Bedside monitoring tools for acute limb ischemia in peripheral venoarterial extracorporeal membrane oxygenation: a narrative review

Introduction

Venoarterial extracorporeal membrane oxygenation (VA ECMO) has become an increasingly utilized form of temporary mechanical circulatory support, with annual worldwide use increasing from fewer than 2,000 runs to more than 20,000 since 2020 (1). The most common configuration accesses the common femoral artery and common femoral vein for the inflow and outflow cannulas, respectively (1,2). The peripheral approach has been associated with lower in-hospital mortality, decreased bleeding risk, and decreased need for blood transfusions when compared with central cannulation and is recommended by Extracorporeal Life Support Organization (ELSO) guidelines (3,4).

Femoral arterial cannulation may partially or completely obstruct antegrade arterial blood flow, resulting in lower-extremity ischemia. Contemporary studies report acute limb ischemia in approximately 10–25% of patients, although rates vary depending on cannulation strategy, distal perfusion catheter (DPC) use, and the definition of ischemia (1,2,5-9). Although prophylactic DPC placement reduces the incidence of ischemic complications and vascular intervention, it does not eliminate the risk of acute limb ischemia (1,2,6,7).

Limb ischemia has been associated with decreased quality of life and increased mortality, underscoring the importance of early recognition and timely intervention (8-10). Diagnosis remains challenging because traditional clinical assessment—including pulse examination, sensory testing, and motor examination—is frequently limited by non-pulsatile flow, deep sedation, neuromuscular blockade, and vasopressor use. Furthermore, transportation for advanced vascular imaging may be impractical in critically ill patients receiving VA ECMO, making reliable bedside monitoring essential. Multiple monitoring modalities are available, including serial physical examination, handheld Doppler assessment, duplex ultrasonography, near-infrared spectroscopy (NIRS), serum biomarkers, and angiographic techniques; however, each possesses important strengths and limitations.

No single bedside monitoring modality has demonstrated sufficient diagnostic accuracy to reliably detect evolving limb ischemia. Consequently, clinicians must integrate complementary tools into a multimodal surveillance strategy. Given the substantial heterogeneity in patient populations, monitoring protocols, diagnostic thresholds, and reported outcomes, a narrative review is well-suited to critically evaluate the available evidence, identify knowledge gaps, and provide a practical framework for bedside surveillance and multidisciplinary management. Although previous reviews have discussed vascular complications of VA ECMO and the management of acute limb ischemia (1,2), none has specifically focused on the comparative strengths, limitations, and integration of contemporary bedside monitoring modalities. We present this article in accordance with the Narrative Review reporting checklist (available at https://jeccm.amegroups.com/article/view/10.21037/jeccm-2026-0024/rc).

Methods

This narrative review summarizes the current evidence regarding bedside monitoring strategies for acute lower-extremity ischemia during peripheral VA ECMO. Relevant literature was identified by the authors through review of the published medical literature, with emphasis on studies evaluating bedside monitoring modalities for the detection and management of acute limb ischemia during peripheral VA ECMO. Original investigations, observational studies, systematic and narrative reviews, clinical practice guidelines, and ELSO guidance documents were included. Additional relevant publications were identified through review of the reference lists of selected articles. Case reports were included selectively when they described novel monitoring approaches or clinically relevant diagnostic techniques not otherwise represented in larger studies. PubMed was used to review literature related to VA ECMO and distal pulse monitoring, with an emphasis on more recent studies and manuscripts, as demonstrated in Table 1.

Given the heterogeneity of the available evidence, including differences in study design, patient populations, monitoring protocols, and reported outcomes, a quantitative synthesis was not performed. Instead, the literature was synthesized narratively with an emphasis on the strengths, limitations, and practical clinical application of currently available bedside monitoring modalities.

