Results and complications of intraaortic balloon pumping in surgical and medical patients

Comparison of anticoagulated versus non-anticoagulated patients with intra-aortic balloon pumps

Background

There is limited guidance regarding the use of anticoagulation in patients on intra-aortic balloon pumps (IABP). The purpose of this study is to compare the safety outcomes in anticoagulated versus non-anticoagulated patients with an IABP.

Methods

This was a single center, retrospective chart review of patients admitted to the coronary care unit or cardiac surgery unit who received an IABP from May 2015 to July 2018. Patients who were anticoagulated with heparin while on an IABP were compared to those who were not anticoagulated. Major endpoints included a composite of thrombotic events and a composite of bleeding events. The major composite endpoint of thrombotic events included the incidence of ischemic stroke, any venous thromboembolism, device thrombosis, and limb ischemia. The major composite endpoint of bleeding events included major access site bleeding, minor access site bleeding, major non-access site bleeding, and minor non-access site bleeding. Minor endpoints included any major endpoint events occurring within 24 and 48 h of IABP insertion, hospital length of stay, intensive care unit length of stay, and in-hospital mortality.

Results

A total of 185 patients were evaluated for inclusion and 147 were included in the final analysis. There were 82 and 65 patients in the heparin and non-heparin groups, respectively. The composite endpoint of thrombotic events occurred in 7.3 and 7.7% in the heparin and non-heparin groups, respectively (p = 1). The composite bleeding endpoint occurred in 20.7 and 20.0% in the heparin and non-heparin groups, respectively (p = 0.91). There were no differences found in minor endpoints between groups.

Conclusion

There were no significant differences found in major endpoints of bleeding and thrombotic events in patients who received anticoagulation while on an IABP versus those who did not receive anticoagulation.

Fondaparinux During Intra-Aortic Balloon Pump Counterpulsation in Acute Myocardial Infarction Patients Undergoing Percutaneous Coronary Intervention

BACKGROUND

Although anticoagulation with unfractionated heparin (UFH) is commonly used during intra-aortic balloon pump (IABP) counterpulsation to prevent thromboembolic events, no data or guidelines exist to support this strategy, especially in the setting of acute myocardial infarction (AMI). This study sought to compare the short-term outcome of UFH vs fondaparinux in AMI patients who underwent successful percutaneous coronary intervention (PCI) and IABP insertion.

METHODS

The anticoagulation therapy of revascularised AMI patients who received IABP counterpulsation and admitted to a tertiary hospital in the last decade was retrospectively evaluated. The primary outcome was the occurrence of all-cause mortality, stroke or transient ischaemic attack, reinfarction, unplanned revascularisation, major or minor limb ischaemia, and any bleeding at 1 month. Propensity score matching was performed to compare the primary outcome between UFH and fondaparinux.

RESULTS

Of 1,355 AMI survivors at 2 days after hospital admission and who underwent successful PCI, an IABP was inserted in 197 (14.5%): 72 (36.5%) were treated with UFH and 125 (63.5%) with fondaparinux (2.5 mg o.d.). At clinical follow-up, completed in 98.5% of cases, the incidence of the primary outcome was 22.5% in UFH and 5.7% in fondaparinux groups (p=0.0009). More than two-thirds of the events included in the primary outcome were related to early bleeding complications. In the matched cohort of 62 patients, the primary outcome occurred in 14 (45.2%) patients in the UFH and two (6.5%) in the fondaparinux group (p=0.01).

CONCLUSIONS

This study suggested that fondaparinux is safer, by reducing early bleeding complications at one month, than UFH in the management of IABP.

Effectiveness of fondaparinux vs unfractionated heparin following percutaneous coronary intervention in survivors of out-of-hospital cardiac arrest due to acute myocardial infarction

AIM

There is no specific evidence on the antithrombotic management of survivors of out-of-hospital cardiac arrest (OHCA) due to acute myocardial infarction (AMI). We sought to compare the short-term outcome of unfractioned heparin (UFH) vs fondaparinux in OHCA survivors due to AMI admitted in our Institution in the last decade.

METHODS

We performed a retrospective cohort study on survivors of OHCA due to AMI managed with UFH or fondaparinux during the hospitalization. The primary outcome was the occurrence of any bleeding, all-cause mortality, cerebrovascular accidents, re-MI, and unplanned revascularization at 1 month. A propensity-score matching was performed to compare the outcome between UFH and fondaparinux.

RESULTS

Out of 2083 AMI patients undergoing successful PCI, OHCA was present in 94 (4.5%): 41 (43.6%) treated with UFH and 53 (56.4%) with fondaparinux. At clinical follow-up, the incidence of the primary outcome was 65.9% in UFH and 35.8% in fondaparinux group (p = 0.007). More than half of the events included in the primary outcome were related to bleeding complications. In the matched cohort of 56 patients, the primary outcome occurred in 46.4% and 25.0% (p = 0.16), while bleeding was present in 32.1% and 7.1% (p = 0.04), in the UFH and fondaparinux group, respectively.

CONCLUSIONS

The present analysis suggests that fondaparinux is safer than UFH in the management of OHCA due to AMI by reducing early bleeding complications at one month.

