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Introduction: Vascular complications are a major issue in V-A ECMO and can affect long term outcome. Among these, Artero-Venous (AV) fistulas may lead to right heart failure. Case History: A 73-years patient supported with V-A ECMO for post-cardiotomy biventricular failure developed right heart failure after V-A ECMO decannulation, requiring V-A ECMO recannulation. The presence of an AV femoral fistula was incidentally revealed during femoral vein cannulation, from which oxygenated blood was unexpectedly drawn. The angiographic assessment confirmed the presence of a fistula between superficial femoral artery and vein, at the site of the first venous ECMO cannulation. This was caused by the venous cannula that inadvertently passed across the artery and created an AV fistula that was opened by the venous cannula removal. The exclusion of the endovascular fistula allowed the right heart failure resolution. Conclusions: In the presence of right heart failure after recent vascular manipulation, AV fistula should be ruled out., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.