Introduction
The intra-aortic balloon pump (IABP) was first used successfully by
Kantrowitz and colleagues (1) in 1968 for patients with cardiogenic
shock. Intra-aortic balloon counterpulsation is commonly used to help
stabilize hemodynamic parameters and improve end-organ function.
Traditionally, IABPs are inserted via the femoral artery; however, this
approach is usually contraindicated in patients with severe peripheral
vascular disease (PVD). The axillary and transaortic routes have been
cited in case reports as alternative routes; however, these frequently
require surgical intervention.(2, 3) We describe a case involving a
percutaneously-placed IABP via a brachial approach for a high-risk
cardiac surgery patient. The patient exhibited severely impaired left
ventricular systolic function, as well as aortic valve infective
endocarditis, resulting in symptomatic heart failure. Repeat surgery was
required for this patient, following severe deterioration of a
previously-implanted Freestyle bioprosthesis as a result of bacterial
infection . We expected that counterpulsation therapy delivered via an
IABP would help to wean the patient off the cardiopulmonary bypass and
maintain hemodynamic stability during the postoperative course. However,
both external iliac arteries were totally occluded, so we decided to
insert the IABP via the brachial artery. Although transbrachial
insertion of an IABP has previously been reported , almost all of the
reported cases were for hemodynamic support during a percutaneous
coronary intervention or coronary artery bypass grafting. In our case,
due to the high risk of the repeated surgery, as well as the absence of
external iliac arteries, transbrachial IABP was effective and useful for
perioperative course.
Case Report
A 63-year-old male with endocarditis-associated structural aortic valve
deterioration and severe left ventricular dysfunction (approximately
20% ejection fraction) was referred to our department for surgical
treatment. The patient had undergone a Bentall operation using a
Medtronic Freestyle stentless aortic bioprosthesis 10 years earlier, and
had also been diagnosed with rectal carcinoma at another hospital. He
was unable to undergo surgery for the carcinoma, due to left ventricular
dysfunction and heart failure. We suspected that the left ventricular
dysfunction was caused by aortic regurgitation, so we decided to treat
the aortic valve first. The aortic valve re-replacement via resternotomy
was a high-risk operation because of the left ventricular dysfunction,
so we decided that an assisting device would be necessary to wean the
patient off the cardiopulmonary bypass and maintain hemodynamic
stability during the postoperative course. We elected to use an
intra-aortic balloon pump due to its ease of use and its access through
the femoral artery. However, both of the patient’s external iliac
arteries were occluded or displayed aplasia. Thus, we decided to insert
the IABP via the brachial artery instead.
In the operating theatre, the left brachial artery was used for access
and was cannulated using a 7 Fr Super Arrow-Flex Sheath Introducer
(Teleflex Medical, PA, US ). A 0.025″ Radifocus Guidewire (Terumo,
Tokyo, Japan) was introduced into the left brachial artery and advanced
up to the subclavian artery under fluoroscopic guidance. The acute bend
between the descending thoracic aorta and the left subclavian artery
made guiding the wire down to the descending aorta difficult. To
facilitate the advancement of the guidewire selectively down to the
descending aorta , a 6 Fr Judkins R diagnostic catheter was advanced
over the guidewire and positioned at the ostium of the left subclavian
artery with its tip pointing downward to the descending aorta, as
confirmed on fluoroscopy. The guidewire was then advanced selectively
down the descending aorta. The 7 Fr IABP (Tokai Medical Products, Aichi,
Japan) was advanced over the guidewire and positioned in the descending
aorta. The IABP was not activated before the surgery, due to the
patient’s aortic value regurgitation pathology.
The cardiac surgery was started only once the safe placement of the IABP
had been ensured. The aortic valve was re-replaced with a new aortic
valve bioprosthesis via resternotomy. The Freestyle bioprosthesis was
visibly infected, so the leaflets were perforated and dissected to
remove the vegetation . While the patient was weaned off the
cardiopulmonary bypass, the transbrachial IABP was activated to maintain
hemodynamic stability. We were able to safely wean the patient off the
cardiopulmonary bypass using the IABP support. The postoperative course
was satisfactory. On postoperative day one, the hemodynamic condition of
the patient was sufficiently stable to safely withdraw the IABP
assistance. We therefore removed the IABP and applied manual compression
to the inserted left brachial artery while ensuring patent hemostasis.
Transthoracic echocardiography, which occurred three months after the
cardiac operation, revealed improvement of left ventricular function,
with a recovery in ejection fraction to 40%. The rectal carcinoma
surgery was performed six months after the cardiac surgery. Over five
years later, the patient is still alive and attends our outpatient
clinic.
