12: 25-yo
with Traumatic
Pulmonary
Hemorrhage
V-V ECMO
Tip of RIJ Dual-Lumen
ECMO Cannula
Suction
Port
Reinjection
Port
Suction
Port
Abdominal View
Right IJ Access

50. Case 13: 66-yo
with Acute on
Chronic Heart
Failure

51. Case 13: 66-yo
with Acute on
Chronic Heart
Failure
V-A ECMO
Tip Of Venous
ECMO Cannula

52. If You Have Interesting Cases Demonstrating ECMO Devices We Invite You To
Send A Set Of Digital PDF Images And A Brief Clinical History To:
michael.gibbs@atriumhealth.org
Your De-Identified Case(s) Will Be Posted On Our Education Website And You
And Your Institution Will Be Recognized!

53. Selected Embedded References:
Banfi C, Pozzi M, Siegenthaler N, Brunner ME, Tassaux D, Obadia JF, Bendjelid K,
Giraud R. Veno-venous extracorporeal membrane oxygenation: cannulation
techniques. J Thorac Dis. 2016 Dec;8(12):3762-3773. doi: 10.21037/jtd.2016.12.88.
PMID: 28149575; PMCID: PMC5227239.
Krieger J, Badulak J. The Use of ECMO in Patients with Cardiopulmonary Failure Due
to COVID-19. American College of Cardiology. 2020 Aug 4.

54. See You Next Month!