Peri-operative Intraaortic Balloon Assist, Decreasing Complications to the Minimum

IABP can be a life-saving procedure, but it carries a significant morbidity and mortality. This makes it imperative to temper our indication JM Alvarez, 1992 [1].

The difference in complications rate is due to physicians' experience and technique MJ Goldberg, 1987 [2].

Intra-aortic balloon assist (IABA) has two main beneficial effects. First, it augments coronary flow through diastolic balloon inflation; second, it reduces after-load through rapid balloon deflation in systole. IABA was first used clinically in 1968 to support the failing circulation of patients after myocardial infarction [3]. Its use was soon extended to patients in need of perioperative support in cardiac surgery [4]. Because there are no physiological shortcomings of IABA, indications for its use is established result from weighing up probable benefits vs. possible harm. Given the fact that any mechanical mishaps with IABA devices of recent manufacture are rare, the expression “possible harm” refers to vascular problems, for all intents and purposes, to limb ischemia, and less frequently to hemorrhage [5]. These two represent about 90 % [6] [7] of all IABA-related complications [6].

In his review paper, Alvarez stated that “The desperate condition of these patients (i. e., who require LABP) forces us begrudgingly to accept the associated morbidity and mortality” [1]. We disagree with this view, and emphasize that such a “desperate condition” may never develop with judicious indication; and even if it does occur, significant vascular complications may be prevented.

It is also reasonable to postulate that if the rate of vascular mishaps could be significantly decreased, the application of perioperative IABA may be considerably liberalized. The purpose of this paper is to present our recommendations based on thirty years experience [8] [9] [10] [11] [12] as to how the current number of complications of IABA may be decreased to the very minimum.

