INTRODUCTION: Femoral veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is used as an ultima ratio to maintain circulation in patients with refractory cardiorespiratory failure, but is also associated with vascular and ischemic complications. Buttock ischemia appears to be an underreported complication in these patients. RESULTS: Over the five-year period, 264 patients were assessed for buttock ischemia, which occurred in seven patients, with an average annual incidence of 2.7%. Unilateral buttock ischemia was observed in six patients, while bilateral buttock ischemia was seen in one patient and led to multiple surgeries in three patients. The CT scans showed that, in all cases, the arterial ECMO cannula covered the origin of the internal iliac artery and revealed additional bilateral atherosclerotic lesions in the iliac arteries. CONCLUSION: Buttock ischemia is a rare and not fully understood complication of femoral VA-ECMO but may lead to clinically significant sequelae. Widespread knowledge and awareness are therefore important to recognize buttock ischemia, followed by individualized strategies for selecting and positioning the arterial cannula.