Ann Thorac Surg 1997;64:859-860
© 1997 The Society of Thoracic Surgeons
How To Do It
Transthoracic Intraaortic Counterpulsation: A Simple Method for Balloon Catheter Positioning
Francesco Santini, MD,
Alessandro Mazzucco, MD
Department of Cardiovascular Surgery, University of Verona Medical School, Verona, Italy
Accepted for publication March 24, 1997.
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Abstract
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Transaortic balloon catheter insertion is an effective method to provide aortic counterpulsation when the conventional retrograde femoral route cannot be used, usually due to severe aortoiliac disease. A simple technique is described to achieve correct transthoracic intraaortic balloon pump catheter insertion and positioning without the need for special equipment.
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Introduction
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Intraaortic balloon counterpulsation was introduced in 1968 for the treatment of patients with cardiogenic shock [1]. Since then, the intraaortic balloon pump (IABP) has proved useful in the management of other cardiac problems including unstable angina, acute myocardial infarction, and postcardiotomy low cardiac output.
When indicated after open heart procedures, transaortic balloon catheter insertion can be an effective option to provide aortic counterpulsation when conventional retrograde femoral insertion is not possible, usually due to the presence of severe aortoiliac disease. A variety of complications related to this approach, however, have been reported, including bleeding, mediastinal infection, balloon rupture, myocardial infarction, and peripheral embolism. Furthermore, catheter malpositioning including aberrant cannulation of aortic branching vessels also has been reported [2–4].
Although intraoperative transesophageal echocardiography can be useful to identify IABP catheter position, its help during the transthoracic insertion maneuver is less reliable. Besides, this tool is not always available, particularly for small patients.
We describe a simple technique to assess correct transthoracic IABP catheter insertion and final position without the need for any special equipment.
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Technique
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Pledgeted pursestring Prolene (Ethicon, Somerville, NJ) sutures are used at the level of the ascending aorta, usually below the cannulation site. Then, regardless of the patient's size, the left pleural space is widely opened and the lung is deflated by the anesthesiologist. During insertion of the balloon catheter without a guidewire via the ascending aorta, the proximal left subclavian artery can be gently occluded temporarily through the left pleural space to prevent its aberrant cannulation (Fig 1A
); during the same maneuver, the distal aortic arch and the descending aorta can be easily manipulated to assess the presence, proper progression, and final position of the catheter into the aortic lumen (Fig 1B). In a hemodynamically unstable patient, the entire procedure can be accomplished while the patient is still on cardiopulmonary bypass.
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Fig 1. . (A) The intraaortic balloon pump catheter is introduced via the ascending aorta. Acting through the left pleural space, the surgeon occludes left subclavian artery to prevent its aberrant cannulation. (B) The proper progression and final position of the catheter can be assessed by gentle manipulation of the descending aorta.
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To date we have applied this technique in 11 patients. It has proved simple and reliable, allowing for the avoidance of any special equipment. Radiographic assessment of IABP catheter position afterward remains mandatory. Transthoracic counterpulsation was not associated with an increase in complications in the series presented.
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Comment
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Intraaortic balloon pump remains the clinician's first choice when mechanical circulatory support is required, particularly after open heart procedures. However, the incidence of failure to insert the IABP catheter through the femoral route is fairly high, ranging from 13% to 21% [2]. In these cases, in a selected group of patients, the transthoracic approach might represent a reasonable option.
Transthoracic IABP insertion, however, has been associated in the past with severe complications, among which malpositioning and aberrant cannulation of arch vessels account for a large percentage, particularly when conventional Seldinger technique has been used [2, 5].
A variety of cannulation procedures for ascending intra-aortic balloon counterpulsation have been previ-ously reported [3, 4]. The technique we describe offers the possibility, by means of gentle manipulation through the left pleural space of the distal aortic arch and descending aorta associated with occlusion of the subclavian artery, both to monitor the progression of the balloon catheter inside the aortic lumen and to judge its final position. Finger compression of the aortic arch, the root of the subclavian artery, and the descending aorta must be very soft to minimize the risk of distal embolization.
This approach appears to reduce the risk of an otherwise totally blind maneuver, avoiding the need of fluoroscopy guidance. In our experience, this reproducible technique proved simple and reliable, without the need for special equipment. Radiographic assessment of IABP position remains mandatory.
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Footnotes
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Address reprint requests to Dr Santini, Department of Cardiovascular Surgery, OCM Borgo Trento, Piazzale Stefani 1, 37126, Verona, Italy.
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References
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- Kantrowitz A, Tjonneland S, Freed PS, Phillips SJ, Butner AN, Sherman JL Jr. Initial clinical experience with intraaortic balloon pumping in cardiogenic shock. JAMA 1968;203:135–40.
- McGeehin W, Sheikh F, Donahoo JS, Lechman MJ, MacVaugh H. Transthoracic intraaortic balloon pump support: experience in 39 patients. Ann Thorac Surg 1987;44:26–30.[Abstract/Free Full Text]
- Hazelrigg SR, Auer JE, Seifert PE. Experience in 100 transthoracic balloon pumps. Ann Thorac Surg 1992;54:528–32.[Abstract/Free Full Text]
- Meldrum-Hanna WG, Deal CW, Ross DE. Complications of ascending aortic intraaortic balloon pump cannulation. Ann Thorac Surg 1985;40:241–4.[Abstract/Free Full Text]
- Tchervenkov CI, Salerno TA. Preliminary experience with a new technique of insertion and removal of the intra-aortic balloon pump into the ascending aorta [Letter]. J Thorac Cardiovasc Surg 1984;87:475.
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Abstract
Introduction