Assessing arterial flow

Physical exam

Physical examination remains the cornerstone of bedside surveillance for acute limb ischemia during peripheral VA ECMO because it is immediately available, inexpensive, repeatable, and capable of identifying evolving vascular compromise without specialized equipment. Whenever feasible, a baseline vascular and neurologic examination should be documented prior to cannulation and repeated immediately after cannulation, followed by serial assessments at least hourly while the arterial cannula remains in place. Serial changes are generally more informative than isolated examination findings, particularly early after cannulation. The examination should include assessment of pulse quality, skin color and temperature, capillary refill, motor function, sensory function, and the development of compartment firmness or swelling.

Serial pulse examination should focus on changes in pulse quality and symmetry over time rather than isolated findings. Assessment of the dorsalis pedis and posterior tibial arteries should be performed routinely, with handheld Doppler evaluation when pulses are not palpable. A change from a palpable pulse to Doppler-only flow, or complete loss of Doppler signals, should prompt immediate evaluation for evolving limb ischemia. However, the presence of a Doppler signal alone does not necessarily indicate adequate distal perfusion, particularly in patients receiving high-dose vasopressors or those supported with non-pulsatile ECMO flow.

Serial neurologic assessment complements the vascular examination by identifying functional consequences of impaired limb perfusion. When feasible, motor and sensory examinations should be performed during sedation interruption and include assessment of distal motor function, light touch sensation, and the development of new weakness, paresthesias, or sensory loss. Progressive pain (when assessable), worsening neurologic deficits, or increasing compartment firmness should also raise concern for evolving compartment syndrome, particularly following restoration of distal limb perfusion after DPC placement.

Despite its central role, physical examination has important limitations in critically ill patients receiving VA ECMO. Deep sedation, neuromuscular blockade, altered mental status, generalized edema, obesity, vasopressor-induced peripheral vasoconstriction, and non-pulsatile arterial flow may all reduce the sensitivity of bedside examination or delay recognition of evolving ischemia. Furthermore, interpretation of subtle changes in pulse quality, skin findings, or neurologic deficits is inherently subjective, resulting in considerable interobserver variability.

Accordingly, physical examination should serve as the foundation of a multimodal limb surveillance strategy but should not be relied upon as a stand-alone diagnostic modality. Any deterioration in vascular or neurologic findings should prompt immediate evaluation with complementary monitoring techniques such as handheld Doppler assessment, duplex ultrasonography, NIRS, or angiography when clinically indicated. Conversely, a reassuring physical examination should not exclude evolving limb ischemia, particularly early after cannulation or in heavily sedated patients.

Handheld Doppler assessment

Handheld Doppler ultrasonography is a simple, inexpensive adjunct to the physical examination that should be performed whenever distal pulses are not palpable or when there is concern for evolving limb ischemia. Compared with pulse palpation alone, Doppler assessment improves the detection of arterial blood flow and facilitates serial bedside evaluation during peripheral VA ECMO. However, the presence of a Doppler signal does not necessarily indicate adequate distal tissue perfusion, as arterial flow may persist despite significant ischemia resulting from reduced flow, microvascular dysfunction, or inadequate DPC function. Conversely, loss of previously detected Doppler signals should prompt urgent evaluation for acute limb ischemia and confirmation with additional monitoring modalities or imaging. Doppler assessment is rapid, widely available, and easily repeatable but remains operator dependent and provides limited anatomic information. Accordingly, handheld Doppler should be incorporated into a multimodal limb surveillance strategy rather than used as a stand-alone diagnostic test.

NIRS tissue oximeter

NIRS is a noninvasive technique that continuously measures regional tissue oxygen saturation (StO₂), allowing continuous real-time assessment of lower-extremity perfusion. Because tissue oxygenation may decline before overt clinical signs such as skin discoloration, delayed capillary refill, or loss of Doppler signals become apparent, NIRS has emerged as an attractive adjunctive monitoring modality during peripheral VA ECMO. When feasible, obtaining baseline pre-cannulation StO₂ measurements may facilitate interpretation of post-cannulation trends and improve recognition of clinically significant declines in tissue oxygenation.

