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In acute respiratory distress syndrome (ARDS) with refractory septic shock, isolated veno–venous (VV) or veno–arterial (VA) extracorporeal membrane oxygenation (ECMO) may lead to differential hypoxia or inadequate tissue perfusion [1]. In this context, MacLaren et al. [2] showed that central ECMO improved the outcomes by guaranteeing systemic oxygenation without differential hypoxia. However, central ECMO has potential limitations due to its invasiveness and the lack of evidence in adult populations. Veno–veno–arterial (VVA) ECMO may offer effective oxygenation and hemodynamic support without differential hypoxia by regulating the return of oxygenated blood to the underperfused coronary and cerebral circulation [3–5]. Therefore, VVA mode can be an alternative treatment modality for ARDS patients with severe septic shock.

Veno–veno–arterial extracorporeal membrane oxygenation treatment in patients with severe acute respiratory distress syndrome and septic shock