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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
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.
Visit Our Website
www.EMGuidewire.com
For A Complete Archive Of Imaging Presentations And Much More!
Airway
Bones
Cardiac
Diaphragm
Effusion
Foreign body
Gastric
Hilum
It’s All About The Anatomy!
Extracorporeal Membrane Oxygenation
ECMO Basics
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
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.
Extracorporeal Membrane Oxygenation
V-V ECMO
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
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.
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.
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.
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.
Extracorporeal Membrane Oxygenation
V-A ECMO
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
Figure 5: V-A ECMO
Central venous blood is drained and
oxygenated blood is returned to the
arterial system.
Extracorporeal Membrane Oxygenation
Cases From Carolinas Medical Center
Case 1: 50-yo in
Cardiogenic
Shock
Tip Of Venous
ECMO Cannula
V-A ECMO
Case 1: 50-yo in
Cardiogenic
Shock
Case 2: 55-yo
with a Large
Tracheal
Laceration
Tip of Reinjection
Cannula
V-V ECMO
Case 2: 55-yo
with a Large
Tracheal
Laceration
Case 3: 28-yo
with a Severe
Asthma
Exacerbation
Case 3: 28-yo
with a Severe
Asthma
Exacerbation
Dual-Lumen RIJ
ECMO Cannula
V-V ECMO
Suction
Port
Reinjection
Port
Case 4: 47-yo in
Cardiogenic
Shock
Tip Of Venous
ECMO Cannula
V-A ECMO
Case 4: 47-yo in
Cardiogenic
Shock
Test yourself!
Cases From Carolinas Medical Center
Case 5: 59-yo In
Cardiogenic
Shock
Tip of Venous
ECMO Cannula
V-A ECMO
Case 5: 59-yo In
Cardiogenic
Shock
Case 6: 30-yo
with Necrotizing
Pneumonia after
Trauma
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
Case 7: 64-yo in
Cardiogenic
Shock
V-A ECMO
Tip Of Venous
ECMO Cannula
Case 7: 64-yo in
Cardiogenic
Shock
Case 8: 70-yo
with a Massive
PE s/p tPA
V-A ECMO
Case 8: 70-yo
with a Massive
PE s/p tPA
Tip Of Venous
ECMO Cannula
Case 9: 49-yo
with Post-Op
Pulmonary
Edema
Case 9: 49-yo
with Post-Op
Pulmonary
Edema
Tip of Reinjection
Cannula
V-V ECMO
Case 9: 49-yo
with Post-Op
Pulmonary
Edema
Abdominal View
Case 9: 49-yo
with Post-Op
Pulmonary
Edema
Tip of Suction
Cannula
V-V ECMO
Abdominal View
Right Femoral Vein Access
Case 10: 37-yo
with Pulmonary
Contusions after
an MVC
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
Case 11: 48-yo
with a Saddle PE
s/p tPA
Case 11: 48-yo
with a Saddle PE
s/p tPA
V-A ECMO
Tip Of Venous
ECMO Cannula
Case 11: 48-yo
with a Saddle PE
s/p tPA
Abdominal View
V-A ECMO
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
Case 12: 25-yo
with Traumatic
Pulmonary
Hemorrhage
Case 12: 25-yo
with Traumatic
Pulmonary
Hemorrhage
V-V ECMO
RIJ Dual-Lumen
ECMO Cannula Suction
Port
Reinjection
Port
Suction
Port
Case 12: 25-yo
with Traumatic
Pulmonary
Hemorrhage
Abdominal View
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
Case 13: 66-yo
with Acute on
Chronic Heart
Failure
Case 13: 66-yo
with Acute on
Chronic Heart
Failure
V-A ECMO
Tip Of Venous
ECMO Cannula
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!
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.
See You Next Month!

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Medical Device Imaging Mastery Project #4: 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!
  • 5. It’s All About The Anatomy!
  • 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.
  • 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.
  • 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!