Isolated Femoral Nerve Neuropathy After Intra-aortic Balloon Pump Treatment

Intra-aortic balloon pump (IABP)-related neuropathy is an infrequent complication, and the development of motor deficits is even rarer in such cases. We report a 37-year-old man with anterior ST-elevation myocardial infarction who received emergent percutaneous coronary intervention and IABP counterpulsation. Weakness and numbness developed after IABP removal despite lack of evidence of ischemia in the involved extremity. Nerve conduction velocity study and electromyogram led to the diagnosis of femoral nerve neuropathy. The neurologic deficits recovered after 6 months of rehabilitation. This case illustrates the importance of bedside neurologic examination of the involved extremity for early detection of possible injury to the femoral nerve in patients after IABP treatment and insertion of larger bore catheter.

In-hospital complications of percutaneous intraaortic balloon counterpulsation

Complications related to intraaortic balloon counterpulsation pumping (IABP) remain a problem despite the development of small caliber balloon catheter shafts and introducer sheaths. The authors report their experience in counterpulsation-related complications of 201 consecutive patients who underwent 212 percutaneous counterpulsation balloon insertions from June 1989 to June 1996 by use of balloons with 8-9.5 French shafts. Of these, 82% were men and 36 (18%) were women, with a mean age of 61 +/-12 years. Indications for counterpulsation were acute myocardial infarction (AMI) (67%), severe left ventricular failure without AMI (20%), dilated cardiomyopathy (4%), unstable angina (3%), high-risk supported percutaneous coronary angioplasty (2%), and others (4%). IABP was instituted at the bedside in the intensive care unit in 82 patients (39%) and in the catheterization laboratory in 130 (61%). Median duration of counterpulsation was 48 hours (range 30 minutes to 25 days) with successful weaning from counterpulsation in 70% (148 of 212) of procedures. Overall in-hospital mortality rate was 45% (90 of 201). The overall complication rate was 22/212 (10.4%). Major complications were present in 10/212 procedures (4.7%): 6 patients with limb ischemia (1 death directly attributed to this complication, 1 with associated septicemia and limb amputation, 3 requiring surgical thromboembolectomy, and 1 with persistent limb ischemia treated medically until his death caused by intractable left ventricular failure), 2 with important bleeding (1 fatal despite vascular surgical repair and 1 requiring blood transfusion) and 2 with balloon rupture requiring vascular surgery. Minor complications were present in 12 procedures (5.7%), 6 with limb ischemia, 3 with local bleeding, and 3 with catheter dysfunction. All of these resolved after balloon removal and required no further intervention. When limb ischemia did develop it occurred after a median delay of 24 hours following balloon insertion (range 2 to 98 hours). The only predictor of limb ischemia among baseline clinical and procedure-related variables was an age greater than 60 years. Compared with previous recent studies, the rate of complications observed in this study performed with small balloon catheters was acceptably low. Limb ischemia was the most frequent complication, often occurred early, and required further intervention in half the cases.

Contemporary utilization and outcomes of intra-aortic balloon counterpulsation in acute myocardial infarction: the benchmark registry

OBJECTIVES

We sought to examine contemporary utilization patterns and clinical outcomes in patients with acute myocardial infarction (AMI) requiring intra-aortic balloon pump (IABP) counterpulsation.

BACKGROUND

Despite increasing experience with and broadened indications for intra-aortic counterpulsation, the current indications, associated complications, and clinical outcomes of IABP use in AMI are unknown.

METHODS

Between June 1996 and August 2001, data were prospectively collected from 22,663 consecutive patients treated with aortic counterpulsation at 250 medical centers worldwide; 5,495 of these patients had AMI.

RESULTS

Placement of an IABP in AMI patients was most frequently indicated for cardiogenic shock (27.3%), hemodynamic support during catheterization and/or angioplasty (27.2%) or prior to high-risk surgery (11.2%), mechanical complications of AMI (11.7%), and refractory post-myocardial infarction unstable angina (10.0%). Balloon insertions were successful in 97.7% of patients. Diagnostic catheterization was performed in 96% of patients, and 83% underwent coronary revascularization before hospital discharge. The in-hospital mortality rate was 20.0% (38.7% in patients with shock) and varied markedly by indication and use of revascularization procedures. Major IABP complications occurred in only 2.7% of patients, despite median use for three days, and early IABP discontinuation was required in only 2.1% of patients.

CONCLUSIONS

With contemporary advances in device technology, insertion technique, and operator experience, IABP counterpulsation may be successfully employed for a wide variety of conditions in the AMI setting, providing significant hemodynamic support with rare major complications in a high-risk patient population.

Thrombogenicity of deflated intraaortic balloon: impact of heparin coating

In a calf model, 3 standard and 3 heparin coated intraaortic balloons (IAB) were inserted and left deflated in the descending aorta during 20 min to simulate balloon rupture. At the end of the experiment, the IAB were examined, and 3 samples of each were collected for scanning electron microscopy (SEM) analysis. None of the heparin coated IAB showed any sign of clot or deposit whereas all 3 standard IAB exhibited clots. SEM revealed no deposit on the heparin coated samples while 8 of the 9 standard samples disclosed deposits (p < 0.001). Morphometrically, 16.1+/-21.4% of the surfaces of the standard samples were covered with deposits whereas all the heparin coated samples were free (p = 0.004). The presence of clots on every standard IAB supports the hypothesis that other than local factors of the insertion site can play a role in the vascular complications of IAB. The absence of clots and deposits on the heparin coated IAB suggests a promising role of such devices in circumventing the tendency of clot formation on deflated balloons while avoiding the drawback of systemic anticoagulation.

