Published online Sep 9, 2026. doi: 10.5492/wjccm.120664
Revised: April 2, 2026
Accepted: April 24, 2026
Published online: September 9, 2026
Processing time: 175 Days and 19.5 Hours
Acute limb ischemia (ALI) is a serious complication of femoral artery cannulation during peripheral veno-arterial extracorporeal membrane oxygenation (VA-ECMO), with reported incidence rates approaching 17%. Although several contributing factors have been described, the fundamental problem is reduced arterial flow distal to the cannulation site, often worsened by systemic vasoconstriction. Distal perfusion catheters (DPC) are the most widely used strategy to prevent this, but the optimal device, technique, and timing remain uncertain due to limited evidence. Early detection with near-infrared spectroscopy, along with emerging approaches such as bidirectional cannulas and artificial intelligence-based prediction tools, may improve prevention and management. This narrative review brings together current evidence on ALI in peripheral VA-ECMO and places particular emphasis on contemporary techniques for DPC placement with practical monitoring.
Core Tip: Acute limb ischemia (ALI) is a major complication of femoral veno-arterial extracorporeal membrane oxygenation (VA-ECMO), driven primarily by impaired distal arterial flow and systemic vasoconstriction. Distal perfusion catheters (DPC) are the most commonly used preventive strategy, though optimal device choice, technique, and timing remain uncertain. Early monitoring with near-infrared spectroscopy and emerging tools such as bidirectional cannulas and artificial intelligence-based prediction models may further reduce risk. This review synthesizes current evidence on ALI in peripheral VA-ECMO and provides clear pictorial depictions of the pathophysiology, available methods, and contemporary techniques for DPC placement and practical monitoring.