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

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.