Controlled limb reperfusion in patients having cardiac operations

HYPOTHESIS

Severe limb ischemia in patients having cardiac operations may occur after intraaortic balloon pump insertion, prolonged femoral vessel cannulation, percutaneous cardiopulmonary bypass, dissecting aneurysms, or emboli. Normal blood reperfusion can cause a postischemic syndrome that increases morbidity and mortality. This clinical study is based on an experimental infrastructure patterned after controlled cardiac reperfusion. (1) It tests the hypothesis that controlled limb reperfusion (i.e., modifying the composition of the initial reperfusate and the conditions of reperfusion) reduces the local and systemic complications seen after normal blood reperfusion. (2) It reports initial clinical application of this strategy in three cardiac surgery centers.

METHODS

Controlled limb reperfusion was applied to 19 patients with signs of severe prolonged unilateral or bilateral ischemia (including paralysis, anesthesia, and muscle contracture); six patients (32%) were in cardiogenic shock. The mean ischemic duration was 26 +/- 6 hours. The reperfusion method includes a 30-minute infusion into the distal vessels of a normothermic reperfusate solution mixed with the patient's arterial blood (obtained proximal to the obstruction) in a 6:1 blood/reperfusate ratio. Data are mean +/- standard error of the mean.

RESULTS

Sixteen patients (84%) survived with salvaged and functional limbs at the time of discharge. No renal, cardiac, pulmonary, cerebral, or hemodynamic complications developed in the survivors. The three deaths occurred in patients undergoing controlled limb reperfusion while in profound postoperative cardiogenic shock; neither postischemic edema nor contracture developed in any of them.

CONCLUSIONS

These findings show that controlled limb reperfusion can be applied readily with standard equipment that is used for cardiac surgery and may salvage limbs while reducing postreperfusion morbidity and mortality.

Vascular complications of intraaortic balloon pumping: unsheathed versus sheathed insertion

Incidence of vascular complications in intraaortic balloon counterpulsation is still high despite major refinements in catheter design and techniques. One hundred twenty-six patients in whom intraaortic balloon pumping was attempted were divided into two groups on the basis of insertion technique. Group 1 included 77 patients in whom the conventional percutaneous insertion was used. In group 2 (n = 45 patients), a sheathless insertion technique was used. The overall vascular complication rate was 19.6%, with the lower limb ischemia as the most common complication. The vascular complication rate was 25.9% in group 1 and 8.8% in group 2 (p < 0.01). Lower limb ischemia was noted in 17 patients in group 1 and 3 patients in group 2 (p < 0.01). These results suggest that sheathless insertion of the intraaortic balloon pump catheter can minimize vascular complications. This technique will be especially useful in patients with peripheral vascular disease, in whom the likelihood of vascular complications is high.

Complications associated with percutaneous placement and use of intraaortic balloon counterpulsation

In-hospital and late complications related to percutaneous placement of 240 intraaortic balloon pump catheters in 231 consecutive patients from March 1985 through June 1990 were reviewed. Mean age was 64 +/- 11 years and 34% were women. Average duration of counterpulsation was 44.2 hours. Indications for counterpulsation included complications of myocardial infarction (34.6%), prophylactic placement before high-risk coronary angioplasty (20.0%) or open heart surgery (12.9%), complicated coronary angioplasty (18.3%), end-stage cardiomyopathy (5.4%) and miscellaneous (8.8%). Early major complications occurred in 11 cases (4.6%) and included limb ischemia requiring surgery (n = 9), bleeding requiring arterial repair (n = 1) and septicemia (n = 1). Other complications included hematoma requiring transfusion (n = 7), limb ischemia resolving with balloon catheter removal (n = 12), and superficial wound infection (n = 1). Overall in-hospital complication rate was 13% (31 of 240). Peripheral vascular disease and diabetes were found to be significant predictors of limb ischemia (p = 0.01 and p = 0.02, respectively). Follow-up information was obtained in 97% of patients with a mean duration of 19 months: 2 patients (1.1%) required vascular surgery for femoral false aneurysms and 1 patient experienced new onset of claudication. In conclusion, compared with previous experience, contemporary intraaortic balloon counterpulsation with percutaneous placement of smaller size (8.5Fr to 10.5Fr) catheters is associated with improved complication profile. This will further enhance the current trend for an expanding role of intraaortic balloon counterpulsation in complex interventional procedures.

Frequency of long-term lower limb ischemia associated with intraaortic balloon pump use

Lower limb ischemia is a frequent complication of intraaortic balloon pump (IABP) use. The incidence and risk factors for acute ischemia have been well-defined, but little is known about long-term ischemic complications. This prospective study evaluated the incidence, nature, progression and predisposing factors for long-term lower limb ischemia in 151 patients who were previously treated with the IABP. These persons were interviewed and their lower extremities examined 12 to 20 months after undergoing IABP counterpulsation. Limb ischemia, characterized primarily by ipsilateral discomfort and diminished pulses, occurred in 18% of those evaluated. Evidence of ischemia worsened over time in 14%. Logistic regression analysis, which was based on variables found to be significant in bivariate analysis, revealed that the occurrence of limb ischemia acutely, cardiogenic shock as an indication for IABP insertion, and smoking (at the time of hospitalization or having quit < 10 years previously) were risk factors for long-term lower limb ischemia. The adjusted odds ratio for acute limb ischemia was 8.89 (95% confidence interval 2.80 to 28.21), for cardiogenic shock 3.59 (95% confidence interval 1.01 to 12.75), and for smoking 2.87 (95% confidence interval 1.10 to 7.46). Increasing numbers of patients are undergoing IABP counterpulsation and a greater proportion of these are surviving their acute event and resuming active lives. It is essential to recognize that detrimental consequences of this device can persist long after hospitalization.

