Interact CardioVasc Thorac Surg 2009;9:369-370. doi:10.1510/icvts.2009.207522
© 2009 European Association of Cardio-Thoracic Surgery
Case report - Assisted circulation |
Intra aortic balloon pump insertion through left axillary artery in patients with severe peripheral arterial disease
Giuseppe Zatteraa,
Pasquale Totaroa,*,
Andrea Maria D'Arminia,b and
Mario Viganòa,b
a Division of Cardiac Surgery, IRCCS Foundation San Matteo, Pavia, Italy
b School of Medicine, University of Pavia, Italy
Received 17 March 2009;
received in revised form 15 April 2009;
accepted 20 April 2009
*Corresponding author. Foundation IRCCS San Matteo, School of Medicine, University of Pavia, Pavia, Italy. Tel.: +39 349 8465085.
E-mail address: ptotaro{at}yahoo.com (P. Totaro).
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Abstract
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Intra aortic balloon pump (IABP) is the mechanical assist device most frequently used in cardiac surgery. Recent demonstration of better outcome following preoperative IABP insertion in high-risk patients has further extended its indication. However, due to an increasing complexity of patients currently referred for cardiac surgery, several patients with potential indication for preoperative and/or postoperative IABP present severe peripheral vascular disease which usually contraindicates IABP insertion. Here we present an alternative technique for IABP insertion in patients with severe peripheral vessel disease.
Key Words: Cardiac surgery; Intra aortic balloon pump; Vascular complications
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1. Introduction
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Intra aortic balloon pump (IABP) is the mechanical assist device most frequently used in cardiac surgery [1]. The extension of IABP indication, as prophylactic tools, for high-risk patients undergoing coronary surgery [2] has contributed to enlarge the potential pool of patients who are candidates to receive IABP. Elderly high-risk patients, however, present frequently severe co-morbidities, including severe peripheral vessel diseases which usually contraindicate routinely trans-femoral IABP insertion. Use of alternative approaches [3–5] in such patients with clinical indication to IABP insertion but high risk of post-insertion vascular complications has to be, therefore, encouraged. Here, we report our preliminary experience using axillary artery as alternative approach for IABP insertion.
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2. Case description
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A 78-year-old male patient was referred to our division complaining of chronic ischemic heart disease with severe left ventricle dysfunction (preoperative LVEF >30%). Preoperative evaluation revealed the presence of severe atherosclerotic peripheral vessel diseases involving abdominal aorta, lower limbs and right renal artery. Epi-aortic vessels were also involved as left carotid artery presented a significant stenosis. Past cardiac medical history of the patient included an anterior acute myocardial infarction, treated medically, back in 1992, followed by progressive left ventricle dilation with increasing dysfunction. After two episodes of congestive heart failure the patient underwent coronary angiography in October 2008, which showed severe triple-vessel disease and the patient was, therefore, referred to our division. Further predictive risk factors for poor outcome also included recent heavy smoking history (back to two months earlier), pulmonary hypertension and emphysema. Myocardial revascularization was scheduled and the patient underwent on-pump triple CABG (sequential vein graft for 1st diagonal branch and LAD, vein graft for RCA) combined with a left ventricle plasty (endoaneurysmorraphy according to the Cooley technique). As a routine in our division, myocardial protection was obtained by means of aortic infusion of crystalloid cardioplegia (single infusion of 1000 ml) and the total aortic cross-clamp time was 28 min. Following a period of reperfusion and despite inotropic support, which was gradually increased up to high dose (adrenaline 0.3  /kg/min, dobutamine 10 /kg/min), several attempts of weaning the patient from cardiopulmonary bypass (CPB) were unsuccessful. Trans-esophageal echo confirmed the depressed overall left ventricle function (EF 25%) with no specific surgical problems. The presence of severe peripheral vessel disease involving the abdominal aorta and lower limbs (also including a previous femoro-popliteal graft back in 2005 followed by two attempts of graft embolectomy) was a clear contra-indication for a standard femoral artery insertion of IABP. We decided, therefore, to attempt IABP insertion through left axillary artery which was exposed at the left deltoid pectorals groove (see Fig. 1a), as previously described by Neri et al. [6]. The above has become our routine approach for axillary artery cannulation and has been used in our division in >100 patients. Following major and minor pectorals muscles incision, axillary artery was identified and a 5-0 polypropylene (Prolene, Ethicon, USA) pursestring was made on the surface of the artery. Under accurate TEE monitoring, which is obviously mandatory in all such cases, a Profile © Datascope IABP 40 ml catheter was easily inserted using a Seldinger technique. The patient was then successfully weaned from CPB. Once the patient was in ICU (see Fig. 1b), hemodynamics increased gradually and the following day weaning off IABP could be started. On postoperative day 2, once hemodynamic parameters were stable, IABP was eventually removed. IABP surgical removal was carried out in ICU, and simply consisted of re-opening the wound and tightening the pursestring. The following postoperative course was characterized by progressive respiratory distress requiring positive airways pressure ventilation. No complications related to axillary artery puncture were reported. The patient was eventually discharged after 34 days.
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Fig. 1. Patient transferred to ICU with IABP inserted surgically through left axillary artery approached at deltoido-pectoralis groove (a). Correct position of IABP checked at chest Rx (b): the proximal marker of the balloon has to be considered instead of the distal marker as with standard IABP inserted through femoral artery.
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3. Discussion
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Alternative approaches for IABP in patients with peripheral vessel disease have to be explored and encouraged due to the increased incidence of elderly high-risk patients undergoing coronary surgery, who potentially could benefit from an IABP. Such patients have frequently a past history of peripheral vascular approaches and or peripheral vessel diseases and, therefore, presented very often contraindications to standard peripheral IABP insertion. Emergency insertion through femoral artery could be attempted but it could cause severe complications [7]. An alternative IABP insertion technique through subclavian artery was initially proposed by Mayer in 1978 [3] and then, with a simplified technique by Mc Bride and co-authors in 1989 [4]. Our experience seems to confirm that axillary artery is a suitable alternative to allow IABP positioning in patients with severe peripheral vessel diseases. Advantages of such approach include also the possibility of mobilizing the patient if a longer support is required, as reported by Cochran et al. [8], who described left axillary artery approach, but with a Dacron graft interposition, as ambulatory procedure for prolonged assistance in patients awaiting cardiac transplantation. Percutaneous brachial approach has been also suggested as an alternative approach for IABP insertion [5, 9], but we do believe that axillary artery approach, despite being more invasive has to be preferred, especially in theatre for patients who cannot be weaned from CPB. Furthermore, we do not consider the graft interposition mandatory as we reported no major complication in axillary artery direct cannulation. Appropriate TEE monitoring is crucial during the insertion and the right position of the catheter has to be checked with a chest X-ray looking at the proximal marker, which is usually easily identified, and corresponds to the distal marker when IABP is inserted through femoral artery. In conclusion, we think that this approach has to be added to the surgical armamentarium as it can be effective in extended IABP utilization even in patients with peripheral vessel diseases.
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Acknowledgements
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Authors thank Matteo Pozzi MD and Fabio Cuttone MD, residents in Cardiac Surgery at IRCCS Foundation San Matteo in Pavia for their precious technical support.
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References
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Abstract
1. Introduction