Central versus peripheral veno-arterial extracorporeal membrane oxygenation during lung transplantation: a systematic...

The use of extracorporeal membrane oxygenation (ECMO) during lung transplantation has progressively expanded and, in many centers, replaced conventional cardiopulmonary bypass. However, it remains unclear whether central or peripheral veno-arterial (VA) ECMO provides superior postoperative outcomes. This study aimed to compare central VA-ECMO (cVA-ECMO) and peripheral VA-ECMO (pVA-ECMO) during lung transplantation, with a focus on survival, primary graft dysfunction grade 3 (PGD3), postoperative ECMO support, and postoperative morbidity.

Three databases were assessed through November 2025. Five retrospective observational studies including 866 patients were included. Overall survival was analyzed using reconstructed individual patient data derived from Kaplan-Meier curves. Random-effects models were applied for all pooled analyses.

There was no significant difference in overall survival (HR 1.224, p=0.13) and in PGD3 at 72 h incidence (OR 1.55; p=0.26) between cVA-ECMO and pVA-ECMO. However, pVA-ECMO was associated with a higher requirement for postoperative ECMO use (OR 6.05; p=0.04), longer duration of extracorporeal support (MD +1.61 days; p=0.01), prolonged mechanical ventilation (MD +2.73 days; p<0.01), and longer intensive care unit length of stay (MD +4.05 days; p<0.01). The risk of limb ischemia requiring invasive treatment was significantly higher with pVA-ECMO (OR 4.94; p=0.001).

Although survival and PGD3 incidence were comparable, pVA-ECMO was associated with greater postoperative morbidity and vascular complications. These findings should be interpreted with caution, and cannulation strategy should be individualized according to patient risk profile, surgical context, and center-specific expertise rather than favoring one approach uniformly.