Experience in 100 transthoracic balloon pumps

We retrospectively reviewed our last 100 consecutive patients who had an intraaortic balloon pump (IABP) placed through the ascending aorta for postoperative cardiogenic shock. Eighty-one patients survived to have their IABP removed and were evaluated for complications. Complications that may have been related to the transthoracic route of IABP introduction included balloon rupture in 6.2% (5/81), cerebral vascular accident in 2.5% (2/81), transient ischemic attack in 1.2% (1/81), bleeding at the IABP arteriotomy site in 3.7% (3/81), and mediastinitis in 3.7% (3/81). Compared with expected rates of development of complications in this high-risk group of patients, it appeared that balloon rupture and mediastinal bleeding were increased because of the transthoracic placement of the IABP. The rates of neurologic events and mediastinal infection do not appear to be increased. Transthoracic IABP placement avoids ischemic problems in the lower extremities and has proved a useful route for IABP introduction.

Medical and Neuropsychiatric Complications Associated with Use of the Intraaortic Balloon Pump

We conducted a retrospective chart review of 195 consecutive patients who had an intraaortic balloon pump (IABP) placed at the Massachusetts General Hospital during the calendar year 1988 to determine the incidence of complications associated with IABP treatment. Demographics, medical and psychiatric history, hospital course, medical and neuropsychiatric complications observed while on the IABP, pharmacological management, and outcome were recorded. Patients ranged in age from 26 to 81 years, with a mean of 62 years. Women comprised only 25% of the sample but had a mortality (40%) twice that of men (20%; p = 0.008). An IABP was inserted for cardiogenic shock in 52% of patients, for refractory angina in 36%, and intraoperatively in 12%. Patients were treated with an IABP for a mean of 4.4 days (range, several hours to 36 days). Complications included delirium (34%), mortality (25%), peripheral vascular insufficiency (17%), bleeding (14%), acute renal failure (14%), infection (8%), and stroke (4.6%). Delirium was associated only with a history of seizures and with development of a residual organic brain syndrome. Mortality was associated with female sex, cardiogenic shock, and number of complications present per patient. Vascular insufficiency was associated with female sex, history of peripheral vascular disease, valve replacement surgery, and mortality. Residual organic brain syndromes were more common in patients in whom delirium developed. A review of the literature on complications associated with IABP therapy is provided. This study highlights the common but previously unrecognized complication of delirium in IABP patients.

A new technique for sheathless percutaneous intraaortic balloon catheter insertion

Intraaortic balloon counterpulsation is helpful for controlling myocardial ischemia and providing hemodynamic support, but its applicability is limited by lower extremity ischemic complications in a significant percentage of patients. We developed a new sheathless technique for percutaneous intraaortic balloon catheter insertion which reduces the effective catheter diameter. A pilot study using this new technique resulted in a 10% rate of limb ischemia, without compromise of balloon function. We conclude that this technique may be useful in reducing the incidence of limb ischemia associated with intraaortic balloon counterpulsation.

Enhancing the applicability and effectiveness of intraaortic balloon counterpulsation

Severe maneuvers designed to enhance the applicability and effectiveness of intraaortic balloon pulsation are presented. (1) Insertion of balloon catheter directly into the ascending aorta. The technique uses an indwelling silastic snare that allows direct insertion of a balloon catheter into the ascending aorta in the course of open heart operations without the necessity of returning the patient to the operating room and reopening the chest at the time of balloon catheter removal. (2) Elimination of electric artifacts in the course of intraaortic balloon assist. A method is presented that utilizes optical rather than electric signals to operate the intraaortic balloon pump and eliminates pacer interference as well as other electrical artifacts. (3) Enhancing assist effectiveness by balloon positioning. In a series of clinical observations, it was found that the effectiveness of balloon assist may be enhanced by as much as 75% by appropriate positioning. The previously held concept that placing the balloon in a subclavian location is optimal is challenged and it is recommended that the proper position of the balloon catheter be determined by using appropriate hemodynamic measurements in different locations. (4) Control of bleeding following removal of percutaneously inserted transfemoral balloon catheter. The technique utilizes a balloon catheter which is introduced into the puncture hole of the femoral artery after minimal surgical dissection and allows direct suturing of the bleeding source.

Intra-aortic balloon counterpulsation with special reference to determinants of survival

From 1981 through 1985 intra-aortic balloon counterpulsation (IABP) was required by 90 patients on a total of 91 occasions. They included 85 (3.1%) of the 2751 patients undergoing open-heart surgery during that time. IABP was used preoperatively in 13 cases, to assist weaning from cardiopulmonary bypass in 64, postoperatively in nine, and without cardiac surgery in five cases. Complications arose from IABP in 24/90 patients (27%). The overall short-term survival rate following IABP was 61%, and the long-term (mean 23 months) rate was 51%. Early recovery of cardiac function was the main determinant of survival. Female sex, renal failure and postinfarction ventricular septal defect and mitral incompetence were over-represented among the nonsurvivors. IABP therefore is useful in reversible left ventricular dysfunction, whereas inadequate perfusion of vital organs with potential for failure of more than one organ system implies diminished likelihood of survival.