Although NIRS has demonstrated promise for early detection of evolving limb hypoperfusion, its diagnostic performance remains only moderate and reported thresholds vary considerably among studies. Proposed intervention criteria include absolute StO₂ values below 40–50%, relative reductions of 15–25% from baseline, or inter-limb differences exceeding approximately 20% (11-14). No threshold has been prospectively validated across diverse patient populations, limiting standardization of NIRS-guided surveillance protocols. Published studies generally demonstrate good sensitivity for detecting evolving limb hypoperfusion but lower specificity, with false-positive findings occurring in the setting of edema, vasopressor-induced vasoconstriction, or impaired microvascular perfusion.

Consequently, serial trends in tissue oxygenation are generally considered more informative than isolated measurements, particularly when interpreted alongside clinical examination and other bedside monitoring modalities. Interpretation of NIRS measurements should also consider important technical and physiologic limitations. Tissue edema, obesity, vasopressor therapy, sensor positioning, skin pigmentation, ambient light interference, and underlying peripheral vascular disease may influence measured StO₂ values independent of true limb perfusion. Furthermore, NIRS primarily reflects microvascular tissue oxygenation rather than large-vessel blood flow and therefore cannot reliably differentiate arterial thrombosis, vasospasm, cannula malposition, or inadequate DPC flow. Accordingly, NIRS should be incorporated into a multimodal surveillance strategy rather than used as a stand-alone diagnostic test. Persistent reductions or downward trends in StO₂ should prompt careful clinical reassessment and confirmation with complementary imaging modalities such as handheld Doppler assessment, duplex ultrasonography, or bedside angiography when clinically indicated. Conversely, reassuring NIRS values should not supersede concerning clinical findings, as significant limb ischemia may still occur despite apparently preserved tissue oxygenation.

Serum markers

Serum biomarkers may provide supportive evidence of limb ischemia or reperfusion injury but have limited utility for early diagnosis. Acute ischemia results in anaerobic metabolism, cellular injury, and release of intracellular contents. Elevations in lactate, potassium, phosphorus, creatine kinase (CK), aspartate aminotransferase (AST), and lactate dehydrogenase (LDH) may suggest ongoing skeletal muscle injury, compartment syndrome, or reperfusion injury, although all are nonspecific. Because these abnormalities generally occur after tissue injury has developed, serum biomarkers lack the sensitivity and specificity required for early detection of acute limb ischemia. Nevertheless, serial laboratory monitoring, particularly of CK and lactate, may identify evolving muscle injury and should prompt careful clinical reassessment when interpreted in conjunction with physical examination and other bedside monitoring modalities (15).

Arterial duplex ultrasonography

Duplex ultrasonography is the preferred bedside imaging modality for evaluating suspected acute limb ischemia during peripheral VA ECMO because it combines real-time anatomic assessment with evaluation of arterial blood flow. In contrast to handheld Doppler assessment, duplex ultrasonography can identify the underlying mechanism of impaired perfusion, including arterial thrombosis, stenosis, vasospasm, cannula malposition, vessel compression, arterial dissection, or DPC dysfunction. Color and spectral Doppler imaging permit assessment of flow direction, peak systolic velocity, and waveform characteristics, providing a comprehensive evaluation of limb perfusion. Visualization of intraluminal thrombus with absent color flow provides direct evidence of arterial occlusion, whereas changes in flow velocity and waveform morphology provide indirect evidence of hemodynamically significant arterial compromise (16-19). In patients with a DPC, duplex ultrasonography can also assess catheter patency and characterize distal arterial flow patterns, which typically demonstrate lower peak systolic velocities and monophasic waveforms compared with native arterial circulation (16,18).

