Get 20M+ Full-Text Papers For Less Than $1.50/day. Start a 14-Day Trial for You or Your Team.

Learn More →

Intra-aortic balloon pump entrapment and surgical removal: a case report

Intra-aortic balloon pump entrapment and surgical removal: a case report CASE REPORT European Heart Journal - Case Reports (2017) 1, 1–5 doi:10.1093/ehjcr/ytx002 Coronary heart disease Intra-aortic balloon pump entrapment and surgical removal: a case report 1 2 2 1 Niall Hardy *, Neasa Starr , John Cosgrave , and Prakash Madhavan 1 2 Department of Vascular Medicine and Surgery, St James’s Hospital, James’s Street, Dublin 8, Ireland; and Department of Cardiology. St James’s Hospital, James’s Street, Dublin 8, Ireland Received 28 July 2017; accepted 29 July 2017 Abstract Intra-aortic balloon pump (IABP) use following myocardial infarction is now infrequent and reserved for cases of cardiogenic shock. As their use declines, so does our ability to promptly recognize and manage potential problems that may arise. A serious but rare complication of IABP insertion is balloon entrapment within the arterial tree. In this report, we share our experience of a case of balloon entrapment within the right common iliac artery and suc- cessful removal of the device via groin cut down under general anaesthesia. Keywords Intra-aortic balloon pump Entrapment Intra-aortic balloon pump management Case report � � � Introduction Learning points . The intra-aortic balloon pump (IABP) was first introduced in the Serious intra-aortic balloon pump (IABP) complications are . 1960s as a means to provide extra haemodynamic support to those . 1 rare; however, they may have major consequences. . in cardiogenic shock. Over the next 40 years, the insertion of an Prompt recognition of blood within the balloon pump’s helium . . IABP became a common occurrence in cases of cardiogenic shock tubing is crucial as it indicates balloon rupture. This should . 2 . not reversed with the use of pharmacological agents. More recent then prompt immediate removal to reduce the risk for . . studies, however, have called into question the mortality benefit of entrapment. IABP use in myocardial infarction, and this has seen a sharp decline in • . All health care professionals involved in IABP use and monitor- 3 their use in recent years. Their use is still widespread, however, and ing should familiarize themselves with their potential complica- the balloon pump remains a viable tool in the management of cardio- tions. This is even more crucial now that they are genic shock. encountered less commonly. Wide ranges of complication rates with the use of the IABP have There have been a number of extrication methods described 4,5 been reported. These vary from as low as 7% up to 50%. The when dealing with balloon pump entrapment. Groin cut down Japanese multi-institutional IABP Balloon Study group noted a 1.7% to allow proximal and distal artery control followed by arterio- 5 balloon rupture rate on the use of the IABP in 2803 patients. tomy is a relatively non-invasive and safe method of device Rupture was indicated by either the presence of blood within the removal. pump tubing or activation of the pump’s rupture alarm system. Of the 43 cases of rupture, 10 cases subsequently required surgical removal. As the use of the balloon pump continues to decline, famili- arity in dealing with their rare, but serious, complications also decreases. Careful monitoring of these devices should be stressed at all times while in situ. * Corresponding author. Tel: þ353 87 9009907, Email: niall.hardy@gmail.com. This case report was reviewed by A. John Camm and C. Fielder Camm. V The Author 2017. Published on behalf of the European Society of Cardiology. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com Downloaded from https://academic.oup.com/ehjcr/article-abstract/1/1/ytx002/4092766 by Ed 'DeepDyve' Gillespie user on 10 April 2018 2 N. Hardy et al. Timeline Day Events ................................................................................................. 