Intraaortic balloon pumping for prolonged circulatory support

Prolonged circulatory support with an intraaortic balloon pump (IABP) is controversial, in part because it has not been performed frequently enough to base treatment policy on adequate data. To help clarify this problem, 733 cases of consecutive patients who were supported by IABP between 1967 and 1982 were analyzed. Twenty-seven patients were supported for 20 days or more (range 20 to 71). Twelve (44%) had prior histories of chronic congestive heart failure. Complications were more frequent in prolonged-support patients than in those assisted for less than 20 days (vascular, 37% vs 15%, p = 0.001; infectious, 67% vs 25%, p = 0.0001; and bleeding, 26% vs 15%, p = 0.04, respectively). The survival rate of prolonged-support patients, however, was 63% (17 of 27), essentially the same as that of the controls (57%, p = 0.5). Of 17 prolonged-pumping patients discharged alive from the hospital, 9 died within 6 months but 8 survived greater than 2 years. Among congestive heart failure patients, none was a long-term survivor. Prolonged IABP support in congestive heart failure patients lacking surgically correctable lesions can extend life while arrangements for definitive therapy are made (transplant, permanent mechanical assistance). Where definitive therapy is unavailable, IABP may provide additional months of life.

Percutaneous intraaortic balloon pumping: four years from Tiblisi

Intraaortic balloon pumping (IABP) has now evolved as the mechanical supportive treatment of choice for the management of refractory left ventricular power failure. A new single-chambered percutaneous intraaortic balloon (Datascope Corp., Paramus, NJ, U.S.A.) has been constructed around a central guidewire. The balloon can be wrapped around the guidewire, enabling its insertion into the femoral artery through a 12-F sheath, inserted by a modified Seldinger technique. A dual-lumen automatic wrapping version has recently been employed. Percutaneous IABP insertion has been performed in 149 patients (mean age 58 years). In our medical group of 75 patients, 59 underwent urgent open heart surgery and 53 (90%) survived. In patients who could not be separated from cardiopulmonary bypass, 23 of 61 (38%) survived. Vascular complications occurred in 10% of the patients. Percutaneous balloon insertion permits the rapid institution of IABP support and broadens the medical and surgical applications of IABP.

Vascular complications of intraaortic balloon counterpulsation

Between February 1973 and December 1986, 4,787 patients underwent open heart surgery at Samuel Merritt Hospital. Retrospective analysis revealed 395 (8 percent) consecutive patients who required hemodynamic support with the intraaortic balloon pump. Thirty percent of the patients had preoperative placement, 56 percent needed the balloon in order to wean from cardiopulmonary bypass, and 14 percent required placement in the postoperative period. The intraaortic balloon pump was instituted with multiple techniques and insertion sites. Three hundred eighty-three balloon catheters (96 percent) were inserted through the groin by surgical cutdown or a percutaneous approach. The remaining devices were inserted through the aortic arch. A 12 F. catheter was utilized in 239 patients (61 percent) and a smaller 10.5 F. catheter was placed in 156 patients (39 percent). The hospital mortality rate was 47 percent. Seventy-two of the 395 patients (24 percent) sustained vascular complications related to balloon use. Major complications occurred in 43 patients. Twenty-nine patients sustained minor complications that resolved spontaneously with balloon removal. Risk factors evaluated included patient gender, New York Heart Association class, catheter size, method of introduction, duration of counterpulsation, and presence of symptomatic peripheral vascular disease. Since percutaneous placement was associated with a significant decrease in complications, we concluded that use of the smaller 10.5 F. catheter placed percutaneously is the safest means of employing the intraaortic balloon pump. A monitoring line is placed percutaneously through the femoral artery in high-risk patients before operation. This allows easier access for intraaortic balloon pump placement in hypotensive patients. The presence of a clinical history of peripheral vascular disease was also a highly significant risk factor for vascular complications. Other risk factors increasing the likelihood of vascular compromise included catheter size and duration of counterpulsation.

Closed-chest decannulation of transthoracically inserted aortic balloon catheter without grafting

A method is presented which allows removal of a balloon assist catheter inserted directly (without a graft) through the ascending aorta in the course of heart surgery without the need for reopening the sternotomy incision. The catheter is inserted through the aortic wall under the protection of two purse string sutures which are temporarily tightened using implantable grade silastic rubber tourniquet. The end of the tourniquet is placed subcutaneously in a subxiphoid position. At the time of discontinuation of balloon assist, the balloon can be removed using local anesthesia without reopening the sternum by exposing the end of the tourniquet substernally, removing the catheter, and plugging the tourniquet. The silastic tourniquet may be left in indefinitely or removed through a similar exposure six to eight weeks after the procedure.

Intraaortic balloon pump insertion: a randomized study comparing percutaneous and surgical techniques

To compare the percutaneous and surgical techniques of intraaortic balloon pump insertion, 101 patients referred for this procedure were randomly assigned to either percutaneous or surgical insertion. Insertion using the designated technique was successful in 45 (88%) of 51 patients with percutaneous insertion and 48 (96%) of 50 patients with surgical insertion (difference not statistically significant). The time from the beginning of the insertion procedure to the initiation of counterpulsation was 13 +/- 8 minutes for the percutaneous technique versus 31 +/- 16 minutes for the surgical technique (p less than 0.001). In the percutaneous group, 10 patients required Fogarty thrombectomy after balloon pump removal, and 1 patient developed severe leg ischemia requiring immediate termination of balloon pump support. In the surgical group, one patient developed leg ischemia requiring surgical intervention, three patients developed sepsis with bacteremia (including one patient who required vein patch repair of the femoral artery), one patient developed a wound infection requiring debridement and one patient had a cerebral embolus. Aortic dissection, aortoiliac perforation or amputation did not occur in either group. Major vascular complications occurred in 11 patients (22%) with percutaneous insertion versus 2 patients (4%) with surgical insertion (p less than 0.05). It is concluded that although the percutaneous technique for intraaortic balloon pump insertion is faster than the surgical technique and is technically easy, it is associated with a higher incidence of vascular complications.

