Extracorporeal membrane oxygenation (ECMO) is one type of extracorporeal life support for patients with cardiopulmonary failure. ECMO may serve as a as bridge to recovery, long-term mechanical support, or transplantation. In patients with isolated respiratory failure, veno-venous (VV) ECMO is the preferred modality, whereas in patients with isolated cardiac or combined cardiopulmonary failure, veno-arterial (VA) ECMO is generally the preferred modality.

At many centers, the preferred technique for institution of ECMO is via peripheral vascular access, as opposed to central access, and this is often done percutaneously. Peripheral cannulation can allow rapid institution of ECMO with minimal morbidity. Although in the majority of patients, peripheral ECMO provides adequate support, there are certain instances in which isolated VA or VV ECMO support may not be sufficient. Some of these instances arise from limitations of peripheral ECMO, such as peripheral vessels potentially limiting the size of cannulae, recirculation of oxygenated blood in VV ECMO, competition with native cardiac output in VA ECMO, and the inability to capture the entire cardiac output. In these situations, modifications or alternative strategy may be required. Before modifying the mechanical support strategy, efforts should be made to manage the situation by optimizing medical management and maximizing the existing platform. This includes the management of refractory hypoxia for patients on VV-ECMO (eg, beta blockade, paralysis, proning, etc) as well as adequate left ventricular decompression for patients on VA ECMO (eg, volume removal, direct left ventricular or left atrial drainage, atrial septostomy, etc).