Published online Sep 9, 2026. doi: 10.5492/wjccm.120664
Revised: April 2, 2026
Accepted: April 24, 2026
Published online: September 9, 2026
Processing time: 175 Days and 19.5 Hours
Acute limb ischemia (ALI) is a serious complication of femoral artery cannulation during peripheral veno-arterial extracorporeal membrane oxygenation (VA-ECMO), with reported incidence rates approaching 17%. Although several contributing factors have been described, the fundamental problem is reduced arterial flow distal to the cannulation site, often worsened by systemic vasoconstriction. Distal perfusion catheters (DPC) are the most widely used strategy to prevent this, but the optimal device, technique, and timing remain uncertain due to limited evidence. Early detection with near-infrared spectroscopy, along with emerging approaches such as bidirectional cannulas and artificial intelligence-based prediction tools, may improve prevention and management. This narrative review brings together current evidence on ALI in peripheral VA-ECMO and places particular emphasis on contemporary techniques for DPC placement with practical monitoring.
Core Tip: Acute limb ischemia (ALI) is a major complication of femoral veno-arterial extracorporeal membrane oxygenation (VA-ECMO), driven primarily by impaired distal arterial flow and systemic vasoconstriction. Distal perfusion catheters (DPC) are the most commonly used preventive strategy, though optimal device choice, technique, and timing remain uncertain. Early monitoring with near-infrared spectroscopy and emerging tools such as bidirectional cannulas and artificial intelligence-based prediction models may further reduce risk. This review synthesizes current evidence on ALI in peripheral VA-ECMO and provides clear pictorial depictions of the pathophysiology, available methods, and contemporary techniques for DPC placement and practical monitoring.
- Citation: Karan N, Patnaik R, Pattanaik SS, Vijayakumar A, Ravinbothayan S, Behera S, Panda C, Barakat M, Meshram A, Samal S, Chawla A. Mitigating limb ischemia in veno-arterial extracorporeal membrane oxygenation: A narrative review of evolving role of distal perfusion catheters. World J Crit Care Med 2026; 15(3): 120664
- URL: https://www.wjgnet.com/2220-3141/full/v15/i3/120664.htm
- DOI: https://dx.doi.org/10.5492/wjccm.120664
Extracorporeal membrane oxygenation (ECMO) is a modified cardiopulmonary bypass circuit providing support to failing organs like heart and lungs, outside the human body. There are primarily 2 types of ECMO configurations namely veno-arterial ECMO (VA-ECMO) and veno-venous ECMO (VV-ECMO). VA-ECMO is a form of temporary mechanical circulatory support for patients with cardiogenic shock. With time, the indications of using VA-ECMO have expanded[1]. The cannulation for VA-ECMO can be done either by percutaneous method or surgical method. In settings of non- cardiotomy shock, femoral vessels have gained preference, in view of the emergent nature of most cardiac shock scena
Most VA-ECMO cohorts report ALI occurring in 20%-30% of patients with femoral cannulation, very similar to Gulkarov et al[3] who reported it in 19.7 % of patients[3,4]. However, a recent systematic review and metanalysis by Guo et al[5] reported a pooled incidence of ALI in VA-ECMO patients as 16.9 %. The incidence of ALI necessitating limb amputation is approximately 1%[6,7]. The prognostic implications of limb ischemia were studied by Gulkarov et al[3] who demonstrated that ALI is an independent predictor of in hospital and mid-term mortality. A systematic review by Marbach et al[8] suggested the routine placement of a distal perfusion catheter (DPC) and use of a small-bore arterial cannula reduced incidence of ALI but did not affect overall mortality.
According to several studies, patients with ALI had similar survival to discharge rates compared to those without vascular complications, often due to the success of early salvage interventions like placement of DPC, fasciotomy and others[9,10]. However, this may suggest that the primary cardiac pathology is the dominant driver of mortality in the acute phase. The purpose of this narrative review is to concisely evaluate current evidence on ALI in VA-ECMO and highlight the emerging role of DPC in its prevention.
