Echocardiography is an indispensable tool for guidance of cannulation for intravascular devices, including veno-venous and venoarterial extracorporeal membrane oxygenation (VV and VA ECMO), intra-aortic balloon pump (IABP) support, and related devices. Fundamental knowledge for the echocardiographer involves confident identification of the appearance of a wire within the right atrium and great vessels and an understanding of the steps necessary for cannula placement. In addition, common malposition problems are important for the echocardiographer to anticipate and recognize. For dual lumen VV ECMO cannulation, the crucial imaging guidance is establishment of a guidewire which passes from the internal jugular vein into the inferior vena cava, without looping in the right heart. The second VV ECMO imaging challenge is to verify that both the distal tip for drainage and the return flow jet are properly oriented. For VA ECMO, the critical echo guidance steps are definitive identification of the aortic and venous guidewires, followed by echo-guided placement of the drainage cannula in the upper right atrial-superior vena cava position. For the IABP, the echo guidance involves identification of contraindications and verification of balloon position just past the left subclavian artery. Areas for future investigation regarding the role of echo in guidance of mechanical circulatory support are mentioned in each section.