Despite these advantages, duplex ultrasonography is not suitable for continuous surveillance and is highly operator dependent. Image acquisition may be limited by obesity, tissue edema, surgical dressings, or overlying ECMO cannulas, and interpretation requires expertise in vascular ultrasonography. Accordingly, duplex ultrasonography is best utilized as a confirmatory bedside imaging modality when abnormalities are detected on physical examination, handheld Doppler assessment, NIRS, or laboratory evaluation. Identification of impaired arterial flow or DPC dysfunction should prompt timely consultation with vascular surgery and consideration of corrective intervention. Conversely, a normal duplex examination should be interpreted within the broader clinical context, as evolving limb ischemia may still occur despite preserved large-vessel flow.

Computed tomography angiography (CTA) and digital subtraction angiography (DSA)

CTA provides rapid, high-resolution vascular imaging of the arterial vasculature and is useful when the diagnosis of acute limb ischemia remains uncertain or when the extent and underlying mechanism of vascular compromise must be defined. CTA can identify arterial occlusion, thrombosis, dissection, vasospasm, cannula malposition, and DPC complications while simultaneously assessing cannula position and the proximal and distal arterial circulation. Delayed venous phase imaging may also identify deep venous thrombosis or venous obstruction when venous congestion or phlegmasia is suspected. Interpretation of CTA in patients receiving VA ECMO can be challenging because altered circuit hemodynamics may produce atypical contrast enhancement and imaging artifacts that mimic vascular pathology. Additionally, the need for patient transport and iodinated contrast limits its role as a routine surveillance modality, particularly in hemodynamically unstable patients or those with impaired renal function (16,19).

DSA remains the reference standard for definitive vascular evaluation and offers the advantage of simultaneous diagnosis and treatment. Contrast injection through the DPC or alternative arterial access allows detailed assessment of arterial anatomy, flow dynamics, and the location of vascular obstruction. Importantly, DSA facilitates immediate endovascular or surgical intervention, including thrombectomy, angioplasty, stent placement, DPC revision, or operative repair when indicated. Because of its invasive nature and resource requirements, DSA is reserved for patients with a high suspicion of limb ischemia requiring definitive diagnosis or therapeutic intervention rather than routine monitoring (1,6,7,9-12,20).

DPCs

In the setting of femoral arterial cannulation, a DPC can be placed in the superficial femoral artery to maintain distal limb perfusion. These catheters are typically 6–8 French and are positioned just distal to the femoral bifurcation. Flow through the DPC is supplied directly from the ECMO circuit and is therefore non-pulsatile. Consequently, diminished Doppler signals or the absence of a palpable distal pulse may occur despite adequate limb perfusion and should be interpreted in conjunction with other clinical findings.

There has been a shift toward prophylactic DPC placement at the time of ECMO cannulation to minimize delays in restoring distal limb perfusion (1). When present, DPC flow should be monitored to ensure adequate perfusion, with ELSO recommending a target flow of approximately 100 mL/min (1). Continuous assessment may be performed using in-line flowmeters, although their use may be limited by cost, availability, and tubing compatibility. Ultrasound-based methods for estimating DPC flow have also been described and represent a reasonable alternative when flowmeters are unavailable, although they do not provide continuous monitoring (13).

Despite DPC placement, limb ischemia may still occur due to thrombosis, kinking, malposition, or inadequate distal flow. Therefore, DPC placement should complement rather than replace serial limb surveillance. Abnormal findings on physical examination, handheld Doppler assessment, NIRS, or duplex ultrasonography should prompt evaluation of DPC patency and function, with angiography reserved for cases requiring definitive diagnosis or intervention (20-22). The advantages and limitations of each of the modalities discussed are listed in Table 2.

Discussion: a practical multimodal surveillance strategy

Despite advances in cannulation strategies, increasing use of DPCs, and the availability of multiple bedside monitoring modalities, acute limb ischemia remains one of the most serious complications of peripheral VA ECMO. Delayed recognition may result in irreversible tissue injury, compartment syndrome, amputation, or death. The available evidence suggests that no single monitoring modality provides sufficient diagnostic accuracy to reliably identify evolving limb ischemia. Rather, each evaluates a different component of limb perfusion, including clinical findings, arterial blood flow, microvascular oxygenation, biochemical evidence of tissue injury, or vascular anatomy.

