Extracorporeal membrane oxygenation (ECMO) in COVID-19 patients: a pocket guide for radiologists

Abstract

During the coronavirus disease 19 (COVID-19) pandemic, extracorporeal membrane oxygenation (ECMO) has been proposed as a possible therapy for COVID-19 patients with acute respiratory distress syndrome. This pictorial review is intended to provide radiologists with up-to-date information regarding different types of ECMO devices, correct placement of ECMO cannulae, and imaging features of potential complications and disease evolution in COVID-19 patients treated with ECMO, which is essential for a correct interpretation of diagnostic imaging, so as to guide proper patient management.

Keywords: Acute respiratory distress syndrome (ARDS); Computed tomography; Coronavirus disease 19 (COVID-19); Extracorporeal membrane oxygenation (ECMO); Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2); X-ray.

Fig. 1

Chest radiographs (antero-posterior view) showing a correct placement of VV-ECMO, b correct placement of femorofemoral ECMO, c correct placement of double lumen ECMO, d incorrect placement of femorofemoral ECMO. The tip of the drainage cannula (arrow) is too close to the tip of the return cannula

Fig. 2

Chest radiographs a before and b after ECMO placement, showing correct placement of cannulae and complete whiteout of both lungs. c Chest radiographs performed at day 9 showing improvement in lung aeration and d) performed after ECMO removal, respectively

Fig. 3

a Chest radiograph showing right pneumothorax. b Chest radiograph and c axial CT image showing pneumomediastinum, left pneumothorax and left subcutaneous emphysema

Fig. 4

Axial CT image demonstrating bilateral lung consolidation in a COVID-19 patient with New Delhi Metallo-β-Lactamase (NDM)-producing Klebsiella pneumoniae

Fig. 5

Axial CT image showing intraventricular hemorrhage in a COVID-19 patient with ECMO

Fig. 6

a Precontrast chest CT image showing hemopneumothorax in a COVID-19 patient with ECMO, rapidly decreasing hemoglobin level and hypotension. Post-contrast CT images in the b arterial (arrow) and c venous phase show active bleeding (arrow)

Fig. 7

Contrast-enhanced CT showing active bleeding fed from branches of the right superior thyroid artery [a, axial image (arrow), b, maximum intensity projection (MIP) view (arrow)]

Fig. 8

Thromboembolic complications detected incidentally on CT examinations of COVID-19 patients treated with VV-ECMO. a Coronal reformatted CT image of a patient with VV-ECMO and thrombosis of the superior mesenteric vein extending to several jejuno-ileal branches. b Axial CT image of a patient with thrombosis of the right internal jugular vein, in whom VV-ECMO had been removed two days earlier. c CT pulmonary angiography examination showing pulmonary embolism (arrows) at the posterior and anterior segments of the right lower lobe

Fig. 9

Potential abdominal complications of COVID-19 in patients treated with VV-ECMO. a Axial CT image shows diverticulitis complicated by a peridiverticular abscess with covered bowel perforation (arrow). b Axial CT image obtained in a patient with multiple organ failure and suspected abdominal bleeding. Notice initial swelling of both kidneys with loss of cortico-medullary differentiation. c Axial CT image obtained in a patient with peripancreatic fluid collections from acute pancreatitis