ECMO-facilitated adult non-cardiac surgery: a structured narrative review

Extracorporeal membrane oxygenation (ECMO) has traditionally been used as rescue support for severe respiratory failure, cardiopulmonary failure, or perioperative cardiac surgical care, but its expanding perioperative role has enabled selected non-cardiac operations in patients otherwise considered too unstable for surgery. We performed a structured narrative review of reported ECMO-assisted adult non-cardiac surgery, focusing on airway, trauma, burn, vascular, and obstetric applications. Published case reports, case series, retrospective cohorts, database analyses, and relevant reviews were identified through structured searches of PubMed/MEDLINE, PubMed Central, and Google Scholar, supplemented by manual reference review. For this review, ECMO-assisted surgery included both planned or enabling ECMO initiated specifically to permit an operation and ECMO-supported surgery performed while a patient was already receiving ECMO for respiratory or circulatory failure. Airway and tracheobronchial surgery represented the most developed application, whereas trauma, burn, vascular, and obstetric reports more commonly described ECMO as rescue or stabilizing support that permitted necessary surgery to proceed. Across specialties, the published experience demonstrates technical feasibility in highly selected reported patients but is dominated by case reports and small observational series, with substantial publication and selection bias and few comparator populations. Multidisciplinary planning, individualized cannulation and anticoagulation strategies, hemorrhage preparedness, anesthetic planning, and postoperative critical care are central to safe implementation. The current literature should not be interpreted as establishing a survival or treatment-effectiveness benefit.

ECMO has evolved from a rescue therapy for severe respiratory or cardiac failure into an increasingly versatile perioperative support strategy (1). Although ECMO has traditionally been associated with cardiothoracic surgery, lung transplantation, and critical care rescue, its expanding use has created new opportunities to support patients undergoing urgent, emergent, or otherwise prohibitive non-cardiac operations.

The use of ECMO to facilitate non-cardiac surgery is conceptually distinct from ECMO used solely as critical care rescue. For purposes of this review, ECMO-assisted non-cardiac surgery encompasses two clinically distinct scenarios. Planned or enabling ECMO refers to extracorporeal support initiated specifically to permit an operation that would otherwise be technically or physiologically prohibitive, such as procedures requiring interruption of conventional ventilation or anticipated transient cardiopulmonary instability. ECMO-supported surgery refers to a necessary non-cardiac operation performed while a patient is already receiving ECMO for respiratory or circulatory failure. These scenarios have different indications and implications and are distinguished throughout this review. Reported applications span airway and tracheobronchial, thoracic oncologic, trauma, burn, vascular, obstetric, abdominal, orthopedic, and neurosurgical procedures. Venovenous ECMO (VV-ECMO) and venoarterial ECMO (VA-ECMO) may therefore function either as an enabling technology for planned operative exposure or as ongoing/rescue support that allows necessary surgery to proceed despite profound respiratory or circulatory failure.

Despite increasing reports of ECMO-assisted non-cardiac surgery, the available literature remains fragmented. Most publications are single-patient case reports, small institutional case series, specialty-specific reviews, or retrospective cohorts focused on narrow operative indications. As a result, there is no unified clinical synthesis of surgical indications, ECMO configurations, perioperative considerations, and reported outcomes across specialties. The purpose of this structured narrative review was to synthesize the reported experience with ECMO-assisted adult non-cardiac surgery, characterize how ECMO has been used in airway, trauma, burn, vascular, and obstetric procedures, identify recurring perioperative and anesthetic themes, and highlight limitations of the evidence base. The goal was to provide a practical framework for multidisciplinary teams rather than to estimate treatment effectiveness or comparative benefit.

We performed a structured narrative review of published literature describing ECMO-assisted adult non-cardiac surgery. This approach was selected because the available evidence is heterogeneous and consists predominantly of case reports, case series, retrospective institutional cohorts, database analyses, and specialty-specific reviews with substantial variation in surgical indications, ECMO configuration, perioperative management, and outcome reporting. A literature search was performed using PubMed/MEDLINE, PubMed Central, and Google Scholar from database inception through July 14, 2026. Search concepts included combinations of “extracorporeal membrane oxygenation,” “ECMO,” “extracorporeal life support,” “ECLS,” “noncardiac surgery,” “non-cardiac surgery,” “perioperative,” and “intraoperative.” Additional specialty-specific searches incorporated terms related to airway and tracheobronchial surgery, trauma, orthopedic surgery, neurosurgery, laparotomy and abdominal surgery, burn surgery and burn excision, vascular and aortic surgery, pulmonary embolectomy, cesarean delivery, pregnancy, and obstetric surgery. Reference lists of relevant reviews and primary publications were examined to identify additional reports. Google Scholar was used as a supplementary citation-discovery source rather than as a source for quantitative study-selection counts. No formal language restriction was applied.

