Removal of Intraaortic Balloon without Vascular Complications Ernest E. Moore, M.D., Bruce Broecker, M.D., James E. DeMeules, M.D., and Laurence H. Coffin, M.D.
Clinical Material and Technique During the twelve-month period from January 1 to December 31, 1974, 27 adult cardiac surgical patients required IABP assistance. The duration of balloon pumping ranged from 12 to 235 hours with a mean of 113 hours. Among the 10 patients who died, the IABP was being utilized at the time of death. In all patients the balloon was inserted by the following technique and reThe intraaortic balloon pump (IABP)has proved moved as described in the 17 survivors. effective in the treatment of low cardiac output The Avco triple-segment IABP is introduced states following acute myocardial infarction and into the descending thoracic aorta through the cardiac operation [5]. Technical articles have femoral artery as described by Kantrowitz and been written describing the method of insertion associates [2]. The length of catheter to be inand removal of the balloon [l-3, 51. A 10 or 12 serted is determined by the distance between mm woven Dacron graft, cut on one end to a the palpated inferior border of the medial head 45-degree angle, is placed over the balloon prior of the clavicle and the common femoral arto insertion through a longitudinal common teriotomy. It is important that the balloon be femoral arteriotomy. An end-to-side anas- inserted through the common femoral artery to tomosis of graft to artery provides flow distal to preserve collateral circulation through the deep the arteriotomy. The graft is ligated to the cathe- femoral artery. After roentgenographic conter. firmation of position, the IABP is secured by Vascular complications consisting of throm- ligating the graft around the balloon. It is imporbus formation, distal embolization, and tant that the ligature closest to the graft-arterial peripheral arterial insufficiency have been re- junction be placed as near as possible to the ported [l, 41. Early-appearing complications common femoral artery. This will create the likely relate to extremely diseased vessels and smallest possible cul-de-sac so that thrombus thrombus formation due to stagnation in the formation in this area of low flow will be minicul-de-sac formed at the graft-artery junction. mal. Heparin, 5,000 units intramuscularly every Late vascular complications may be caused by twelve hours, and 10% low-molecular-weight leaving potentially infected graft material in dextran, 20 ml per hour, are used throughout place, narrowing the artery by ligation or sutur- balloon pumping. ing of the graft, or leaving a persistent cul-de-sac At removal, the previously placed graft is carefor thrombus formation. fully excised from the femoral artery. The wound and removed graft are cultured. A Fogarty catheFrom the Department of Surgery, Section of Thoracic & Car- ter is passed distally into the superficial and diac Surgery, and the Mary Fletcher Unit, University of deep femoral arteries. The distal vessels are Vermont Medical Center, Burlington, VT. heparinized. An oval-shaped patch graft is Accepted for publication June 3, 1975. Address reprint requests to Dr. DeMeules, Mary Fletcher fashioned from woven Dacron and sutured onto the arteriotomy (Figure). After satisfactory arteUnit, MCHV, Burlington, VT 05401.
ABSTRACT A technique for inserting and removing the intraaortic balloon pump without vascular complications is described. Prevention of clot formation at the graft-arterial junction, preservation of collateral circulation by insertion in the common femoral artery, removal of potentially infected graft material, and enlargement of the common femoral artery by patch angioplasty are important factors.
566
567 How to Do It: Moore et al: Removal of Intraaortic Balloon
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Comment A method of repairing the common femoral artery following removal of the IABP has been used successfully in 17 patients. There have been no instances of peripheral arterial insufficiency, false aneurysm, embolism, or infection in surviving or dead patients. The success of this technique rests on (1) the prevention of clot formation due to stasis by placing the ligature around the graft and catheter close to the femoral artery, and (2) the use of a patch graft to enlarge the lumen of the usually diseased artery rather than narrowing it by suturing or ligating the previously placed graft. The observation that the only thrombus found in this group of patients was in the removed graft segment leads us to believe that excision of this segment followed by patch angioplasty is important to prevent vascular complications. References
Patch angioplasty of common femoral arteriotomy after removal of graft and passage of Fogarty embolectomy catheter.
rial flow is confirmed by palpating the distal pulses, the wound is irrigated with an antibiotic solution and closed. At the time of balloon removal in all surviving patients, no thrombus was found on balloon or catheter surfaces, none was recovered from distal femoral vessels, and only small fragments of thrombus were seen in the removed graft.
