Cerebral Perfusion After Repair of Congenital Diaphragmatic Hernia with Common Carotid Artery Occlusion After ECMO Therapy

Abstract

Abstract. Aim: To prospectively evaluate cerebral perfusion after repair of congenital diaphragmatic hernia (CDH) and right-common-carotid-artery (rCCA) Congenital diaphragmatic hernia (CDH) occurs in approximately one in 3,000-4,000 live births (1). A defect of the diaphragm leads to herniation of abdominal organs into the thoracic cavity. Lung hypoplasia and secondary pulmonary hypertension are the major causes of death (2). The implementation of new therapeutic strategies has improved the survival rate even in those patients with severe CDH (3). If conservative treatment in newborns with CDH fails, extracorporeal membrane oxygenation (ECMO) therapy is an important alternative for accomplishing sufficient oxygenation of the newborns. The Congenital Diaphragmatic Hernia Study Group showed an improved survival rate in patients with CDH after ECMO therapy, in whom, without ECMO, mortality was predicted to be higher than 80% (4). As a consequence, morbidity plays an increasing role in patients with CDH. Not only pulmonary problems but also neurological disorders have been identified as significant morbidities among CDH survivors (5, 6). In a study by McGahren et al., 8/12 (67%) ECMO survivors showed delayed neurological development compared to only 5/21(24%) of the non-ECMO-treated survivors.In CDH, veno-arterial ECMO is usually performed. Vascular access is usually achieved by insertion of the ECMO cannulas through the right common carotid artery (rCCA) and the right internal jugular vein. At the time of decannulation, ligation or surgical reconstruction of the rCCA can be performed but secondary occlusion of the surgical reconstructed rCCA can occur (7). Büsing et al. investigated 2-year-old children with history of CDH and reconstruction of the rCCA after ECMO therapy. Their study showed that in 72% of the patients, the rCCA was found to be occluded or highly stenotic using contrast-enhanced magnetic resonance angiography (7). Using Doppler ultrasound in 5-year-old patients, Desai et al. reported that most of the reconstructed rCCAs after ECMO therapy were patent and in only 24% of the patients there was significant 557

ECMO in neonates: The association between cerebral hemodynamics with neurological function

“…The brain perfusion could be maintained by the anterior and posterior communicating arteries or extracranial collateral vessels despite stenosis or occlusion after the RCCA reconstruction. The extracranial collateral vessels were mainly filled by the right internal carotid artery with the thyrocervical trunk, the right external carotid artery and the occipital artery ( 33 ), which may be similar to permanent ligation of the RCCA.…”

White Matter Integrity Differences in 2-year-old Children Treated with ECMO: A Diffusion-Weighted Imaging Study

“…This study incorporates 56 children (mean age at measurement: 25.88 months, SD = 5.52 months) suffering from CDH, which were investigated in our institution according to the local follow-up program including MRI [25; 26]. All children born between 2011 and 2017 in whom the conventional MRI and DWI measurements were of diagnostic quality were considered for inclusion.…”

ECMO utilization in infants with congenital diaphragmatic hernia in the USA

“…Besides the high mortality rates associated with ECMO, it also carries an increased risk for morbidities, such as poorer neurodevelopmental outcomes, [7][8][9] hearing loss, 7 hemorrhagic and thrombotic complications, 10 sacrifice of a common carotid artery, 11 renal impairment, 12 infections 13 and growth failure. 14 Given such burden, it is essential to understand national trends in ECMO use, to understand costs and to reevaluate the risk factors for ECMO use in neonates with CDH.…”