References

• 1 Alvarez J M, Gates R, Rowe D, Brady P W. Complications from intra-aortic balloon counterpulsation: a review of 303 cardiac surgical patients.  J Cardiovasc Surg. 1992;  6 530-535
• 2 Goldberg M J, Rubenfire M, Kantrowitz A. Intraaortic balloon pump insertion: a randomized study comparing percutaneous and surgical techniques.  JACC. 1987;  9 515-523
• 3 Kantrowitz A, Tjonneland S, Freed P S. et al . Initial clinical experience with intraaortic balloon pumping in cardiogenic shock.  J Am Med Ass. 1968;  203 113-118
• 4 Buckley M J, Craver J M, Gold H L, Mundth E D, Daggett W M, Austen W G. Intra-aortic balloon pump assist for cardiogenic shock after cardiopulmonary bypass.  Circulation. 1973;  48 (1 Suppl) III90-III94
• 5 Busch T, Sirbu H, Zenker D, Dalichau H. Vascular complications related to intraaortic balloon counterpulsation: an analysis of ten years experience.  Thorac Cardiovasc Surg. 1997;  45 55-59
• 6 Christenson J T, Badel P, Simonet F, Schmuziger M. Preoperative intraortic balloon pump enhances cardiac performance and improves the outcome of redo CABG.  Ann Thorac Surg. 1997;  64 1237-1244
• 7 Ferguson J J, Cohen M, Freedman R J. The current practice of intra-aortic counterpulsation: results from the Benchmark Registry.  J Am Coll Card. 2001;  38 1456-1462
• 8 Masters T N, Harbold N B, Hall D G. et al . Intra-aortic balloon counterpulsation in acute cardiogenic shock.  NC Med J. 1975;  36 157-161
• 9 Robicsek F. Closed chest decannulation of transthoracically inserted aortic balloon catheter without grafting.  J Cardiovasc Surg. 1987;  2 327-329
• 10 Robicsek F, Masters T N, Rice H, Morency R P. Enhancing the applicability and effectiveness of intra-aortic balloon counterpulsation.  J Card Surg. 190;  4 321-327
• 11 Robicsek F. Six years' experience with closed-chest decannulation of transthoracally inserted cardiac-assist balloon catheters.  Texas Heart Inst J. 1992;  19 51-53
• 12 Robicsek F. Invited comment: Exact positioning of intraaortic balloon counterpulsation device.  Eur J Cardio-thorac Surg. 1992;  6 53
• 13 Baskett R JF, Ghali W A, Maitland A, Hirsch G M. The intraaortic balloon pump in cardiac surgery.  Ann Thorac Surg. 2002;  74 1276-1287
• 14 Macoviak J, Stephenson L W, Edmunds L H, Harken A, MacVaugh H. The intraaortic balloon pump an analysis of five years experience.  Ann Thorac Surg. 1980;  29 451-459
• 15 Alpert J V, Parsonnet R J, Golden-Kranz E K, Bhuktan D, Brief B J, Gielchinsky I, Abel R M. Limb ischemic during intra-aortic balloon pumping.  Arch Surg. 1976;  111 1190-1195
• 16 Patel J J, Kopistansky C, Boston B, McBride R, Rzepela A, Asia R A De, Cohen M. Prospective evaluation of factors associated with intraaortic balloon rupture.  ASAIO J. 1996;  42 (1) 37-40
• 17 Swartz M T, Sakamoto T, Arai H, Reedy J E, Salenas L, Yuda T, Standeven J W, Pennington D G. Effects of intraaortic balloon position on renal artery blood flow.  Ann Thorac Surg. 1992;  53 604-610
• 18 Alderman J D, Gabliani G I, McCabe C H. et al . Incidence and management of limb ischemia with percutaneous wire-guided intraaortic balloon catheters.  J Am Coll Cardiol. 1987;  9 524-530
• 19 Goldberger M, Tabak S, Shah P. Clinical experience with intra-aortic balloon counterpulsation in 112 consecutive patients.  Am Heart J. 1986;  11 497-502
• 20 Iverson L IG, Herfindahl G, Ecker R R, Young J N, Ennix C L, Lee J, Dunning C, Whisenant A, May I A. Vascular complications of intraaortic balloon counterpulsation.  Am J Surg. 1987;  154 99-103
• 21 Martin R S, Moncure A C, Buckley M J, Austen W G, Akins C, Leinback R C. Complications of percutaneous intra-aortic balloon insertion.  J Thorac Cardiovasc Surg. 1983;  85 186-190
• 22 Shahian D M, Nepune W R, Ellis F H, Maggs P R. Intra-aortic balloon pump morbidity: a comparative analysis of risk factors between percutaneous and surgical techniques.  Ann Thorac Surg. 1983;  36 644-653
• 23 Bergman D, Nichols A B, Weiss M B, Powers E, Martin E C, Casarella W B. Percutaneous intra-aortic balloon insertion.  Am J Cardiol. 1980;  46 261-264
• 24 LeFemine A A, Kosowsky B, Madoff I, Black H, Lewis M. Results and complications of intra-aortic balloon pumping in surgical and medical patients.  Am J Cardiol. 1977;  40 416-420
• 25 Silbramanian V A, Goldstein J E, Sos T A, McCabe J C, Hoover E A, Gay W A. Preliminary clinical experience with percutaneous intra-aortic balloon pumping.  Circulation. 1980;  62 (Suppl 1) 123-129
• 26 Vignola P A, Swaye P S, Gosselin A J. Guidelines for effective and safe percutaneous intra-aortic balloon pump insertion and removal.  Am J Cardiol. 1981;  48 660-664
