Bidirectional arterial cannulae for peripheral extracorporeal life support: a scoping review

Background Distal perfusion strategies for extracorporeal life support (ECLS) vary widely and remain associated with complications such as limb ischemia and distal malperfusion. Bidirectional arterial cannulae, which direct blood flow in two directions, may preserve distal perfusion without compromising extracorporeal support. This review summarizes bidirectional cannula designs used at peripheral vascular sites. Methods A literature search was conducted in November 2025 in accordance with PRISMA-ScR guidelines. Eligible studies reported original data on bidirectional ECLS cannulae used at peripheral vascular sites. Given the limited and heterogeneous literature, a scoping review approach was used and findings were synthesized narratively. Results Sixteen records describing eleven cannula designs were included, comprising multiple prototypes and one commercially available device (Bi-Flow™, LivaNova). Designs were grouped into general archetypes. The selected literature spans computational, benchtop, animal, and clinical studies with broad variation in methodology, terminology, target vessel, ECLS modality, and outcome reporting. Clinical reports only described preserved distal perfusion and acceptable device complications in selected settings, while nonclinical studies supported the feasibility of diverse design concepts. Identified gaps included limited comparative data, single-center experience, variable outcome reporting, and scarce commercial translation. Conclusion Bidirectional arterial cannulae represent a promising approach to reducing limb ischemia and distal malperfusion during ECLS, though current evidence remains at the feasibility stage relative to contemporary distal perfusion strategies. This scoping review identified a small, heterogeneous, and clinically immature evidence base. Future work should focus on larger comparative studies, standardized reporting, and continued technological development in flow distribution, size range, and fixation strategies.