Feasibility of anticoagulation-free peripheral veno-arterial extracorporeal membrane oxygenation in re-do lung transplantation

Background: To evaluate the feasibility and safety of anticoagulation-free peripheral veno-arterial extracorporeal membrane oxygenation (VA-ECMO) during lung re-transplantation and to assess its impact on blood transfusion requirements and clinical outcomes. Methods: In this single-center retrospective cohort (January 2023–April 2025), we included adults undergoing bilateral re-do lung transplantation on peripheral VA-ECMO with an anticoagulation-avoidance protocol; primary lung transplants were not included. Data on patient demographics, intraoperative transfusion volumes, postoperative complications, and survival were collected. The primary outcomes were intraoperative packed red blood cell transfusion volume and overall survival; secondary outcomes included incidence of primary graft dysfunction, acute kidney injury, and hemorrhagic and thromboembolic events. Continuous variables are reported as medians with interquartile ranges, and survival was estimated using the Kaplan–Meier method. Results: Seven patients (median age, 42 years; range, 30–56 years) underwent re-transplantation for chronic lung allograft dysfunction. The median intraoperative transfusion requirement was 560 ml (interquartile range 280–1050 ml). One patient developed primary graft dysfunction of grade 3and two developed stage 3 acute kidney injury requiring renal replacement therapy. Two developed deep venous thrombosis nonrelated to ECMO cannulation; no pulmonary embolism occurred. At a median follow-up of 469 days, all patients survived without evidence of recurrence of chronic lung allograft dysfunction. Conclusions: Full anticoagulation-free peripheral VA-ECMO during lung re-transplantation is feasible and safe, with acceptable complication rates and potential reduction in transfusion requirements. Larger, multicenter studies are warranted to confirm these findings.