Comments
The intra-aortic balloon pump offers only limited circulatory support,
and has not shown prognostic benefits in recent clinical trials. For
this reason, and according to the latest guidelines, its use is not
routinely recommended in patients with cardiogenic shock. Nevertheless,
it is still widely available in most centers, and facilitates an
increase in diastolic coronary flow during the perioperative course that
might be beneficial in patients with high-risk coronary anatomy and
impaired left ventricular systolic function. Noël and colleagues first
reported the transbrachial insertion of an 8 Fr IABP catheter for
ventricular assistance during percutaneous coronary intervention.(4)
Bundhoo and colleagues recently suggested that a left transbrachial
approach for IABP insertion might reduce the risk of neurological
complications relative to the standard transfemoral approach.(5)
Transaortic and axillary placement of IABPs have also been described.(2,
3) However, these techniques are costly and risky, require major
vascular intervention, and necessitate the use of general anesthesia.
The brachial artery is superficial, easily accessible, and amenable to
manual compression to achieve adequate hemostasis. Although
transbrachial insertion of IABPs has been reported, in almost all cases
it was for hemodynamic support during a percutaneous coronary
intervention or a coronary artery bypass grafting. We used the
transbrachial IABP in a high-risk repeat cardiac surgery, as well as to
wean the patient off the cardiopulmonary bypass and maintain hemodynamic
stability during the postoperative course.
However, this technique has several potential disadvantages . First, the
use of a catheter via the brachial approach seems to be riskier than via
the femoral approach in terms of access site complication, such as limb
ischemia, or vascular laceration necessitating surgical repair. Second,
the catheter shaft may kink during insertion, which could cause
narrowing or closure of the inner lumen of the catheter and eventually
lead to insufficient balloon dilatation. Third, the risk of
cerebrovascular events increases, because the catheter crosses over the
ostium of the vertebral and internal cerebral arteries.
In our case, we used the left brachial route as opposed to the right.
Despite being technically more challenging, we chose the left side
because it avoided all the cerebral vessels (apart from the left
vertebral artery) and reduced the risk of cerebral embolization.
Furthermore, it allowed the surgeon to operate from the right side of
the patient.
To prevent the catheter from developing a kink, we used the Super
Arrow-Flex Sheath Introducer (Teleflex Medical, PA, US), which has a
coil-wire design that allows the sheath to flex at any point and in any
direction without kinking or losing support. It also exhibits good
steerability for negotiating tortuous anatomies. After IABP placement,
we monitored for limb ischemia using digital pulse oximetry, radial
pulse palpation, hand temperature monitoring, and the application of
systemic heparinization. The ECG was used as the trigger signal, since
we were unsure whether the ‘upside down’ IABP would sense the central
aortic pressure sufficiently for the arterial pressure wave form to be
effective as the triggering mechanism.
In conclusion, adequate and sustained hemodynamic support using a
transbrachial IABP was achieved in our high-risk patient without
significant complications, thus reducing perioperative risk. A left
transbrachial percutaneous approach may thus be a safe and effective
alternative if femoral artery access cannot be achieved.
References
1) Kantrowitz A, Tjonneland S, Freed PS, Phillips SJ, Butner AN, Sherman
JL Jr. Initial clinical experience with intra aortic balloon pumping in
cardiogenic shock. JAMA. 1968;203:135-40.
2) Burack JH, Uceda P, Cunningham JN Jr. Transthoracic intraaortic
balloon pump: a simplified technique. Ann Thorac Surg 1996;62:299–301.
3) H’Doubler PB Jr, H’Doubler WZ, Bien RC, et al. A novel technique for
intraaortic balloon pump placement via the left axillary artery in
patients awaiting cardiac transplantation. Cardiovasc Surg
2000;8:463–5.
4) Noe¨l BM, Gleeton O, Barbeau GR. Transbrachial insertion of an
intraaortic balloon pump for complex coronary angioplasty. Catheter
Cardiovasc Intervent 2003;60:36–39.
5) Bundhoo S, O’Keefe PA, Luckraz H, Ossei-Gerning N. Extended duration
of brachially inserted intra-aortic balloon pump for myocardial
protection in two patients undergoing urgent coronary artery bypass
grafting. Interact CardioVasc Thorac Surg 2008;7:42–44.
Figure Legends
Fig. 1: Three-dimensional computed tomography of the aorta. This reveals
the total occlusion of the bilateral external iliac arteries.
Fig. 2: (Left) A 0.025″ Radifocus Guidewire (Terumo, Tokyo, Japan) was
introduced into the left brachial artery and advanced downward to the
descending aorta. A 7 Fr Super Arrow-Flex Sheath Introducer (Teleflex
Medical, PA, US) was advanced over the guidewire and positioned at the
ostium of the left subclavian artery (red arrow) with its tip pointing
downward to the descending aorta. The 7 Fr intra-aortic balloon pump
(Tokai Medical Products, Aichi, Japan) was advanced over the guidewire
and positioned in the descending aorta. (Right) Transbrachial access for
intra-aortic balloon pump support.