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A more recent trend is the shift from the reactive or emergency management to the pro-active or prophylactic placement of a distal perfusion cannula to avoid or reduce limb ischaemia-related complications. Multiple alternative cannulation techniques to the distal perfusion cannula have been developed to maintain distal limb perfusion, including end-to-side grafting, external or endovascular femoro-femoral bypass, retrograde limb perfusion (e.g., via the posterior tibial, dorsalis pedis or anterior tibial artery), and, more recently, use of a bidirectional cannula. Venous congestion has also been recognized as a potential contributing factor to limb ischaemia development and specific techniques have been described with facilitated venous drainage or bilateral cannulation being the most recent, to reduce or avoid venous stasis as a contributor to impaired limb perfusion. Advances in monitoring techniques, such as near-infrared spectroscopy and duplex ultrasound analysis, have been applied to improve decision-making regarding both the monitoring and management of limb ischaemia. This narrative review describes the evolution of techniques used for distal limb perfusion during peripheral VA ECMO.<\/jats:p>","DOI":"10.1177\/02676591241236650","type":"journal-article","created":{"date-parts":[[2024,4,23]],"date-time":"2024-04-23T05:35:25Z","timestamp":1713850525000},"page":"23S-38S","update-policy":"https:\/\/doi.org\/10.1177\/sage-journals-update-policy","source":"Crossref","is-referenced-by-count":20,"title":["Evolution of distal limb perfusion management in adult peripheral venoarterial extracorporeal membrane oxygenation with femoral artery cannulation"],"prefix":"10.1177","volume":"39","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-2037-3907","authenticated-orcid":false,"given":"Jorik","family":"Simons","sequence":"first","affiliation":[{"name":"Department of Cardio-Thoracic Surgery, CARIM School for Cardiovascular Diseases, Heart and Vascular Center, Maastricht University Medical Center, Maastricht, The Netherlands"},{"name":"Department of Intensive Care Medicine, Maastricht University Medical Center, Maastricht, The Netherlands"},{"name":"Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Barend","family":"Mees","sequence":"additional","affiliation":[{"name":"Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands"},{"name":"Department of Vascular Surgery, CARIM School for Cardiovascular Diseases, Heart and Vascular Center, Maastricht University Medical Center (MUMC+), Maastricht, The Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Graeme","family":"MacLaren","sequence":"additional","affiliation":[{"name":"Cardiothoracic Intensive Care Unit, National University Health System, Singapore"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"John F","family":"Fraser","sequence":"additional","affiliation":[{"name":"Critical Care Research Group, The Prince Charles Hospital, University of Queensland, Brisbane, QLD, Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3147-5044","authenticated-orcid":false,"given":"Akram M","family":"Zaaqoq","sequence":"additional","affiliation":[{"name":"Department of Anesthesiology, Division of Critical Care, University of Virginia, Charlottesville, VA, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5132-0958","authenticated-orcid":false,"given":"Sung-Min","family":"Cho","sequence":"additional","affiliation":[{"name":"Division of Neuroscience Critical Care, Department of Neurology, School of Medicine, Johns Hopkins University, Baltimore, MD, USA"},{"name":"Division of Neuroscience Critical Care, Department of Anesthesiology and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Bhavesh M","family":"Patel","sequence":"additional","affiliation":[{"name":"Department of Critical Care, Mayo Clinic Arizona, Scottsdale, AZ, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Daniel","family":"Brodie","sequence":"additional","affiliation":[{"name":"Division of Pulmonary and Critical Care Medicine, Department of Medicine, School of Medicine, The Johns Hopkins Hospital, Baltimore, MD, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jan","family":"B\u011blohl\u00e1vek","sequence":"additional","affiliation":[{"name":"2nd Department of Medicine - Department of Cardiovascular Medicine, General University Hospital in Prague, Prague, Czech Republic"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mirko","family":"Belliato","sequence":"additional","affiliation":[{"name":"SC AR 2 Anestesia e Terapia Intensiva Cardiotoracica, Foundation IRCCS Policlinico San Matteo, Pavia, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jae-Seung","family":"Jung","sequence":"additional","affiliation":[{"name":"Department of Thoracic and Cardiovascular Surgery, Korea University Medicine, Seoul, Republic of Korea"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Leonardo","family":"Salazar","sequence":"additional","affiliation":[{"name":"Department of Intensive Care, Fundaci\u00f3n Cardiovascular de Colombia, Bucaramanga, Colombia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7356-9036","authenticated-orcid":false,"given":"Paolo","family":"Meani","sequence":"additional","affiliation":[{"name":"Department of Cardio-Thoracic Surgery, CARIM School for Cardiovascular Diseases, Heart and Vascular Center, Maastricht University Medical Center, Maastricht, The Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Silvia","family":"Mariani","sequence":"additional","affiliation":[{"name":"Department of Cardio-Thoracic Surgery, CARIM School for Cardiovascular Diseases, Heart and Vascular Center, Maastricht University Medical Center, Maastricht, The Netherlands"},{"name":"S. Gerardo Hospital is the hospital of the departmen, Monza, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Michele","family":"Di Mauro","sequence":"additional","affiliation":[{"name":"Department of Cardio-Thoracic Surgery, CARIM School for Cardiovascular Diseases, Heart and Vascular Center, Maastricht University Medical Center, Maastricht, The Netherlands"},{"name":"Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Demetris","family":"Yannopoulos","sequence":"additional","affiliation":[{"name":"Center for Resuscitation Medicine, University of Minnesota Medical School, Minneapolis, MN, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lars Mikael","family":"Broman","sequence":"additional","affiliation":[{"name":"Department of Pediatric Perioperative Medicine and Intensive Care, ECMO Centre Karolinska, Karolinska University 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