**Abstract**

As utilisation of peripheral extra-corporeal life support (ECLS) is becoming clinical routine, its associated complications become more frequent. Distal limb perfusion in femoral cannulation remains one of the Achille's heels in patients with peripheral ECLS. Unless detected early, limb ischemia may result in loss of limb and sometimes life. A protocol-based approach, precautions during ECLS implantation and explantation procedures and continuous monitoring of the limb during ECLS support are key elements in preventing this complication. Utilisation of a distal limb perfusion cannula helps in prevention as well as management of limb ischemia; however, it may sometimes cause more damage than help. Management and consequence of limb ischemia essentially depends on its severity at the time of detection as well as time of intervention. This chapter offers a brief review of the burden of limb ischemia, means to prevent and approaches to manage it.

**Keywords:** extra-corporeal life support, limb ischemia, complications, distal limb perfusion