A comprehensive literature search was performed using the PubMed/MEDLINE database covering the period from January 2010 to February 2026. Search terms included combinations of “extracorporeal membrane oxygenation”, “ECMO”, “veno-arterial ECMO”, “limb ischemia”, “acute limb ischemia”, “distal perfusion catheter”, “distal limb perfusion”, “vascular complications”, “femoral cannulation”, “perfusion monitoring”, and related terms. Boolean operators and MeSH terms were used where applicable to refine the search.
We included English-language publications reporting on adult patients undergoing peripheral VA-ECMO with documented limb ischemia, limb-perfusion monitoring, or DPC-related interventions. Priority was given to multicenter studies, randomized controlled trials, systematic reviews, consensus statements, and large observational cohorts. Case reports and small case series were included only when they described novel DPC techniques, innovative monitoring strategies, or unique presentations of limb ischemia. Exclusion criteria included non-English publications, abstract-only reports, conference proceedings without full manuscripts, and studies focused exclusively on non-ECMO vascular pathology.
A narrative review approach was selected to allow integration of heterogeneous study designs, evolving clinical practices, and emerging technologies in limb-protection strategies during VA-ECMO, rather than pursuing a quantitative synthesis that would be limited by variability in study methodology and outcome definitions.
While the immediate impact of mortality may be masked by confounding risk factors of primary disease severity and high mortality, the long-term consequences of limb ischemia are profound. Retrospective analysis by Nejim et al[11] in a single center study over 10 years revealed that patients who developed ALI had significantly lower 4-year survival rates (46.8% vs 65.1%). After adjusting for age, comorbidities and severity of illness, the development of ALI increased the 4-year mortality hazard by 80% (hazard ratio 1.80). This suggests that ALI is not merely a treatment complication but a systemic insult that correlated with a higher risk of late cardiovascular events and permanent disability[11].
Various pathophysiological and procedural factors interact to cause ALI during femoral cannulation, primarily by obstr
| Risk factor category | Specific risk factor | Pathophysiological impact and mechanism of ischemia | Ref. |
| Demographic factors | Younger age | Younger patients often have smaller femoral artery diameters and a paucity of collateral circulation, making them more susceptible to luminal obstruction by large cannulas. They may also be more prone to reactive vasospasm | Foley et al[12] |
| Female sex | Women generally have smaller arterial diameters than men, which may increase the risk of flow compromise when large cannulas are used | Kim et al[13] | |
| Comorbidities | Peripheral arterial disease | Pre-existing atherosclerosis increases the risk of plaque dislodgement and distal embolism during cannulation. Diseased vessels are also more prone to dissection during the procedure | Yau et al[14], Liao et al[15], Zimpfer et al[16] |
| Diabetes mellitus | Chronic microvascular disease and endothelial injury in diabetic patients likely impair the limb's ability to compensate for hypoperfusion, especially in low-flow states | Hu et al[17] | |
| Chronic pulmonary disease (COPD/bronchial asthma) | Associated with an inflammatory state that induces endothelial damage and is often linked to subclinical or undiagnosed atherosclerotic plaque burden | Yau et al[14] | |
| Procedural/mechanical factors | Arterial cannula size | Large-bore cannulas cause mechanical obstruction of the femoral artery, significantly reducing or completely blocking antegrade blood flow to the distal limb | Lunz et al[10] |
| Absence of distal perfusion | Without an antegrade distal perfusion catheter, the limb remains dependent on collateral flow which is often insufficient to overcome the cannula-related obstruction | Lamb et al[6] | |
| IABP co-insertion | Concurrent use of an intra-aortic balloon pump often requires bilateral femoral cannulation, compounding the risk of arterial obstruction and distal malperfusion | Hu et al[17] | |
| Cannulation setting (bedside vs OR) | Bedside/ICU cannulations, often performed during active resuscitation (ECPR), are associated with higher risks of vascular injury, hematomas, and suboptimal placement compared to the controlled OR environment. | Son et al[2] | |
| Clinical/hemodynamic status | High VIS-max | High doses of vasopressors induce peripheral vasoconstriction, which, when superimposed on mechanical cannula obstruction, critically impairs distal tissue perfusion | Hu et al[17] |
| Low baseline perfusion | Lower baseline tissue oxygenation (rSO2) values prior to cannulation may indicate pre-existing vascular optimization needs or heightened sensitivity to flow changes | Coelho et al[18] |
A study by Hu et al[17] consolidates type 2 diabetes mellitus as an independent risk factor for ALI in the VA ECMO population. A retrospective review of 154 patients by Yau et al[14] identified diabetes and peripheral arterial disease as significant multivariate predictors of limb ischemia.