Incidence and management of limb ischemia with percutaneous wire-guided intraaortic balloon catheters

In 103 patients who underwent placement of 106 percutaneous wire-guided intraaortic balloon catheters between August 1983 and January 1986, all placements were successful and the average duration of counterpulsation was 3.4 +/- 1.6 days. During counterpulsation, 45 patients developed limb ischemia that required premature balloon removal in 29 patients. The development of limb ischemia was significantly related to the presence of diabetes (risk ratio 2.0), peripheral vascular disease (risk ratio 1.9), female gender (risk ratio 1.8) and the presence of a postinsertion ankle-brachial pressure index less than 0.8 (risk ratio 7.9). There was no association between the development of limb ischemia and age, body surface area, balloon size (10.5F/12F) or adequacy of anticoagulation. Fifteen patients underwent vascular surgery for treatment of balloon-related limb ischemia, which was associated with one operative death. Nine patients had persistent limb ischemia (seven asymptomatic, two symptomatic) at the time of hospital discharge. Improvements in wire-guided balloon technology have increased the probability of successful balloon placement over that of surgical placement and have reduced the incidence of major aortic injury, but there is no evidence that these improvements have reduced the incidence of limb ischemia or its sequelae. This should be borne in mind before proceeding with balloon insertion in patients with one or more risk factors for developing limb ischemia.

Intraaortic balloon entrapment: a complication of balloon perforation

A patient in whom perforation of a percutaneously inserted intraaortic balloon resulted in a clot formation inside the balloon is described. The balloon could not be withdrawn percutaneously and was lodged in the femoral artery. It was removed surgically, and the artery was repaired.

Intraaortic balloon pumping 1967 through 1982: analysis of complications in 733 patients

Between June 1967 and December 1982, 872 attempts at intraaortic balloon pumping (IABP) were made in 733 patients. Nearly 75% of the patients were men; the proportion of women has increased in recent years. The principal indication for IABP support initially was cardiogenic shock, but over the years, preoperative support, weaning from cardiopulmonary bypass and unstable angina have become the primary indications. Complications of IABP were classified and distributed by severity (minor: I [15%] and II [26%]; major: III [3%] and IV [1%]) and type ([vascular [22%], infectious [22%], and bleeding [7%]). Vascular complication rates were higher in women (32 vs 18%; p = 0.0001), in diabetic patients (32 vs 20%, p = 0.003), and in hypertensive patients (27 vs 20%, p = 0.02). These did not vary with the duration of IABP support (range of duration 0 to 76 days). The rate of infectious complications was related to location where IABP was performed (coronary care unit 26%, operating room 12%). The rate of fever and bacteremia increased significantly with duration of IABP support, but the rate of local wound infection did not. In conclusion, most IABP complications are minor, resolve after balloon removal, are related to vascular status of the patient and, with the exception of bacteremia, are independent of IABP duration.

Clinical experience with intra-aortic balloon counterpulsation in 112 consecutive patients

Intra-aortic balloon pumping (IABP) was attempted in 112 consecutive patients, resulting in successful placement in 49 of 50 (98%) patients when the percutaneous technique was used and in 60 of 62 (97.3%) patients when the surgical technique was used. Complications following acute myocardial infarction and perioperative problems were the two most frequent (47% and 52%, respectively) indications for IABP. A favorable survival was observed in patients with acute myocardial infarction with ventricular septal defect undergoing surgery after IABP (80%) and in patients in whom IABP was used in the perioperative setting (57.6%); survival remained poor in patients with postinfarction shock or severe heart failure (20% and 23%, respectively). Complications related to IABP occurred in 23 (20.5% patients but tended to occur more frequently in patients undergoing placement by the percutaneous route than by the surgical route (31% vs 9.6%; p less than 0.03) and in patients over age 70. Thus IABP can be successfully inserted in the majority of patients, but the high complication rate, especially with the percutaneous route, suggests caution in its indiscriminate use, particularly in patients whose mortality remains high despite its use.

Complications of ascending aortic intraaortic balloon pump cannulation

Choice of a route of cannulation for intraaortic balloon counterpulsation during cardiopulmonary bypass is related to accessibility. In those patients in whom it is impossible to pass the intraaortic balloon pump (IABP) into the common femoral artery, ascending aortic cannulation is a rapid and direct method of insertion. Eight patients are described in whom ascending aortic IABP cannulation was undertaken to enable weaning from cardiopulmonary bypass after cardiac surgical procedures. The following problems were encountered: graft infection, aberrant cannulation of the left subclavian artery, left coronary artery embolism, and inability to close the sternum due to mechanical tamponade. A technique is described for insertion of the IABP using a polytetrafluoroethylene (Impra) graft and closed-chest decannulation. Although considerable morbidity and mortality are associated with ascending aortic cannulation, it is simple, fast, and effective, and should be considered for all patients requiring postoperative IABP support in whom peripheral vascular disease makes access difficult.