Reports were considered eligible for the specialty-specific synthesis if they described one or more adult patients undergoing a non-cardiac operation while supported with VV-ECMO, VA-ECMO, or a hybrid configuration, or if ECMO was initiated perioperatively to enable the operation. Studies were excluded if ECMO was used exclusively for cardiac surgery, postcardiotomy shock, heart transplantation, lung transplantation, or extracorporeal cardiopulmonary resuscitation without an associated non-cardiac surgical procedure. When specialty-specific non-cardiac evidence was sparse, broader ECMO literature was used only to contextualize cross-cutting topics such as vascular cannulation complications and anticoagulation and was distinguished from the principal non-cardiac surgical evidence. Duplicate publications encountered across overlapping searches were consolidated by title, authorship, and digital object identifier when available. Because this review was designed as a structured narrative review rather than a formal systematic or scoping review, a prospectively maintained record-level screening database, quantitative duplicate log, and PRISMA flow diagram were not generated. Results were synthesized qualitatively by surgical specialty, with attention to ECMO indication, support configuration, planned/enabling versus ongoing/supportive use, anticoagulation, perioperative complications, and reported outcomes. Quantitative meta-analysis was not performed because of substantial clinical and methodological heterogeneity. The reproducible search framework is provided in Supplementary Appendix S1, and the principal publications informing the narrative synthesis are summarized in Supplementary Table S1.

Airway surgery

Airway and tracheobronchial surgery represented the largest and most mature subgroup of ECMO-facilitated non-cardiac surgery. Unlike the burn, vascular, trauma, and obstetric subgroups, airway reports commonly describe planned ECMO initiation to facilitate surgery when conventional ventilation, cross-field ventilation, jet ventilation, or rigid bronchoscopy is expected to be unsafe or impossible. Indications include critical central airway obstruction, tracheal stenosis, tracheobronchial tumors, carinal resection, traumatic airway disruption, iatrogenic tracheal injury, and complex tracheal or bronchial reconstruction. In one of the most extensive narrative reviews on the subject, Slama et al. summarized 168 published extracorporeal life support (ECLS)-supported airway surgery cases, categorized by operative indication and support mode (2).

Several institutional case series demonstrate the feasibility of ECMO support across a range of airway procedures. Chang et al. reported 7 cases of intraoperative ECMO use during tracheal surgery for oncologic resections; venovenous ECMO (VV-ECMO) was used for 10–31 min, all 7 operations were completed safely, and there were no in-hospital deaths (3). Kim et al. described 15 patients receiving ECMO for airway obstruction, including 7 patients cannulated for VV-ECMO to permit tracheal resection and reconstruction (4). Lang et al. reported 10 complex tracheobronchial procedures supported with central or peripheral venoarterial ECMO (VA-ECMO), including carinal and bronchovascular sleeve resections (5). Chen et al. described 7 VV-ECMO-assisted tracheobronchial operations and concluded that VV-ECMO was feasible when oxygenation could not be safely maintained using conventional intraoperative strategies (6). Voltolini et al. reported 10 patients undergoing major airway surgery supported with VV-ECMO, with 4 patients requiring postoperative VV-ECMO to facilitate early extubation (7).

The airway subgroup differs from other surgical categories in several important ways. First, ECMO was frequently elective or preemptive, rather than purely rescue therapy or stabilization. Second, the operative goal was often to create an unobstructed surgical field without an endotracheal tube crossing the lesion or anastomosis. Third, VV-ECMO was commonly sufficient when isolated gas-exchange support was needed, while VA-ECMO was selected for patients with hemodynamic compromise, anticipated major bleeding, or procedures requiring more complete cardiopulmonary support. Finally, airway surgery reports more consistently described ECMO as an enabling technology rather than only salvage support. Despite these strengths, the literature remains largely observational, highly selective, and there are no randomized studies defining thresholds for ECMO use, optimal cannulation strategy, or standardized anticoagulation management in airway surgery.

