Peripheral veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) cannulation in children poses a significant clinical challenge due to wide variations in body size, vessel caliber, and risk profiles.

This literature review examines current cannulation practices in pediatric patients.

The study analyzed large datasets from the Extracorporeal Life Support Organization (ELSO) registry, focusing on neurologic and limb complications associated with carotid versus femoral artery use.

Despite general recommendations favoring carotid cannulation in children under 15–20 kg and femoral access in larger, ambulatory patients, ELSO data show a persistent reliance on carotid cannulation even in older children. In four major ELSO studies, carotid use ranged from 45% to 94% among children over 5 years of age. Neurologic complication rates varied widely, from 7% to 23%, with some studies linking carotid access to higher risk of CNS injury, while others found no significant difference. Femoral cannulation, although theoretically safer neurologically, carried notable risks of limb ischemia—reported between 7.5% and 20%—and potential need for vascular interventions or amputations.

This review highlights the lack of standardized practice and the influence of local expertise, anatomical variability, and data limitations. It also underscores the need for clearer definitions and better reporting in future studies. While carotid cannulation remains prevalent across age groups, growing evidence of limb complications with femoral access invites reconsideration of the “transition point” in pediatric ECMO cannulation strategies. Until more definitive data emerge, individualized decision-making guided by patient characteristics and institutional experience remains essential.