Extracorporeal membrane oxygenation in infants with congenital diaphragmatic hernia: Follow-up MRI evaluating carotid artery reocclusion and neurologic outcome

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 extracorporeal 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.