Accordingly, early recognition depends on integrating complementary monitoring techniques into a structured surveillance strategy. Serial physical examination should remain the cornerstone of assessment and be supplemented by handheld Doppler evaluation because both are inexpensive, immediately available, and easily repeated. Adjunctive modalities such as NIRS may facilitate earlier recognition of evolving tissue hypoperfusion, whereas duplex ultrasonography provides important diagnostic information regarding the underlying mechanism of impaired arterial perfusion. CTA and DSA should generally be reserved for patients requiring definitive diagnosis or therapeutic intervention. Importantly, placement of a DPC should complement rather than replace continued surveillance, as limb ischemia may still occur despite apparently adequate distal perfusion.

Abnormal findings identified through this surveillance strategy should prompt timely multidisciplinary evaluation involving the ECMO team, vascular surgery, and when appropriate, interventional specialists. Early vascular surgery consultation is particularly important when serial bedside assessments suggest evolving limb ischemia or when imaging identifies arterial thrombosis, cannula malposition, DPC dysfunction, or persistent hypoperfusion requiring intervention.

Another consistent observation across the available literature is that serial trends are generally more informative than isolated measurements. Progressive deterioration in pulse quality, tissue oxygenation, Doppler signals, laboratory values, or duplex findings frequently precedes overt clinical ischemia. Therefore, clinicians should emphasize longitudinal assessment and integration of multiple complementary modalities rather than dependence on individual diagnostic thresholds. Institution-specific surveillance protocols that standardize serial assessment, define triggers for escalation, and promote timely vascular consultation may facilitate earlier recognition and intervention. An example surveillance algorithm is presented in Figure 1.

Figure 1 Multimodal surveillance algorithm for acute limb ischemia during peripheral VA ECMO. ALI, acute limb ischemia; CK, creatine kinase; CTA, computed tomography angiography; DP, dorsalis pedis; DPC, distal perfusion catheter; DSA, digital subtraction angiography; LABS, laboratory tests; NIRS, near-infrared spectroscopy; PT, posterior tibial; rSO₂, regional oxygen saturation; VA ECMO, venoarterial extracorporeal membrane oxygenation.

Future research should focus on prospective validation of multimodal surveillance protocols, standardization of NIRS thresholds, continuous assessment of DPC function, and integration of physiologic monitoring with predictive analytics such as hemodynamic monitoring of flow throughout the VA ECMO circuit (23). Machine learning approaches that combine serial bedside monitoring data with patient-specific clinical variables may eventually improve early detection of limb ischemia, although these technologies remain investigational.

Although the available evidence supports a multimodal approach, important knowledge gaps remain. Most studies are retrospective, surveillance protocols vary considerably between centers, and validated diagnostic thresholds for many monitoring modalities are lacking. Future prospective multicenter studies are needed to establish standardized surveillance protocols and determine whether integrated monitoring strategies improve limb salvage and patient-centered outcomes.

Conclusions

Acute limb ischemia remains a serious complication of peripheral VA ECMO despite advances in cannulation techniques and increasing use of DPCs. No single bedside monitoring modality reliably detects evolving limb ischemia, and each provides complementary information regarding vascular perfusion. Early recognition therefore depends on integrating serial physical examination, handheld Doppler assessment, adjunctive technologies such as NIRS, targeted vascular imaging, and ongoing evaluation of DPC function within a structured surveillance strategy. Future prospective studies should focus on developing standardized monitoring protocols and validating multimodal surveillance pathways capable of improving limb salvage and clinical outcomes.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://jeccm.amegroups.com/article/view/10.21037/jeccm-2026-0024/rc

Peer Review File: Available at https://jeccm.amegroups.com/article/view/10.21037/jeccm-2026-0024/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jeccm.amegroups.com/article/view/10.21037/jeccm-2026-0024/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

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