This letter responds to the systematic review and meta-analysis by Ryota et al, which examines the safety profile of ECMO cannulation performed by intensivists. The authors report an overall complication rate of 2% per cannula and 5% per patient, with higher rates observed in VA ECMO compared to VV ECMO. We emphasized that the safety of ECMO cannulation is multifactorial, influenced by institutional infrastructure, structured training programs, adherence to protocols, credentialing standards, and quality improvement initiatives. Although procedural volume and surgical backup are important, standardization of training curricula and institutional policies play a pivotal role in optimizing safety.
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