1 Patient presents acutely with chest pain 3 weeks post- percutaneous coronary intervention (PCI) and stent- ing to left anterior descending artery (LAD). Angiogram performed: stent thrombosis causing left anterior descending/first diagonal (LAD/D1) occlu- sion—thrombus aspirated and stenting performed— TIMI 3 flow Figure 1 Axial computed tomography image showing intra-aortic Hypotensive: dobutamine 5 lg/kg/min infusion balloon pump lodged within right common iliac artery. Swan Ganz commenced catheter located in right femoral vein. 2 Worsening hypotension—increasing dobutamine requirements. Increased to 10 lg/kg/min. Insertion of IABP 4 (p.m.) Patient improving—reducing dobutamine require- ments. Decision made to remove pump. Blood noted in tubing at the time of attempted removal—balloon entrapment 5 (a.m.) Groin cut down and surgical removal of pump Case presentation A 56-year-old woman presented with sudden onset central chest pain and shortness of breath on a background of PCI and stenting for worsening angina 3 weeks before. Figure 2 Occlusion of right external iliac artery due to intra- On examination, the patient was dyspnoeic with a heart rate of aortic balloon pump entrapment. 100 beats/min and blood pressure of 110/70 mmHg. Normal S1 and S2 heart sounds were present on auscultation. An electrocardiogram was performed, which showed normal sinus rhythm with ST- Over the next 48 h, the patient’s condition improved with a reduc- elevation in leads I and aVL. The patient was haemodynamically stable . . tion in ionotropic requirements and stable renal function. Due to this on presentation; however, the condition of the patient deteriorated . marked improvement in haemodynamic parameters, the decision to and a dobutamine infusion was commenced at a rate of 5 ug/kg/min. . remove the device was made. The patient was then transferred for primary PCI. The patient was . At the time of removal, however, it was noticed that there on aspirin and clopidogrel 75mg along with atorvastatin 40 mg at . was blood within the helium tubing suggesting device perforation. night. . The pump was removed without difficulty to 10 cm, at which point The patient had a 10 pack-year smoking history; however, they significant resistance was encountered suggesting balloon entrap- had not smoked for the past 10 years. Background medical history ment. Right lower limb pulses were not palpable, however, Doppler was significant for hyper-cholesterolaemia and a spontaneous intra- signals were present distally. cranial bleed 4 years previously. The vascular surgery team was contacted and a computed tomog- A coronary angiogram was performed that confirmed a LAD/D1 raphy angiogram was performed, which showed the tip of the balloon occlusion caused by a stent thrombosis. Thrombus aspiration and to lie within the distal right common iliac artery (Figures 1–3). stenting was performed with good result and TIMI 3 flow. Unfractionated heparin was re-commenced at 1000 IU/h. Clopidogrel was switched to ticagrelor following the procedure. The patient was brought to the operating theatre for cut down Despite successful intervention, the patient remained persistently and removal under general anaesthesia. hypotensive and an echo revealed a reduced ejection fraction of A transverse incision was made in the right groin and extended 10–15% with anterior apicoseptal hypokinesis, a dilated left atrium inferiorly to form a T shape. A femoral arteriotomy was performed and moderate functional mitral regurgitation. Dobutamine require- after achieving proximal and distal control of the common femoral ments increased to 10 lg/kg/min, and the decision was made to insert . artery. The existing arterial puncture site with catheter in situ was an IABP and Swan Ganz catheter for management of the persistent . extended transversely, and the balloon was extracted without diffi- hypotension in the setting of a reduced ejection fraction. This was . culty. On inspection following removal, a significantly sized solid done percutaneously via the right groin. Unfractionated heparin was . thrombus was visible within the lumen of the balloon (Figure 4). commenced at 1000 IU/h. . Downloaded from https://academic.oup.com/ehjcr/article-abstract/1/1/ytx002/4092766 by Ed 'DeepDyve' Gillespie user on 10 April 2018 Intra-aortic balloon pump entrapment and surgical removal 3 Figure 4 Solid thrombus within balloon lumen. Figure 3 Tip of intra-aortic balloon pump within distal right com- mon iliac artery. Figure 5 Solid intraluminal thrombus. A Fogarty catheter was used to perform an iliac embolectomy, The device used in this case involved a 40 cm polyurethane bal- which