Elective VA-ECMO may also have an enabling role in selected non-cardiac surgical patients with severe baseline cardiac dysfunction, particularly in the setting of thoracic oncologic resections. Novellis et al. described a patient with stage cIIA lung cancer and severe postischemic dilated cardiomyopathy (left ventricular ejection fraction 23%) who underwent left upper lobectomy with pulmonary artery angioplasty using planned intraoperative VA-ECMO (8). In this case, ECMO provided prospective cardiopulmonary support to permit potentially curative resection in a patient otherwise considered at prohibitive operative risk, although the evidence for this strategy remains limited to highly selected case-level experience.

Trauma surgery: surgical management of neurologic, orthopedic, and abdominal injuries

ECMO use to stabilize patients with traumatic injuries is widely described, with reported outcomes generally comparable to ECMO use in other critically ill populations (9, 10). A unique challenge in trauma is that patients may require multiple operations across several surgical subspecialties while simultaneously experiencing respiratory failure or cardiovascular collapse. In this setting, ECMO is principally used to stabilize severe respiratory failure or shock so that time-sensitive operative injuries can be addressed.

Historically, neurologic trauma has been considered a relative contraindication to ECMO; however, ECMO has increasingly been used to stabilize selected patients while definitive injuries are addressed. Reports of ECMO used before or during neurosurgical intervention remain limited to case reports and case series. Mader et al. published a multicenter retrospective analysis from the Trauma Registry-DGU and found that 1.1% of patients with neurologic trauma received VA- or VV-ECMO, with 61.8% surviving to discharge (11). Friesenecker and colleagues reported a patient with severe acute respiratory distress syndrome (ARDS), a large intracerebral hematoma with midline shift, and multiple other injuries after a 10-foot fall who was placed on VV-ECMO to facilitate craniotomy (12). That patient was later discharged with full neurologic recovery at follow-up. Lee et al. reported a case series of 8 trauma patients with traumatic brain injury requiring ECMO before or during neurosurgical procedures; 5 of 8 survived to discharge (13). As ECMO utilization expands in patients with neurologic trauma, multidisciplinary collaboration remains paramount to address bleeding risk, anticoagulation timing, and overall neurologic prognosis.

Polytrauma patients with orthopedic injuries may benefit from early fixation of long-bone fractures, which has been associated with improved outcomes and reduced intensive care unit (ICU) and hospital length of stay (14, 15). These patients may require substantial blood transfusion, increasing the risk of transfusion-related acute lung injury (TRALI), and may also be at risk for fat embolism, further increasing the likelihood of ARDS or cardiovascular collapse requiring ECMO (14, 16). Accordingly, stabilization of polytrauma patients with concomitant respiratory failure and/or shock may allow definitive orthopedic fixation to proceed. Five case reports and small series describe successful femoral fracture fixation while on ECMO, with all reported patients surviving to discharge (17–21). Kakalecik et al. also described successful fixation of a pelvic ring fracture during VV-ECMO support (19). Martins Lima et al. described a patient with ARDS and an unstable thoracic spinal fracture who underwent posterior spinal fixation while supported with ECMO (22).

Abdominal injuries, whether blunt or penetrating, may require damage-control laparotomy to promptly address abdominal compartment syndrome, hemorrhage, or bowel ischemia. Recent literature describes trauma patients supported predominantly with VV-ECMO who required damage-control laparotomy. Ghneim et al. published a single-center retrospective study of 52 patients supported with VV-ECMO before or after damage-control laparotomy: 21 were cannulated before laparotomy and 31 postoperatively, with an overall survival rate of 58% (23). After adjustment for confounders, patients who could tolerate anticoagulation had improved survival, and the authors concluded that damage-control laparotomy should not be considered a contraindication to VV-ECMO, or vice versa (23).

