Point-of-Care Ultrasound-Guided Peripheral Veno-Arterial Extracorporeal Membrane Oxygenation Cannulation in Adult Patients.

Point-of-care ultrasound (POCUS) has become an important imaging modality for guiding peripheral veno-arterial extracorporeal membrane oxygenation (VA-ECMO) cannulation. This protocol describes the integration of POCUS throughout the peripheral VA-ECMO cannulation workflow, including pre-procedural assessment, real-time procedural guidance, and post-cannulation verification. During the pre-procedural assessment, POCUS facilitates differentiation of arteries from veins, measurement of vessel diameter to estimate appropriate cannula size, and identification of vascular pathology, including plaques, thrombosis, and stenosis. During cannulation, combined out-of-plane and in-plane ultrasound techniques enable real-time visualization of the guidewire, confirmation of guidewire placement within the target vessel, and avoidance of posterior wall perforation or injury to adjacent structures. Following cannulation, POCUS is used to verify drainage cannula positioning at the inferior vena cava-right atrium junction and arterial return cannula positioning at the external or common iliac artery level, and to assess for complications such as cardiac tamponade, cannula malposition, and thrombosis. Compared with landmark-based or fluoroscopy-guided techniques, POCUS provides bedside imaging without ionizing radiation and supports continuous procedural guidance without interrupting resuscitation. This protocol provides a practical, evidence-based approach for ultrasound-guided peripheral VA-ECMO cannulation and focuses specifically on vascular access and cannulation rather than broader VA-ECMO management.