Diabetic patients are often characterized by presence of endothelial dysfunction and impaired collateral circulation making the distal tissues highly vulnerable to perfusion. These group of patients are at high risk for dislodgement of calc
The impact of age on limb ischemia is multifactorial. Some studies have identified younger age as a predictor for ALI, theorizing that younger patients have smaller arterial diameters and impaired collateral circulation, making them more prone to occlusion[12,14,16]. However, no studies have specifically looked into the common femoral artery (CFA) and cannula diameter in leg ischemia[13].
Female sex has also emerged as an independent risk factor for vascular complications (odds ratio 1.82) potentially due to smaller average vessel sizes compared to male counterparts[19].
Early observational data by Lunz et al[10] demonstrated that ischemia related vascular complications during VA ECMO by femoral cannulation are strongly influenced by the underlying indication, and size of cannula. The groups of post cardiotomy cardiogenic shock and acute myocardial infarction (AMI) related cardiogenic shock showed the highest rates of limb ischemia and vascular complications. The higher incidence reflects global circulatory failure rather than just local arterial obstruction due to cannulation[2,10].
Multiple studies report higher vascular complication rates in the extracorporeal cardiopulmonary resuscitation (ECPR) ECMO vs non-ECPR ECMO groups[18-20]. The higher incidence of ALI in this group can be attributed to emergent nature of cannulation, which are often traumatic and not guided by ultrasound. The concurrent use of an intra-aortic balloon pump (IABP) has been identified as an independent risk factor, likely due to the mechanical obstruction of the femoral and iliac arteries and the disruption of aortic flow patterns[17]. On the contrary, Lunz et al[10] reported lower incidence of ALI in the ECPR group. Plausible reasons for such findings could be attributed to younger age of patients and shorter duration of ECMO support.
The intensity of resuscitation and the level of pharmacological support serve as proxies for the risk of ALI. Higher peak vasoactive-inotropic score max within the first 24 hours is strongly associated with ischemic events, reflecting the impact of vasopressor induced peripheral shutdown[17].
Wang et al compared cannulation techniques in adult patients receiving VA-ECMO and concluded that patients receiving peripheral cannulation were associated with fewer complications but the peripheral cannulation was associated with higher incidence of ALI, but significant association could not be established in multivariate analysis[9]. Son et al[2] focused on the place of cannulation and techniques of cannulation and studied the incidence of ALI and bleeding in patients requiring VA-ECMO. A univariate analysis identified that operating room cannulation was associated with lower incidence of ALI. Zimpfer et al[16] studied late vascular complications in patients receiving VA-ECMO and identified the presence of technical problems during ECMO and previous presence of peripheral vascular disease as independent predictors for the same.
The ‘standard’ DPC technique involves placement of a 5 Fr to 8 Fr wire reinforced catheter into the superficial femoral artery (SFA) ipsilateral to the femoral arterial cannula, either by open or percutaneous technique to establish antegrade flow to the lower extremity (Figure 1). DPCs typically rely on a side port of the arterial cannula to draw oxygenated blood, which is then delivered through a short extension segment, usually about six inches long, connected to an intervening three-way stopcock that allows routine flow assessment and the option to administer arterial vasodilators. These catheters come in a wide range of 5-14 Fr sizes, though in practice the most frequently used devices are central venous catheters or vascular introducer sheaths, generally 6-8 Fr, because they are easy to place and provide adequate distal flow.
