A Novel Retrograde Implantation Technique for Distal Limb Perfusion During VA-ECMO: From Bench to Clinical Routine

All articles of this category (opens in new window) Background: Lower limb ischemia is a well-recognized complication in patients treated with veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Placement of a distal perfusion catheter (DPC) may prevent this severe complication; however, percutaneous DPC implantation can be highly challenging in emergency situations. In this study, we describe the preclinical development and clinical evaluation of a novel retrograde DPC implantation technique. Methods: Computational flow analyses of the retrograde perfusion setting were performed, followed by in-vitro model simulations. After preclinical testing, clinical implementation was carried out. Between January 2019 and May 2025, 68 patients underwent percutaneous femoral VA-ECMO implantation with retrograde DPC placement. The DPC was inserted retrograde into the femoral artery and connected to the ECMO circuit. Adequate lower limb perfusion was confirmed by fluoroscopy, ultrasound, and clinical examination. ECMO explantation was performed either percutaneously using vascular closure devices or surgically. Results: Computational flow measurements demonstrated sufficient distal limb perfusion using retrograde perfusion. In-vitro evaluation using a 3D-printed ECMO simulation model with various cannula sizes confirmed the feasibility of retrograde distal perfusion. Clinically, all 68 patients received retrograde DPC placement (7-French) at the time of ECMO cannulation. Femoral arterial cannula sizes ranged from 17F to 21F. Mean ECMO support duration was 5.4 ± 4.0 days. Weaning and explantation were successful in 58.8% ( n = 40). Open surgical explantation was required in 22 patients, while fluoroscopy-guided percutaneous explantation was performed in 46 patients. After interventional closure, vascular patency was verified via the retrograde DPC. During ECMO support and after decannulation, no patient developed limb ischemia. Two patients required temporary balloon occlusion of the access femoral artery after device closure, and one patient underwent implantation of a covered stent. Overall, in-hospital mortality was 51.5%. Conclusion: This novel technique of retrograde DPC implantation is safe and feasible, providing effective prevention of lower limb ischemia during femoral VA-ECMO. Retrograde arterial puncture facilitates rapid DPC placement and supports interventional ECMO explantation by enabling fluoroscopic evaluation and vascular rescue strategies in the event of closure device failure. Publication History Article published online: 17 February 2026 © 2026. Thieme. All rights reserved. Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany