Acute limb ischemia (ALI) remains one of the most common complications of peripheral veno-arterial extracorporeal membrane oxygenation (V-A ECMO). Across heterogeneous cohorts, reported ALI rates vary widely (≈8–30% and higher in selected series), reflecting differences in patient selection, cannulation technique, and monitoring practices. Despite mounting observational and meta-analytic evidence, there is still no unified, evidence-graded guidance on when and how to use a distal perfusion cannula (DPC). How to size, connect, monitor adequacy, and how to adapt protocols when V-A ECMO is combined with femoral Impella (ECPELLA). Figure 1 shows the common DPC orientation.

Evidence currently associates prophylactic DPC or the use of smaller-bore arterial return cannulae with lower odds of limb ischemia. Random-effects meta-analysis studies report risk reductions of ~60% with prophylactic DPC and ~60% with smaller return cannulae [2, 5]. Single-center and registry studies reinforce these findings and highlight the multifactorial nature of ALI (artery size relative to cannula, sex, age, atherosclerotic burden, shock severity, vasopressor dose, and decannulation technique).