Intraaortic balloon counterpulsation

The physiologic principle of hemodynamic circulatory support for the failing left ventricle must be directed toward reducing left ventricular work and myocardial oxygen demand and increasing myocardial oxygen supply. This support can best be accomplished with the use of intraaortic balloon counterpulsation. Support of the failing heart after cardiopulmonary bypass was the most frequent indication for counterpulsation treatment in our reported series. This type of assist was required in 5.2 percent of my patients. I reviewed the reports from three medical centers and added our own results in patients who required intraaortic balloon counterpulsation for weaning from cardiopulmonary bypass. Of a total of 399 patients, 255 or 73 percent were weaned off the balloon assist device and of this group, 239 or 60 percent were subsequently discharged from the hospital. Among patients who required intraaortic balloon counterpulsation for postoperative pump failure, 43 (70 percent) of 66 patients were weaned off the intraaortic balloon device, and 35 (53 percent) were later discharged from the hospital. A 24 percent survival rate occurred in patients with cardiogenic shock treated solely with counterpulsation; however, the survival rate increased to 52 percent when those patients subsequently received cardiac catheterization and appropriate surgical intervention.

Accelerated renovascular hypertension following intra-aortic balloon counter-pulsation

A 62-year-old man developed high serum renin arterial hypertension following thoraco-abdominal dissection which resulted from insertion of an intra-aortic balloon pump (IABP). Nephrectomy resulted in cure of medically unmanageable hypertension.

Identification of patients at high risk for complications of intraaortic balloon counterpulsation: a multivariate risk factor analysis

Risk factors for vascular complications of intraaortic balloon (IAB) counterpulsation were evaluated in 206 consecutive patients. The approach was percutaneous in 105 patients and surgical cutdown in 101. Vascular complications occurred in 42 patients, and of these 21 required surgery. Multivariate analysis demonstrated the following major risk factors for vascular complications: preexisting peripheral vascular disease (PVD) defined as a history of claudication, femoral bruit or absent pedal pulse (p less than 0.01); and the use of the percutaneous approach (p = 0.02). Evidence of PVD was particularly predictive of major vascular complications requiring surgery (p less than 0.01). In patients with evidence of previous PVD, the risk for a major vascular complication was 31% with the percutaneous, and 16% with the surgical cutdown approach. Without PVD, the risk for a major vascular complication was 4 times higher in women (15%) than in men (3.5%), but in the presence of PVD gender had no significant effect (p = 0.03). Age, duration of IAB counterpulsation and indication for insertion were not significant risk factors. It is concluded that (1) without previous PVD, women are at greater risk than men for major vascular complications (due to smaller arterial size); and (2) evidence of previous PVD identifies patients at high risk for major vascular complications with IAB counterpulsation, particularly by way of the percutaneous approach.

Intraaortic balloon pump morbidity: a comparative analysis of risk factors between percutaneous and surgical techniques

We reviewed our concurrent experience with percutaneous insertion versus surgical placement of the intraaortic balloon pump over a two-year period both to compare morbidity and to provide guidelines for the choice of method in particular patient groups and clinical settings. The effects on morbidity of sex, age, emergency placement, coexisting peripheral vascular disease, and duration of counterpulsation were determined. Sex was a highly significant factor, with low complication rates (3/29 or 10.3%) for percutaneous insertion in men and an inordinately high morbidity (12/17 or 70.6%) in women (Fisher exact test: p = 4.611 X 10(-5)). This difference may be due to the smaller size of the femoral artery in women. We conclude that percutaneous insertion is the preferred technique for most men but that direct exposure of the femoral artery should be employed in women. Given the serious morbidity encountered with each technique, there is no justification to broaden the indications for intraaortic balloon counterpulsation.

Myonephropathic-metabolic syndrome as a complication of cardiopulmonary bypass

We encountered eight rare cases of myonephropathic metabolic syndrome (MNMS) which developed as a complication of the femoral arterial cannulation (FAC) during cardiopulmonary bypass (CPB). Seven were boys ranging in age from 4-17 years, and all had undergone open heart surgery using CPB with a hemodilution technique. These eight corresponded to 1.9 per cent of the 420 patients treated with CPB before June, 1974. The pump priming fluid used was either Ringer's lactate solution alone or that containing a small amount of colloidal solution. Duration of CPB ranged from 52 min to 2 hrs and 42 min, but the FAC period was more than 3 hrs in each case. Acute renal failure occurred in 3 and 2 required peritoneal dialysis. Severe respiratory insufficiency occurred in 2 and one died 3 months after the operation. The most effective means to prevent the development of MNMS seems to be the local cooling of the cannulated limb during FAC. MNMS did not occur in 444 cases of CPB with FAC after July 1974, and here local cooling was applied in all cases.

Mechanical techniques of circulation support: a percutaneous intra-aortic balloon device

As medical indications for intra-aortic balloon (IAB) pumping expand, many physicians without surgical expertise are faced with the decision to institute circulatory support. Accordingly, to facilitate rapid establishment of cardiac assist and to obviate the need for operative insertion and removal, a 40-cc single-chambered device was designed for percutaneous insertion by the Seldinger technique. Hemodynamic augmentation produced by the percutaneous balloon is similar to that obtained with conventional IAB. It appears that complications related to IAB insertion may be decreased by the percutaneous method.