1. Dunkman WB, Leinbach RC, Buckley MJ, et al: Clinical and hernodynamic results of intra-aortic balloon pumping and surgery for cardiogenic shock. Circulation 46:465, 1972 2. Kantrowitz A, Phillips SJ, Butner AN, et al: Technique of femoral artery cannulation for phase-shift balloon pumping. J Thorac Cardiovasc Surg 56:279, 1968 3. Saini VK, Berger RL: Technique of aortic balloon catheter deployment with the use of a Fogarty catheter. Ann Thorac Surg 14:440, 1972 4. Scheidt S, Wilner G, Mueller H, et al: Intra-aortic balloon counterpulsation in cardiogenic shock report of a co-operative clinical trial. N Engl J Med 288:979, 1973 5. Weber KT, Janicki JS: Intraaortic balloon counterpulsation. Ann Thorac Surg 17:602, 1974
Clinical Material and Technique During the twelve-month period from January 1 to December 31, 1974, 27 adult cardiac surgical patients required IABP assistance. The duration of balloon pumping ranged from 12 to 235 hours with a mean of 113 hours. Among the 10 patients who died, the IABP was being utilized at the time of death. In all patients the balloon was inserted by the following technique and reThe intraaortic balloon pump (IABP)has proved moved as described in the 17 survivors. effective in the treatment of low cardiac output The Avco triple-segment IABP is introduced states following acute myocardial infarction and into the descending thoracic aorta through the cardiac operation [5]. Technical articles have femoral artery as described by Kantrowitz and been written describing the method of insertion associates [2]. The length of catheter to be inand removal of the balloon [l-3, 51. A 10 or 12 serted is determined by the distance between mm woven Dacron graft, cut on one end to a the palpated inferior border of the medial head 45-degree angle, is placed over the balloon prior of the clavicle and the common femoral arto insertion through a longitudinal common teriotomy. It is important that the balloon be femoral arteriotomy. An end-to-side anas- inserted through the common femoral artery to tomosis of graft to artery provides flow distal to preserve collateral circulation through the deep the arteriotomy. The graft is ligated to the cathe- femoral artery. After roentgenographic conter. firmation of position, the IABP is secured by Vascular complications consisting of throm- ligating the graft around the balloon. It is imporbus formation, distal embolization, and tant that the ligature closest to the graft-arterial peripheral arterial insufficiency have been re- junction be placed as near as possible to the ported [l, 41. Early-appearing complications common femoral artery. This will create the likely relate to extremely diseased vessels and smallest possible cul-de-sac so that thrombus thrombus formation due to stagnation in the formation in this area of low flow will be minicul-de-sac formed at the graft-artery junction. mal. Heparin, 5,000 units intramuscularly every Late vascular complications may be caused by twelve hours, and 10% low-molecular-weight leaving potentially infected graft material in dextran, 20 ml per hour, are used throughout place, narrowing the artery by ligation or sutur- balloon pumping. ing of the graft, or leaving a persistent cul-de-sac At removal, the previously placed graft is carefor thrombus formation. fully excised from the femoral artery. The wound and removed graft are cultured. A Fogarty catheFrom the Department of Surgery, Section of Thoracic & Car- ter is passed distally into the superficial and diac Surgery, and the Mary Fletcher Unit, University of deep femoral arteries. The distal vessels are Vermont Medical Center, Burlington, VT. heparinized. An oval-shaped patch graft is Accepted for publication June 3, 1975. Address reprint requests to Dr. DeMeules, Mary Fletcher fashioned from woven Dacron and sutured onto the arteriotomy (Figure). After satisfactory arteUnit, MCHV, Burlington, VT 05401.
ABSTRACT A technique for inserting and removing the intraaortic balloon pump without vascular complications is described. Prevention of clot formation at the graft-arterial junction, preservation of collateral circulation by insertion in the common femoral artery, removal of potentially infected graft material, and enlargement of the common femoral artery by patch angioplasty are important factors.
566
567 How to Do It: Moore et al: Removal of Intraaortic Balloon
\
Comment A method of repairing the common femoral artery following removal of the IABP has been used successfully in 17 patients. There have been no instances of peripheral arterial insufficiency, false aneurysm, embolism, or infection in surviving or dead patients. The success of this technique rests on (1) the prevention of clot formation due to stasis by placing the ligature around the graft and catheter close to the femoral artery, and (2) the use of a patch graft to enlarge the lumen of the usually diseased artery rather than narrowing it by suturing or ligating the previously placed graft. The observation that the only thrombus found in this group of patients was in the removed graft segment leads us to believe that excision of this segment followed by patch angioplasty is important to prevent vascular complications. References
Patch angioplasty of common femoral arteriotomy after removal of graft and passage of Fogarty embolectomy catheter.
rial flow is confirmed by palpating the distal pulses, the wound is irrigated with an antibiotic solution and closed. At the time of balloon removal in all surviving patients, no thrombus was found on balloon or catheter surfaces, none was recovered from distal femoral vessels, and only small fragments of thrombus were seen in the removed graft.
1. Dunkman WB, Leinbach RC, Buckley MJ, et al: Clinical and hernodynamic results of intra-aortic balloon pumping and surgery for cardiogenic shock. Circulation 46:465, 1972 2. Kantrowitz A, Phillips SJ, Butner AN, et al: Technique of femoral artery cannulation for phase-shift balloon pumping. J Thorac Cardiovasc Surg 56:279, 1968 3. Saini VK, Berger RL: Technique of aortic balloon catheter deployment with the use of a Fogarty catheter. Ann Thorac Surg 14:440, 1972 4. Scheidt S, Wilner G, Mueller H, et al: Intra-aortic balloon counterpulsation in cardiogenic shock report of a co-operative clinical trial. N Engl J Med 288:979, 1973 5. Weber KT, Janicki JS: Intraaortic balloon counterpulsation. Ann Thorac Surg 17:602, 1974
