CTICasesVeno-Arterial ECMO Flow Patterns
Imaging findings
CT in a patient with cardiac arrest on veno-arterial (VA) ECMO demonstrates contrast material layering in the vena cava, right atrium, and coronary sinus, completely skipping the non-functioning heart, with a contrast-fluid level and smoke in the ascending and descending aorta. Retrograde arterial flow from the femoral artery cannula perfuses the descending aorta, while the upper extremity/arch vessels show variable contrast dilution from competing unopacified blood if there is any residual left ventricular function.
Key takeaways
Veno-arterial (VA) ECMO provides cardiopulmonary support by draining venous blood and pumping oxygenated blood retrogradely into the arterial system (typically femoral artery). This retrograde flow competes with the heart's forward ejection, which can create a watershed area in the aortic arch. If the lungs are injured and the LV is functioning, deoxygenated blood is ejected forward to the brain/upper body while oxygenated ECMO blood perfuses the lower body (Harlequin syndrome or North-South syndrome).
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