• 27 Meco M, Groimegnee A, Yassini A, Bellisario A, Mazzar E, Babbini M, Pedigliere A, Panisi P, Tarelli A, Frigiola A, Menicanti L, Cirri S. Mortality and morbidity of intra-aortic balloon pumps.  J Cardiovasc Surg. 2002;  43 17-33
• 28 Gottlieb S O, Brinker J A, Broken A M. et al . Identification of patients at high risk for complications with intraaortic balloon counterpulsation: a multivariate risk factor analysis.  Ann Cardiol. 1984;  53 1135-1139
• 29 Miller J, Dodson T, Salam A, Smith R. Vascular complications following intra-aortic balloon pump insertion.  Am Surg. 1992;  58 232-238
• 30 Santini F, Morreecco A. Safer approach in transthoracic intraaortic balloon cannulation.  Eur J Cardio-Thorac S. 1996;  10 928
• 31 Rodigas P, Bridges K. Occlusion of the left internal mammary artery with intraaortic balloon: clinical implications.  J Thor Card Surg. 1986;  91 (1) 142-143
• 32 Gueldner T L, Lawrence G H. Intraaortic balloon assist through cannulation of the ascending aorta.  Ann Thor Surg. 1975;  19 88-92
• 33 Lamberti J, Cohn L, Collins J. Iliac artery cannulation for intra-aortic balloon counterpulsation.  J Thorac Cardiovasc Surg. 1974;  67 976-977
• 34 Torchiana D, Hirsch G, Buckley M. et al . Intraaortic balloon pumping for cardiac support: trends in practice and outcome, 1968 - 1995.  J Thorac Cardiovasc Surg. 1997;  113 758-769
• 35 Nauheim K S, Swartz M T, Pennington D G, Fiore A C, McBride L R, Peigh P S, Barnett M G, Vaca K J, Kaiser G C, Willman V L. Intraaortic balloon pumping in patients requiring cardiac operations.  J Thorac Cardiovasc Surg. 1992;  104 (6) 1654-1660
• 36 Hazelrigg S R, Auer J E, Seifert P E. Experience in 100 transthoracic balloon pumps.  Ann Thorac Surg. 1992;  54 528-532
• 37 Roe B B, Chatterjee K. Transaortic cannulation for balloon pumping: report of a patient undergoing closed chest decannulation.  Ann Thor Surg. 1976;  21 568-570
• 38 Sirbu H, Busch T, Aleksic I, Friedrich M, Dalichau H. Ischaemic complications with intra-aortic balloon counter-pulsation: incidence and management. Cardiovasc Surg 2000 8 1 66-71
• 39 Meldrum-Hanna W G, Deal C W, Ross D E. Complications of ascending aortic intraaortic balloon pump cannulation.  Ann Thorac Surg. 1985;  40 241
• 40 McCabe J C, Abel R M, Subramanian V A, Gay W A. Complications of intraaortic balloon insertion and counterpulsation.  Circulation. 1978;  57 769-784
• 41 Johnson M S, Lalka S G. Successful treatment of an iatrogenic infrarenal aortic dissection with serial wallstents.  Ann Vasc Surg. 1997;  11 295-299
• 42 Mackenzie D J, Wagner W H, Kulber D A. et al . Vascular complications of the intraaortic balloon pump.  Am J Surg. 1992;  164 517
• 43 Funk M, Ford C F, Foell D W, Bonini S, Sexton D L, Ostfeld A M, Cabin H S. Frequency of long-term lower limb ischemia associated with intraaortic balloon pump use.  Am J Cardiol. 1992;  70 (13) 1195-1199
• 44 Todd G J, Bregman D, Voorhees A B, Reemtsma K. Vascular complications associated with percutaneous intra-aortic balloon pumping.  Arch Surg. 1983;  118 (8) 963-964
• 45 Barnett M, Swartz M T, Peterson G J. et al . Vascular complications from intraaortic balloons: risk analysis.  J Vasc Surg. 1994;  19 81-89
• 46 Cox P M, Kellet M, Goran S F, Morton J, Wolvek S. Plaque abrasion and intra-aortic balloon leak.  Chest. 1995;  108 (6) 1945-1948
• 47 Horowitz M D, Otero M, de Marchena E J, Neibert R M, Novak S, Bolooki H. Intraaortic balloon entrapment.  Ann Thorac Surg. 1993;  56 368-370
• 48 Aru G, King J, Hovaguimian H, Floten H, Ahmad A, Starr A. The entrapped balloon: report of a possibly serious complication.  J Thorac Cardiovasc Surg. 1986;  91 146-149
• 49 Fukushima Y, Yoshioka M, Hirayama N, Kashiwagi T, Anitsuka T, Koga Y. Management of intra-aortic balloon entrapment.  Ann Thor Surg. 1995;  60 109-111
• 50 Tchervenkov C I, Salerno T A. Preliminary experience with a new technique of insertion and removal of the intra-aortic balloon pump into the ascending aorta (letter to the editor).  J Thorac Cardiovasc Surg. 1984;  87 (3) 475-477
• 51 Eltchaninoff H, Dimas A P, Whitlow P L. Complications associated with percutaneous placement and use of intraaortic balloon counterpulsation.  Am J Cardiol. 1993;  71 (4) 328-332
• 52 Gutfinger D, Ott R, Miller M. et al . Aggressive preoperative use of intraaortic balloon pump in elderly patients undergoing coronary artery bypass grafting.  Ann Thorac Surg. 1999;  67 610-613
• 53 Naunheim K, Swartz M, Pennington D. et al . Intraaortic balloon pumping in patients requiring cardiac operations.  J Thorac Cardiovasc Surg. 1992;  104 1654-1661