<h3>Purpose</h3> Routine intraoperative (IO) ECMO has been proposed as the preferred strategy for lung transplantation (LTX). We reviewed the clinical outcomes and complications of patients who underwent LTX with IO ECMO support at a low-volume center. <h3>Methods</h3> All consecutive patients who underwent LTX between 2008 and 2020 were included in the study. Demographics, the type and duration of supports, and patient outcomes were retrospectively reviewed. Uni-and multivariate analysis was performed as appropriate. <h3>Results</h3> Out of 201 lung transplants, 95 (47.2%) were performed on intraoperative support, of which 55 (27,3%) with IO ECMO. The indications for support were switch from preoperative in 28 cases (50.9%) and IO respiratory or hemodynamic instability in 24 (43.6%). The predominant baseline disease was IPF (45.4%). IO support was VA in 41 (74,5%), VV in 13 (23.6%), VAV in 1 (1.8%). ECMO configuration was peripheral in 49 cases (89%). Most supports were placed with a cut-down approach (69.1%). The average duration of support was 472 min±32,2. In 23 patients (41.8%) the IO support was extended postoperatively. The median ICU and hospital LOS were 12 (2-137) and 42 days (2-204) respectively and were significantly longer compared to patients who did not receive IO support. At least one complication occurred in 22 patients (40%), while 7 (10.9%) had more than one. The most frequent complications were postoperative hemothorax (23%), limb ischemia (9%), lymphocele (5.1%), IO harlequin syndrome (3.6%). Complications required surgical revision in 79.3% of cases. 1-yr (77.1% vs 83.3%) but not 5-yr (66.9% vs 70.1%) Kaplan-Meier survival of patients supported with IO ECMO was less favourable compared to non-supported patients, with borderline statistical significance (p=0.05%). On univariate analysis, no pre-operative or IO parameter was significantly associated with the development of complications. On multivariate analysis, the development of at least one complication was significantly associated with hospital stay (p=003), ICU stay (=.0002), duration of postoperative intubation (p=0.03). <h3>Conclusion</h3> IO ECMO during LTX has a relevant impact on the development of early complications after LTX at a small volume Institution, increases the length of intubation and hospital stay, and decreases 1-yr survival. These results may support the local policy to attempt transplantation off support if tolerated.