The DPC should be positioned below the arterial cannula. When an arterial cannula is used together with a percu
Extracorporeal life support organization (ELSO) guidelines recommend puncture for the DPC in the CFA below the arterial cannula but above the bifurcation and guided into the SFA[1]. The use of ultrasound guidance is emphasized. Size recommended is a short 6-8 Fr reinforced cannula, connected to the arterial cannula vent port. Flows in the DPC should ideally reach at least 100 mL/minute, and placement at the time of ECMO initiation helps prevent delays that increase the risk of limb ischemia.
The SFA is the main conduit of blood flow to the lower leg and foot. When VA-ECMO cannulation compromises flow in the CFA, the SFA becomes the vessel whose perfusion is most at risk. Delivering oxygenated blood into the SFA through a DPC directly restores flow to the distal limb precisely where ischemia develops (Figure 2).
In contrast, the DFA, also called as the profunda femoris artery, primarily supplies the thigh musculature, not the lower leg. Although it has collateral branches, anatomically these may be insufficient to reliably perfuse the calf and foot during ECMO-related obstruction. A DPC placed in the DFA may show good flow on monitoring but may fail to protect the distal limb, and may allow ischemia to progress despite apparently adequate perfusion. Thus, care should be exercised to ensure the DPC is not inadvertently inserted into the DFA, as this vessel terminates in the thigh.
Hu et al[17] suggested a 4S approach to mitigate limb ischemia complications in patients on VA-ECMO. 4S approach includes appropriate site of cannulation, optimum size of cannula, systemic evaluation post cannulation for signs of ischemia and timely salvage interventions for early ischemia. In a study by Yau et al[14], routine placement of DPCs did not affect the incidence of limb ischemia. This may be attributed to the fact that the sample who received routine DPCs was quite small to affect the overall outcome.
Lamb et al[6] studied adult patients greater than 18 years requiring VA-ECMO by percutaneous peripheral cannulation and established an arterial protocol which included routine placement of a DPC into the proximal SFA at the time of cannulation, continuous monitoring with near-infrared spectroscopy (NIRS) and open repair during decannulation. In this study, the routine DPC placement was associated with zero ischemic events, while therapeutic DPC placement in patients developing limb ischemia led to resolution of symptoms and return to preischemic values on NIRS tracings.
Monitoring of limb ischemia in VA-ECMO is best done with a multi-faceted approach (Figure 3).
The six aspects of vascular assessment, namely pulse, pallor, pain, paraesthesia, paralysis, and poikilothermia should be evaluated hourly by bedside personnel[21]. In patients supported with VA-ECMO, however, the reliability of these clinical indicators is often limited due to several confounding factors, including limb edema, jaundice, deep sedation, neuromuscular blockade, analgesia, vasopressor therapy, and the use of therapeutic hypothermia (Figure 4).
Assessment of flow through the DPC should be performed by direct visualization of blood movement at the catheter hub, commonly facilitated by transillumination. In addition, hourly inspection for catheter kinking, obstruction, or thrombus formation is recommended to ensure uninterrupted distal limb perfusion.
NIRS is currently regarded as an important modality for continuous, non-invasive monitoring of regional tissue oxygen saturation (rSO₂) in patients on VA-ECMO[18,22]. Normal rSO₂ values typically range from 60% to 75%. Observational studies have shown that an absolute rSO₂ value below 40%-50% has been associated with critical limb hypoperfusion. Furthermore, an inter-limb rSO₂ difference exceeding 15% is suggestive of cannula-related mechanical obstruction[23]. A reduction of 25% or more from baseline rSO₂ values may indicate evolving limb ischemia or a decline in systemic perfusion. ELSO guidelines recommend tissue oxygen saturation measured by NIRS should remain above 50%, ideally closer to 60%, and the inter-limb rSO₂ difference should not exceed 20%. However, validated universal cut-offs are unavailable and center-specific NIRS triggers for rSO₂ values should be incorporated as per patient context.