Unsuspected vascular disease: a potential limitation to the use of the intra-aortic balloon

Since vascular tortuosity of stenosis may preclude placement of the intra-aortic balloon, 63 consecutive patients (37 men) having routine Judkins' cardiac catheterization had an aortogram prior to withdrawal of the last catheter. No patient had a history of claudication, palpable aneurysms, pulse deficit, or bruit. No complications occurred. Significant peripheral vascular disease was found in ten patients: three had aortic, one had iliac, and six had femoral stenosis or tortuosity. All were men. The age of patients with peripheral vascular disease was 61.4 +/- 7.7 years, while those without were 56.9 +/- 9.3 years (P = NS). No difficulty was encountered entering the femoral artery in any patient; there was difficulty advancing the catheter in five of ten (50%) patients with peripheral vascular disease and in three of 54 (6%) patients without (P less than 0.002). Fifteen patients without peripheral vascular disease had normal coronary arteries, while none with peripheral vascular disease was normal. In patients with coronary disease, the number of vessels involved was the same in both groups. Peripheral vascular disease that might preclude placement of the intra-aortic balloon occurs in 14% of patients undergoing cardiac catheterization and 18% of patients with coronary artery disease. Aortography may be safely performed and should be considered during routine cardiac catheterization in patients who may require intra-aortic balloon placement.

Shock in acute myocardial infarction: evolution of physiologic therapy

In the past 25 years the treatment of shock in myocardial infarction has evolved into a physiologic approach based on on-line measurements of hemodynamic variables. This has aided in the development of new pressor agents so that a family of pharmacologic agents is now available. Appropriate use of vasodilators and recognition and treatment of intravascular volume depletion have increased survival. Recognition and appropriate treatment of the preshock state have decreased the incidence of shock. The criteria for use of mechanical support and surgical intervention are soundly established; the use of thrombolytic therapy and balloon angioplasty for this syndrome is ready to be evaluated.

Percutaneous intraaortic balloon counterpulsation. Clinical effectiveness and hazards

Because of its greater ease and rapidity of insertion, the percutaneous intraaortic balloon in many institutions has become the primary method for implementing counterpulsation. We report the results and complications of 113 attempted procedures in a variety of clinical settings. We had a high (93.8 percent) insertion success rate. However, our 18.6 complication rate was similar to the experience reported for the surgical method of insertion. Thus, the original anticipation of reduced complications with this method has not been realized in this and other recent reports.

Bilateral renal artery thrombotic occlusion: a unique complication following removal of a transthoracic intraaortic balloon

An intraaortic balloon pump (IABP) was inserted through the ascending aorta during a coronary artery bypass operation. Five days later, after removal of the IABP and ligation of the end-to-side Dacron graft, the patient became acutely anuric. Abdominal aortography demonstrated a large "trapeze-shaped" thrombus which occluded both renal arteries. Following thrombectomy the patient recovered, with eventual return of renal function to the preoperative state.

Radionuclide assessment of left ventricular function in patients requiring intraoperative balloon pump assistance

Twenty-three surviving patients who were weaned from cardiopulmonary bypass with intraaortic balloon pump assistance returned for follow-up radionuclide left ventricular (LV) function and thallium 201 perfusion studies at a mean of 23 +/- 3 months following operation. It was found tat despite profound intraoperative myocardial depression requiring intraaortic balloon assistance, 13 patients had no change (within 10%) in the resting LV ejection fraction compared with the preoperative measurement. Among all 23 patients, there was no difference between mean (+/- standard error of the mean) preoperative and postoperative resting LV ejection fraction (48 +/- 4 vs 46 +/- 4%, p = not significant [NS]). Only 11 patients had perioperative myocardial infarction documented by new Q waves in the electrocardiogram, by elevation of creatine kinase-MB fraction, or by defects on thallium 201 imaging not explained by documented myocardial infarction before operation. Overall, postoperative resting LV ejection fraction was not different from the preoperative value in patients with perioperative myocardial infarction (44 +/- 7 vs 47 +/- 5%, p = NS). Postoperative resting LV ejection fraction rose by greater than 10% compared with preoperative values in 4 patients (3 with aortic valve replacement), remained within the 10% limit in 9 patients, and fell by greater than 10% in 10 patients (7 with perioperative myocardial infarction). Only 4 out of 16 patients studied at follow-up with exercise radionuclide studies demonstrated a normal LV response to exercise (greater than 5% increase in LV ejection fraction). Thus, among survivors requiring intraaortic balloon pump assistance for weaning from cardiopulmonary bypass, LV performance at rest is frequently preserved. In addition, 11 of the 23 patients had evidence of perioperative myocardial infarction, indicating a component of reversible intraoperative LV dysfunction.

Percutaneous intraaortic balloon insertion

A new single chambered percutaneous intraaortic balloon has been constructed around a central guidewire. The balloon can be wrapped around the guidewire, enabling its insertion into the femoral artery through a 12F sheath inserted with the conventional Seldinger technique. Percutaneous intraaortic balloon insertion has been performed in 27 patients (mean age 58 years) for a variety of medical and surgical indications. Percutaneous balloons could not be advanced into the aorta in two patients (7.4 percent) with severe bilateral aortoiliac occlusive disease. In all 25 patients undergoing intraaortic balloon pumping satisfactory circulatory support was achieved, and 21 (84 percent) of the patients survived to be discharged from the hospital. The mean duration of intraaortic balloon pumping was 3.5 days. Percutaneous intraaortic balloon insertion requires less than 5 minutes and has been successfully performed in the cardiac catheterization laboratory, coronary care unit, operating room and recovery room. After direct balloon removal, external pressure was applied for 30 minutes. No patient experienced hematoma of the groin, aortic dissection, compromised distal pulses or late wound complications. Percutaneous balloon insertion permits the rapid institution of circulatory support and broadens the medical and surgical applications of intraaortic balloon pumping.