Mitigating limb ischemia in veno-arterial extracorporeal membrane oxygenation: A narrative review of evolving role of distal perfusion catheters

Table 3 Strategies for distal perfusion catheter insertion in veno-arterial extracorporeal membrane oxygenation with patient-profile guidance

DPC strategy	Definition	Ideal patient profile	Rationale
Upfront prophylactic	DPC placed at the time of arterial cannulation before any ischemic signs appear	(1) High-risk anatomy (small femoral artery, PAD, diabetes); (2) Large-bore arterial cannula (≥ 19-21 Fr); (3) Anticipated prolonged VA-ECMO run; (4) Obesity or difficult future access; and (5) History of limb ischemia or prior ECMO-related ALI	Prevents early ischemia, avoids emergent intervention, stabilizes distal perfusion from the outset
Selective monitored	No initial DPC; limb is closely monitored with predefined triggers for insertion	(1) Low-to-moderate ischemia risk; (2) Adequate femoral artery size; (3) Short ECMO duration expected; (4) Reliable monitoring available (NIRS, Doppler, serial exams); and (5) Percutaneous cannulation with minimal vascular trauma	Avoids unnecessary DPC placement while enabling timely intervention when early ischemic changes develop
Rescue	DPC inserted only after acute limb ischemia has already developed	(1) Rapidly progressive or established ischemia; (2) Late presenters without prior prophylactic DPC; (3) Cannula-related complications (malposition, thrombosis, dissection); and (4) Emergent ECMO cannulation where prophylaxis was not feasible	Salvage strategy to restore perfusion and prevent irreversible tissue injury, often combined with additional vascular procedures

DPC: Distal perfusion catheter; PAD: Peripheral arterial disease; ECMO: Extracorporeal membrane oxygenation; ALI: Acute limb ischemia; NIRS: Near-infrared spectroscopy.