A case report describes the successful treatment of a critically ill elderly patient with severe acute respiratory distress syndrome (ARDS) caused by SARS-CoV-2 using veno-venous extracorporeal membrane oxygenation (VV-ECMO) with a single-site double-lumen cannula (SDLC) inserted through the right internal jugular vein. This cannula allowed unrestricted access to the lower extremities, thus promoting early physical therapy and early mobilization to preserve muscle and brain function. A single injection site reduced the risk of infection and simplified care compared to multiple cannulae. The strategic approach included awake ECMO with ultraprotective ventilation to support lung recruitment and spontaneous breathing, with patient risk of lung injury (P-SILI) monitoring. Cannula placement was guided by real-time transesophageal echocardiography to avoid recirculation or cardiac damage, although it required more intensive anticoagulation and risk of bleeding. Despite the high predicted mortality according to prognostic scores, the patient achieved a favorable outcome. This triad - SDLC VV-ECMO, vigilance and early rehabilitation - is suitable for selected patients with prolonged support in specialist centers.