The trauma literature therefore demonstrates that operative intervention during ECMO is technically feasible in selected reported patients, particularly when VV-ECMO stabilizes severe respiratory failure sufficiently to permit definitive management of traumatic injuries. However, these observations derive largely from case reports, small series, and retrospective cohorts and should not be interpreted as evidence that ECMO improves survival or procedural outcomes compared with alternative strategies. Across these studies, anticoagulation remains a central challenge because trauma patients frequently have substantial bleeding risk; several reports have associated the ability to tolerate systemic anticoagulation with improved outcomes (9, 23).

Burn surgery

The burn surgery literature is limited and consists primarily of case reports, small institutional experiences, and protocol-based reports rather than comparative studies. However, much like trauma surgery, the evidence for ECMO in burn patients is growing. Across the identified burn-specific publications, ECMO was used for severe inhalation injury or burn-associated acute respiratory distress syndrome, with operative intervention required for burn excision, debridement, dressing changes, or wound coverage performed while patients remained supported with VV-ECMO. Bain et al. provided one of the first detailed reports specifically focused on performing burn excision during VV-ECMO support, emphasizing the need for coordinated anesthetic, perfusion, burn surgery, blood bank, and critical care planning (24). Schmidt et al. subsequently described perioperative management strategies for burn patients undergoing surgery while receiving VV-ECMO, reporting experience from a major burn center and proposing a standardized perioperative protocol centered on multidisciplinary planning, individualized anticoagulation management, and point-of-care coagulation monitoring (25).

Reported burn cases demonstrate that necessary excision, debridement, and wound care can be performed during ECMO in carefully selected patients with severe respiratory or cardiopulmonary failure. Bleeding risk, anticoagulation management, infection, circuit protection, temperature control, and the resource intensity of repeated wound care remain dominant perioperative challenges. Broader burn ECMO reports and reviews have focused on VV-ECMO as rescue therapy for severe burn-associated ARDS, but the evidence specific to operative burn care during ECMO remains sparse (26–28). Because published experience is highly selected and largely noncomparative, these reports establish technical feasibility but are insufficient to define optimal surgical timing, anticoagulation targets, or survival benefit.

Vascular surgery

The vascular surgery literature regarding ECMO use focuses on aortic and major vascular procedures in which VA-ECMO was used either as planned intraoperative circulatory support or as rescue support during acute cardiopulmonary collapse. Abouliatim et al. described ECMO-supported abdominal aortic aneurysm surgery in 2 high-risk patients, suggesting that ECMO may expand operative options for patients considered unsuitable for conventional open repair or endovascular aneurysm repair (29). Lee et al. reported intraoperative rescue with VA-ECMO and damage-control management during repair of traumatic aortic injury, illustrating the role of ECMO as salvage support when profound cardiopulmonary instability precludes necessary vascular intervention (30).

More recent reports broaden the use of ECMO in vascular cases from rescue support to planned adjunctive perfusion. Shoukry et al. described 2 vascular cases using planned VA-ECMO, including support for high-risk thoracoabdominal aortic aneurysm repair and bridge support during emergent pulmonary embolectomy; both patients tolerated the procedures and were discharged postoperatively (31). Schoephoerster et al. reported VA-ECMO for distal perfusion during open thoracoabdominal aortic aneurysm repair in 4 patients, proposing potential advantages compared with conventional cardiopulmonary bypass, including lower anticoagulation targets, reduced blood-air interface, and avoidance of systemic cooling (32). Aortic surgery reviews similarly emphasize that ECMO may be considered in selected high-risk vascular cases, although the evidence remains limited to technical reports and small case series (33).

Peripheral ECMO cannulation introduces an additional set of vascular risks that are particularly relevant when extracorporeal support is used to facilitate surgery. Vascular complications have been characterized across post-cardiotomy cohorts, systematic reviews, and contemporary reviews (34–36). A systematic review of 47 studies involving 6,583 patients reported an overall pooled vascular complication rate of 29.5%, with limb ischemia occurring in 12.6%, significant bleeding in 15.4%, and cannulation-site bleeding in 12.6% of patients (35). These complications occur more frequently with VA-ECMO than with VV-ECMO and include acute limb ischemia, arterial thromboembolism, cannulation-site bleeding or hematoma, arterial dissection or perforation, compartment syndrome, and later arterial stenosis or pseudoaneurysm formation (34–36). Preventive strategies include ultrasound-guided vascular access, selection of the smallest arterial cannula capable of providing adequate support, and consideration of prophylactic distal perfusion cannulation when femoral arterial VA-ECMO is used. Distal extremity perfusion should be assessed serially by physical examination, Doppler evaluation, and, when available, near-infrared spectroscopy. The study by Baran et al. further demonstrated that the pattern of vascular complications differs between percutaneous and open femoral cannulation strategies, emphasizing that access technique itself influences vascular risk (34). When ischemia is suspected, prompt duplex ultrasonography or angiography and correction of reversible causes are required; management may include distal perfusion cannula revision or placement, ECMO cannula repositioning, thrombectomy, vascular reconstruction, or fasciotomy when compartment syndrome develops (34–36).