Bedside angiography using the reperfusion line: Bedside angiography may be performed by injecting iodinated contrast through the DPC, allowing real-time visualization of the superficial femoral and popliteal arteries using a portable X-ray system equipped with a flat-panel detector positioned beneath the affected limb[24]. This technique mitigates the risks associated with transporting critically ill patients on VA-ECMO to the catheterization laboratory.
Comprehensive ultrasound modalities: Advanced ultrasound techniques, including shear wave elastography (SWE) and contrast-enhanced ultrasound (CEUS), have emerged as adjunctive tools for evaluating limb perfusion. SWE enables quantification of tissue stiffness and has been shown to identify microcirculatory abnormalities in the medial gastrocnemius muscle that may not be detected by NIRS. However, published evidence supporting the use of CEUS for assessing ALI in patients on VA-ECMO is essentially lacking[25-27].
Lactate: A secondary elevation in serum lactate levels in patients receiving VA-ECMO support should prompt consideration of limb ischemia or mesenteric ischemia as aetiologies[28].
Creatine kinase and myoglobin: Progressive increases in creatine kinase and myoglobin levels are associated with ischemia-related rhabdomyolysis and may indicate the development of compartment syndrome[29].
Antithrombin III: Reduced Antithrombin-III levels at the time of arterial cannulation have been linked to an increased incidence of limb ischemia in patients undergoing VA-ECMO support[21].
Currently, there are no validated dedicated risk stratification tools developed to identify patients on VA-ECMO who are at increased risk for ALI and who may benefit from DPC placement.
Tier 1 measures include ECMO-specific strategies whereas tier 2 measures have been commonly used in vascular surgery for limb-threatening ischemia in other settings (e.g., trauma, embolism, peripheral arterial disease), but they have not been systematically validated in the unique physiology of VA-ECMO.
Optimize ECMO flow: Weaning trials during VA-ECMO may entail reducing ECMO flows. This may lead to reduced flow through the DPC as well. Bearing this in mind, ECMO flows may have to be increased temporarily during weaning to mitigate limb ischemia.
Reduce vasopressors: The optimum dose of vasopressors which will avoid worsening of limb ischemia is unknown. Doppler arterial and venous signals are important to ascertain the establishment or reversibility of limb ischemia. Simu
Reposition cannula: Repositioning cannula to contralateral limb or different site such as subclavian artery, axillary artery or aorta may be needed in limb threatening cases.
DPC insertion: DPC insertion in the proximal SFA helps restore distal limb perfusion (Table 2)[30-32]. Three suggested approaches to DPC placement in VA-ECMO are described (Table 3). These include upfront prophylactic, selective monitored, and rescue strategy[6,33,34].
| Ref. | Type of study | Distal perfusion catheter strategy | Limb ischemia incidence | Impact of acute limb ischemia on outcomes |
| Kaufeld et al[30], 2019 | DPC strategy based | Upfront prophylactic (77%) vs none | 3.38% with DPC vs 21.42% without DPC | Absence of DPC identified as an independent risk factor for critical limb ischemia (P < 0.001). Authors suggest to have mandatory distal limb perfusion |
| Lamb et al[6], 2017 | DPC strategy based | Upfront prophylactic (60%) | 0% with DPC vs 33% without DPC | Survival in patient with ALI was 25% compared to 42% overall survival; only 1 patient required amputation. Continuous monitoring with NIRS suggested if DPC not placed prophylactically |
| Son et al[2], 2021 | DPC strategy based | Selective monitored (44%) | 20% incidence of ALI | DPC placement did not significantly reduce the risk of ALI |
| Liao et al[15], 2020 | DPC strategy based | Upfront prophylactic (100%) | 20.11% incidence of ALI | Peripheral artery disease was the primary independent risk factor for ALI despite DPC |
| Hu et al[17], 2022 | DPC strategy based | Rescue (only after clinical signs) | Limb ischemia complications were noted in 10.6% of total patients, with 8.4% patients requiring a rescue DPC | Authors suggest to optimize cannulation strategies during establishment of VA-ECMO |
