Venoarterial extracorporeal membrane oxygenation (V-A ECMO) is a technique used to provide short-term circulatory and respiratory support in patients with refractory cardiogenic shock and cardiac arrest who do not respond to conventional therapies. Due to its increased use in recent years, a thorough understanding of its pathophysiological effects, indications, monitoring, and clinical management is required. The present review provides a practical update on the management of adult patients receiving V-A ECMO support, covering hemodynamic effects on the native circulation, cannulation strategies, multimodal monitoring, and therapeutic goals in the different support phases. In addition, the main associated complications, escalation strategies, weaning criteria, and organizational aspects essential to ensuring safe and effective care are reviewed. Finally, this review discusses the ethical considerations inherent in the use of this complex therapy. This integrative and clinically oriented approach aims to support decision-making in Intensive Care Units managing highly complex patients.