High-risk acute pulmonary embolism (PE) represents a particularly important application of ECMO-supported vascular intervention. In patients presenting with refractory shock, severe right ventricular failure, or cardiac arrest, VA-ECMO can rapidly restore systemic perfusion and oxygenation while definitive reperfusion therapy is organized. ECMO should therefore generally be viewed as a bridge to treatment rather than treatment of the embolic burden itself. A multidisciplinary pathway should rapidly determine candidacy for systemic thrombolysis, catheter-directed therapy or mechanical thrombectomy, and surgical pulmonary embolectomy. Patients with persistent hemodynamic instability in whom thrombolysis is contraindicated or unsuccessful may particularly benefit from ECMO stabilization followed by catheter-based or surgical clot extraction. Baran et al. described an algorithmic strategy in which VA-ECMO was initiated preoperatively for profound hemodynamic instability or intraoperatively when patients could not be separated from cardiopulmonary bypass following embolectomy; hybrid venoarterial-venous (VAV) ECMO was used when significant respiratory failure or differential hypoxemia persisted despite VA support (37). Although such pathways remain institution-specific and are not supported by randomized trials, they illustrate how early ECMO deployment can be incorporated into multidisciplinary PE response pathways to permit definitive surgical or catheter-based reperfusion in otherwise unstable patients (37).

The vascular literature describes ECMO as a flexible adjunct in selected high-risk operations, with reported indications including hemodynamic support, distal perfusion, oxygenation support, and rescue from intraoperative cardiopulmonary collapse. Compared with airway, trauma, obstetric, and burn applications, vascular reports more commonly use VA-ECMO rather than VV-ECMO, reflecting the need for circulatory support or distal organ perfusion during major vascular procedures. These reports remain predominantly technical reports and small case series and therefore demonstrate feasibility rather than comparative effectiveness.

Obstetrics

The obstetric literature on ECMO consists primarily of cesarean delivery performed during ongoing ECMO support for severe maternal cardiopulmonary failure. Early reports demonstrate the feasibility of cesarean delivery while supported by ECMO. Panarello et al. reported a successful cesarean section after one month of VV-ECMO support, with subsequent maternal weaning from ECMO after delivery (38). Kim et al. described successful general anesthesia and cesarean delivery using VA-ECMO support in a patient with fulminant peripartum cardiomyopathy (39).

The COVID-19 era expanded the obstetric ECMO literature, with several case reports and series describing cesarean delivery during VV-ECMO for refractory hypoxemic respiratory failure. Webster et al. published a 10-year case series of 54 pregnant and postpartum patients requiring ECMO, identifying ARDS as the most common indication and reporting survival among a substantial proportion of mothers and fetuses when ECMO was initiated during pregnancy or delivery (40). Li et al. described five critically ill pregnant women treated with ECMO for respiratory or circulatory failure (41). Additional case reports document cesarean delivery in pregnant patients on VV-ECMO for COVID-19 or other causes of refractory respiratory failure, including emergent delivery for maternal deterioration or obstetric indications such as placental abruption (42–44). In addition to these case reports and series, larger systematic reviews have evaluated ECMO use in peripartum patients. Kourampi et al. described 13 studies and reported survival ranging from 33% to 100% across studies (45). Lu et al. identified 1,460 reported cases of pregnant patients receiving VA- or VV-ECMO and reported survival rates of 62.8% for VA-ECMO and 83.6% for VV-ECMO (46).