resulted in the removal of a small clot. The arteriotomy site . loon, which can be easily inflated and deflated with helium. Helium is was closed uneventfully as was the skin. The Swan Ganz catheter was . used as it is a low-viscosity gas that facilitates its quick introduction left in situ. Good distal pulses were present following the procedure. . and removal to the balloon in diastole and systole, respectively. Testing of the balloon post-removal showed a number of small . Complications associated with balloon perforation such as in this holes and a very solid thrombus that could not be fragmented with case can be catastrophic. Arterial helium embolism is a documented finger pressure (Figures 5 and 6) complication of larger perforations in the balloon membrane allowing The patient encountered no post-operative complications from a sudden introduction of a large volume of helium into the systemic the surgery and was discharged home. Management of heart failure in circulation and resulting in significant neurological deficit and even the setting of a reduced ejection fraction is ongoing. 7,8 death. The use of carbon dioxide in place of helium significantly . lowers the risk of embolus, given its increased solubility in blood; . however, its higher density means a slower diffusion coefficient and it Discussion . 9 . is therefore not commonly used. . Smaller micro-perforations such as in this case tend to result in the Although their use is decreasing, IABPs are the most commonly used . entry of blood into the lumen of the catheter. This is because pres- mechanical assist devices in the management of haemodynamic insta- . sure inside the balloon is not sufficient enough to overcome the sur- bility, which is not amenable to less invasive strategies. It is an effec- . face tension at the balloon—blood interface and as a result blood tive way to increase both diastolic blood pressure and coronary . 6 . moves into the cavity. As blood is drawn into the balloon on defla- perfusion while reducing afterload. . tion, it results in the formation of clot within the balloon, which is par- In general, the complication rate with the use of IABPs is low, given . ticularly hard and can prevent withdrawal of the catheter through the the cohort of patients involved. Analysis of just under 17 000 balloon . vasculature, as was the case in this report. Entrapment is seen more pump insertions from 1996 to 2000 showed a 7% incidence of all com- . commonly within the female vasculature, and this is felt to be due to plications with the use of an IABP. Major complication rates were the narrower calibre of the female femoral artery. The presence of 2.6% and a mortality rate of 0.5% as a direct result of IABP use. Other atherosclerosis is also a known risk factor for entrapment. studies have suggested higher complication rates ranging from 20% to As the use of balloon pump becomes less common in the era of 50%. When complications arise, however, they have the potential to PCI via a radial approach, this case report should serve to highlight be extremely serious including the loss of limbs and even death. Downloaded from https://academic.oup.com/ehjcr/article-abstract/1/1/ytx002/4092766 by Ed 'DeepDyve' Gillespie user on 10 April 2018 4 N. Hardy et al. controlled proximally in cases where the catheter tip resides above the inguinal ligament. . 13 . Fukushima et al. describe a case of entrapment within the aorta . of a 68-year-old gentleman, where removal was carried out using a . guidewire with fluoroscopy via the axillary artery. . As is evident from this, there have been numerous techniques . used since the late 1980s for the removal of entrapped aortic balloon . pumps. In the case reported herein, it was possible to gain both prox- imal and distal control of the involved vessels to ensure any bleeding could be controlled quickly and adequately should the need arise. The technique used here did not require the need for retro perito- neal aortic exposure, and the associated morbidity that comes with this, as suggested by Millham et al. Pre-operative imaging to delin- eate anatomy and identify the location of obstruction is vital in plan- ning the most appropriate approach on a case-by-case basis, as it helps determine the most appropriate method for its removal. If blood is noted within the external tubing supplying