ABSTRACT Background Early utilization of extracorporeal membrane oxygenation (ECMO) improves the clinical outcomes of patients with severe primary graft dysfunction (PGD3) after lung transplantation. Although there is a survival benefit, the impact of ECMO on airway complications has not been investigated. This study aims to describe the clinical association between posttransplant methods of support and the severity of acute airway anastomosis complications in patients with PGD3 following bilateral lung transplantation. Methods Data from adult bilateral lung transplant patients diagnosed with PGD3 at our institution were retrospectively reviewed. Bronchial anastomosis necrosis (ischemia reperfusion injury [IRI]) that developed within a month after transplantation was graded. The data were compared among the groups of veno‐venous ECMO (VV‐ECMO) ( n = 77), veno‐arterial ECMO (VA‐ECMO) ( n = 14), and mechanical ventilation (MV, n = 33). Results Higher levels of support (VV/VA‐ECMO) were associated with a lower incidence of PGD3, which was highest in recipients on MV only ( M 2 = 19.54, r = −0.41, p &lt; 0.001). In a multivariable competing risk analysis, VV‐ECMO was protective against chronic allograft dysfunction (CLAD) relative to the MV group (HR: 0.36 [0.13–0.96], p = 0.042). There was no relationship between posttransplant support and survival. Conclusion This study suggests posttransplant VV‐ECMO support in patients who develop PGD3 may confer a protective advantage over MV alone in the prevention of ischemic reperfusion injury. VV‐ECMO was associated with lower IRI grades and lower rates of BOS after transplantation. Future studies investigating the causal mechanisms are warranted.

Veno‐Venous Extracorporeal Membrane Oxygenation Support for Severe Primary Graft Dysfunction Is Associated With Reduced Airway Complications After Lung Transplantation