| Lunz et al[10], 2019 | DPC strategy based | Selective monitored (50% of ALI cases) | 43.9% incidence of ALI | Cannula size and indication of ECMO noted to be most important factors for development of ALI |
| Yau et al[14], 2019 | DPC strategy based | Upfront prophylactic (29.8%) | 22% incidence of ALI | Lack of prophylactic DPC or arterial cannula size not primary drivers of ALI, rather younger patients, history of diabetes and peripheral arterial disease are at increased risk of ALI |
| Kim et al[31], 2017 | ALI monitoring based | Upfront prophylactic (noted as insufficient without NIRS) | ALI incidence not explicitly given for the group | 0% fasciotomy rate in NIRS group vs 13.9% in the control group (P = 0.04). Also, the mean time to distal perfusion was shorter in NIRS group, suggesting the early institution of NIRS to be valuable |
| Vinogradsky et al[32], 2023 | ALI monitoring based | Selective monitored (NIRS-guided placement) | Limb ischemia requiring surgical intervention in NIRS group (2.6%) vs non-NIRS group (8.5%) | Continuous NIRS monitoring as guidance for selective insertion of DPC is an effective strategy |
| 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 |
Decannulation planning: Thoughtful decannulation planning, including early assessment of arterial integrity, timing of weaning, and strategies to minimize residual vascular injury, plays a key role in preventing progression or recurrence of limb ischemia in VA-ECMO.
Fogarty embolectomy: Fogarty embolectomy remains the surgical gold standard for managing limb ischemia due to acute arterial thromboembolism in VA-ECMO patients, utilizing an arterial cutdown for the targeted extraction of distal thrombi. By advancing a balloon-tipped catheter past the occlusion and withdrawing it while inflated, surgeons effectively restore perfusion and mitigate the risk of limb loss.
Endovascular stenting: While first line management for acute ischemia often involves establishing distal perfusion through a catheter or removing thrombi via catheter-directed thrombolysis or mechanical thrombectomy, stenting plays several critical roles like resolving underlying stenotic lesions revealed after clot removal, stabilizing arterial dissections caused by large-bore cannulation, maintaining flow after mechanical or aspiration thrombectomy, enhancing flow to tibial vessels in complex multi-level disease.
Fasciotomy for compartment syndrome: An intracompartmental pressure exceeding 30 mmHg necessitates emergent four-compartment fasciotomy via comprehensive medial and lateral incisions to ensure total decompression. Post-operatively, these patients require complex wound management, often including vacuum-assisted closure therapy and subsequent skin grafting.
Hybrid surgical-endovascular approaches: Approaches like surgical embolectomy or mechanical thrombectomy followed by endovascular stenting achieves higher vessel patency and stabilization than surgery alone[35,36].
When to consider amputation: In cases of irreversible limb ischemia, proceeding for early limb amputation is considered to prevent secondary complications of necrosis, bleeding and sepsis.
Future priorities in reducing limb ischemia during VA-ECMO center on improving cannula design, enhancing monitoring, and generating stronger evidence to guide practice. Emerging devices that incorporate distal perfusion directly into the cannula may lessen the need for separate DPC placement, while automated perfusion-tracking systems could allow earlier recognition of compromised limb flow[37-39]. Greater consistency across centres will require internationally aligned protocols for DPC use and monitoring. High-quality randomized trials comparing upfront prophylactic with selective monitored DPC placement remain essential to determine the most effective strategy[40]. While artificial intelligence (AI) has been explored as a means to improve echocardiographic monitoring during ECMO, there remains a need for predictive AI-based tools that can identify patients at greatest risk and guide more individualized management of ALI[41]. Together, these developments outline a streamlined research agenda focused on device innovation, standardized care, comparative effectiveness, and improved risk prediction.
With the increased implementation of VA-ECMO as a tool for mechanical circulatory support, the incidence of limb ische
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