Across obstetric reports, ECMO served as a bridge through maternal respiratory or cardiopulmonary failure while surgery was undertaken for fetal indications, maternal decompensation, gestational timing, or obstetric emergencies. VV-ECMO predominated in isolated respiratory failure, whereas VA-ECMO or hybrid support was used in cardiogenic shock, pulmonary embolism, or peripartum cardiomyopathy. The literature consistently highlights multidisciplinary coordination among maternal-fetal medicine, obstetric anesthesia, ECMO, neonatology, perfusion, and critical care teams. However, most operative reports are single cases or small series and larger ECMO pregnancy cohorts are not restricted to surgical patients; therefore, reported survival should not be interpreted as an estimate of the effect of ECMO-facilitated delivery. Evidence remains insufficient to define optimal timing of delivery, anticoagulation interruption, neuraxial versus general anesthesia, or maternal-fetal risk stratification.

Perioperative and anesthetic considerations

Anticoagulation and hemostatic management

Anticoagulation during ECMO-assisted surgery requires balancing prevention of circuit and patient thrombosis against the potentially substantial bleeding risk imposed by the operative procedure. Unfractionated heparin (UFH) remains the most commonly used anticoagulant. Commonly referenced Extracorporeal Life Support Organization (ELSO) anticoagulation ranges include an anti-factor Xa activity of approximately 0.3–0.7 IU/mL, activated partial thromboplastin time (aPTT) of approximately 60–90 s, and activated clotting time (ACT) of approximately 180–220 s (47). These ranges are reference targets rather than validated requirements for every ECMO patient and should not be applied rigidly during high-risk surgery.

Reduced-intensity, delayed, or temporarily anticoagulation-free strategies have increasingly been described when bleeding risk is prohibitive. In trauma patients, a contemporary review summarizes standard targets of ACT 180–220 s or aPTT 40–80 s for patients without substantial bleeding risk, lower-intensity targets of ACT 120–140 s or aPTT 35–50 s for moderate bleeding risk, and delayed or heparin-free strategies for patients with active intracranial hemorrhage or immediately after surgery (48). Burn surgery provides another directly perioperative example: Schmidt et al. reported a low-dose heparin protocol targeting an aPTT of approximately 40 s during VV-ECMO-supported burn surgery, combined with point-of-care viscoelastic testing and targeted correction of coagulation abnormalities (25). These examples demonstrate that anticoagulation intensity should be tailored to the surgical indication, ECMO configuration, circuit blood flow, active bleeding, and thrombotic risk.

Any reduced- or no-anticoagulation strategy requires frequent assessment for oxygenator or circuit thrombosis and serial evaluation of patient coagulation. Anti-factor Xa activity and aPTT generally correlate more closely with heparin effect than ACT, although discordance among tests is common and viscoelastic testing may provide additional information in actively bleeding surgical patients (47). At present, no universally validated anticoagulation target exists specifically for ECMO-assisted non-cardiac surgery, supporting an individualized multidisciplinary approach. A cross-specialty summary of predominant ECMO modes, indications, cannulation considerations, perioperative risks, and anticoagulation approaches is provided in Table 1.

Cannulation, positioning, monitoring, and anesthetic management

Perioperative planning should begin with selection of an ECMO configuration and cannulation strategy that provides the required physiologic support without compromising surgical exposure or patient positioning. VV-ECMO is generally favored when isolated gas-exchange support is required, whereas VA-ECMO is used when substantial circulatory support is necessary. Cannula sites should be reviewed jointly by the surgical, anesthesia, perfusion, and ECMO teams before transport and positioning, with particular attention to avoiding cannula migration, kinking, compression, or loss of venous drainage during lateral, prone, or other non-supine positioning. Airway operations additionally require configuration of cannulas and tubing away from the operative field, while femoral VA-ECMO requires ongoing assessment of ipsilateral limb perfusion and consideration of distal perfusion strategies when appropriate (2–7, 22, 34–36).

Hemorrhage preparedness is central to ECMO-assisted surgery because the underlying illness, systemic anticoagulation, platelet dysfunction, acquired coagulation abnormalities, and the operation itself may all contribute to bleeding. For trauma, burn, major vascular, and obstetric procedures, teams should anticipate the potential need for rapid blood-product replacement and ensure immediate access to laboratory or point-of-care coagulation testing. Anticoagulation reduction, interruption, or temporary heparin-free support may be considered when bleeding risk is prohibitive, but these strategies require close surveillance for patient and circuit thrombosis. Communication regarding the timing of heparin dosing, incision, anticipated high-risk portions of the operation, and resumption of anticoagulation should be explicit and documented (23–25, 47, 48).

