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Extracorporeal Membrane Oxygenation in Infants with Congenital Diaphragmatic Hernia: Follow-Up MRI Evaluating Carotid Artery Reocclusion and Neurologic Outcome

¹ Department of Clinical Radiology, University Hospital Mannheim, University of Heidelberg, Theodor Kutzer Ufer 1-3, Mannheim 68167, Germany.
² Department of Pediatrics, University Hospital Mannheim, University of Heidelberg, Mannheim, Germany.
³ Department of Pediatric Surgery, University Hospital Mannheim, University of Heidelberg, Mannheim, Germany.

OBJECTIVE. The purpose of our study was to prospectively assess, using MRI and MR angiography, the cerebral and vascular status of 2-year-old children with congenital diaphragmatic hernia (CDH) in whom carotid artery reconstruction was performed after neonatal extra-corporeal membrane oxygenation (ECMO) therapy and to compare the neurologic development of children with vascular reocclusion with that of CDH children with successful repair and with non-ECMO controls.

SUBJECTS AND METHODS. A total of 30 infants (17 boys, 13 girls; 2 ± 0.26 years) were included. Of these, 18 (60%) infants received arteriovenous ECMO therapy with subsequent reconstruction of the right common carotid artery (RCCA). Two years postoperatively, the children were examined with cerebral MRI, including 3D time-of-flight and contrast-enhanced 3D MR angiography of the intra- and extracranial brain-supplying arteries. The pathologic findings were analyzed for the ability to predict impaired neurologic development.

RESULTS. The RCCA was occluded or highly stenotic in 13 (72%) of 18 children. All infants showed intra- and extracranial collaterals and a patent internal carotid artery. The average duration of ECMO was not longer than in cases of successful reconstruction (p =1). The ECMO group showed a significantly greater incidence of cerebral injuries (p = 0.007) but no relevant impairment in neurologic development compared with controls (p = 0.26). Unsuccessful RCCA repair had no predictive value for a poor neurologic outcome (p =1).

CONCLUSION. The outcome of RCCA repair after ECMO is possibly poorer than expected, with vascular occlusion or high-grade stenosis occurring in almost three quarters of patients. Although reocclusion of the RCCA does not increase the risk for cerebral lesions or an impaired neurologic development during the first 2 years postoperatively, the overall benefit of RCCA repair remains doubtful, and the potential long-term risk arising from these plaques has yet to be assessed.

Keywords: carotid artery • congenital diaphragmatic hernia • extracorporeal membrane oxygenation therapy • MR angiography

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