Anesthetic and ventilatory management should be individualized to the reason ECMO is being used. In airway surgery, ECMO may permit markedly reduced ventilation or temporary interruption of conventional ventilation to improve exposure, with postoperative continuation of VV-ECMO in selected patients to facilitate early extubation (3–7). In patients already supported for ARDS, lung-protective ventilation should generally be maintained during surgery while adequate ECMO flow and gas exchange are confirmed after each change in position. In VA-ECMO-supported patients, arterial pressure, pulsatility, ventricular loading, and end-organ perfusion require continuous assessment. Choice of general versus regional or neuraxial anesthesia depends on procedure, anticoagulation status, hemodynamic stability, and airway considerations; the obstetric literature illustrates the need for especially careful coordination of anesthetic technique with anticoagulation and delivery timing (38–46). Postoperatively, the team should define whether ECMO remains necessary for the underlying cardiopulmonary indication, establish airway and ventilation goals, reassess cannula position and bleeding, and agree on anticoagulation resumption and criteria for decannulation.

Limitations

This review has important methodological limitations. It was designed as a structured narrative review rather than a formal systematic or scoping review; consequently, a prospectively maintained screening database, quantitative duplicate log, and PRISMA flow diagram were not available. Although a structured search framework and explicit eligibility criteria were used, comprehensive capture of every published report cannot be guaranteed. Inclusion of case reports, case series, retrospective cohorts, database analyses, and prior reviews also creates substantial heterogeneity and introduces the possibility that individual patients are represented both in primary publications and subsequent reviews.

Publication and selection bias are likely substantial. Unusual, technically successful, or favorable ECMO-assisted operations performed at experienced centers are more likely to be reported than unsuccessful attempts or patients considered but not selected for ECMO. Accordingly, reported survival percentages and descriptions of successful procedures should not be interpreted as estimates of treatment effectiveness. Furthermore, consistent comparator populations are generally absent, preventing conclusions regarding whether ECMO improves mortality, perioperative complications, completion of surgery, or functional recovery compared with alternative strategies.

Finally, patient populations, indications for ECMO, timing relative to surgery, cannulation strategies, anticoagulation protocols, operative urgency, and outcome definitions vary markedly across specialties. Planned enabling ECMO and surgery performed during pre-existing ECMO support represent clinically distinct scenarios and should not be assumed to have equivalent risk or benefit. These limitations preclude quantitative pooling and underscore that the present review establishes a clinical framework and maps reported experience rather than determining comparative effectiveness.

ECMO-assisted adult non-cardiac surgery is an emerging perioperative strategy described across multiple surgical specialties. The most mature reported experience exists in airway and tracheobronchial surgery, where ECMO is often initiated electively or preemptively to provide gas exchange while preserving operative exposure. In contrast, trauma, burn, vascular, and obstetric reports more commonly describe surgery during ongoing rescue or stabilizing ECMO support for severe respiratory failure, cardiopulmonary collapse, or otherwise prohibitive physiologic risk.

Across specialties, the published literature demonstrates that selected non-cardiac operations can be technically performed during ECMO support at experienced centers. Recurring practical themes include multidisciplinary planning, procedure-specific cannulation, careful patient positioning, individualized anticoagulation, hemorrhage and transfusion preparedness, anesthetic and ventilatory planning, and coordinated postoperative critical care. VV-ECMO is most commonly described for isolated gas-exchange support, whereas VA-ECMO is used when circulatory support or distal organ perfusion is required.

These observations should be interpreted cautiously. The evidence is dominated by highly selected case reports and small observational series, with substantial publication and selection bias, heterogeneous indications and management, and few meaningful comparator groups. The available literature therefore cannot establish that ECMO improves survival or other clinical outcomes compared with alternative strategies. Until more robust multicenter and comparative data are available, ECMO-assisted non-cardiac surgery should remain a selective strategy undertaken by experienced multidisciplinary teams, with decisions tailored to the patient's physiology, operative requirements, bleeding risk, and likelihood of achieving a meaningful surgical objective.