the balloon pump, it should prompt swift extraction of the balloon. Helium should be the only thing within the helium tubing and blood can only enter if the balloon surface has been damaged. Often an alarm will sound on the IABP console if blood gets in this tubing, but this is unre- liable and often will not sound, as was the situation in this case. Vigilance in monitoring this tubing is therefore paramount in the overall care of patients under IABP support. If blood is noted—it . should prompt the removal of the balloon within 30 min, as the lon- . ger it is left after its rupture the drier the clot becomes and the less . likely it is to extract at the bedside. . Close monitoring of the balloon pump at ward level to allow for . swift extraction in the event of complication and therefore obviating . the need for surgical intervention is crucial. This case report should serve to highlight the importance of strict vigilance of IABPs by ward staff that may be less familiar with their use and complications as bal- loon pump use becomes more infrequent. . Author Contributions Figure 6 Small holes visible when water is introduced under pressure. . N.H. and N.S. were involved in compilation of data and writing of this . piece. J.C. and P.M. were lead consultants/senior authors involved in . the management of the case. the importance of close observation and rapid action to remove the Consent IABP in the event of perforation. Immediate action can result in the successful removal of the device Informed consent was obtained from this patient for publication of before the development of dense clot. The use of intraluminal throm- this case history and associated images in line with COPE bolytic administration can be used to aid removal; however, its use in recommendations. cases where the balloon thrombus has been present for a period of . >1 h, such as in this case, is debatable, given the solid consistency of . Conflicts of interest: none declared. 12–15 . the clot. . The optimal removal strategy of an entrapped IABP is still unclear, . References given its rarity. A number of different approaches have been refer- . 1. Kantrowitz A, Tjonneland S, Freed P. Intra aortic balloon pumping. JAMA 1968; 203:988. enced in the literature with varying degrees of success. The length of . 2. Kushner FG, Hand M, Smith SC Jr, King SB 3rd, Anderson JL, Antman EM, Bailey time elapsed from balloon rupture to recognition of entrapment . SR, Bates ER, Blankenship JC, Casey DJ Jr, Green LA, Hochman JS, Jacobs AK, along with balloon location are important factors that will dictate Krumholz HM, Morrison DA, Ornato JP, Pearle DL, Peterson ED, Sloan MA, Whitlow PL, Williams DO. 2009 Focused updates: ACC/AHA guidelines for the management options. management of patients with ST-elevation myocardial infarction (updating the Millham et al. reported two cases of entrapment in 1991 at the . 2004 guideline and 2007 focused update) and ACC/AHA/SCAI guidelines on end of which they concluded that the abdominal aorta should be percutaneous coronary intervention (updating the 2005 guideline and 2007 Downloaded from https://academic.oup.com/ehjcr/article-abstract/1/1/ytx002/4092766 by Ed 'DeepDyve' Gillespie user on 10 April 2018 . focused update): a report of the American College of Cardiology Foundation/ . 7. Frederiksen JW, Smith J, Brown P, Zinetti C. Arterial helium embolism from a American Heart Association Task Force on Practice Guidelines. Circulation. 2009; ruptured intraaortic balloon. Ann Thorac Surg 1988;46:690–692. 120:2271–2306 8. Richter S, Hu ¨cksta ¨dt T, Aksakal D, Klitscher D, Wowra T, Till H, Schier F, 3. Thiele H, Zeymer U, Neumann FJ, Ferenc M, Olbrich HG, Hausleiter J, Waha A, Kampmann C. Embolism risk analysis—helium versus carbon dioxide. J Laparoendosc Richardt G, Hennersdorf M, Empen K, Fuernau G, Desch S, Eitel I, Hambrecht R, Adv Surg Tech A 2012;22:824–829. Lauer B, Bohm M, Ebelt H, Schneider S, Werdan K, Schuler G. Intra-aortic bal- 9. Wolf JS Jr. Gas embolis: helium is more lethal than carbon dioxide. loon counterpulsation in acute myocardial infarction complicated by cardiogenic J Laparoendosc Surg 1994;4:173–7. shock (IABP-SHOCK II): final 12 month results of a randomised, open-label trial. 10. Intra Aortic Balloon Perforations. Hazard update. Health Devices 1997;26: Lancet. 2013;382:1638–1645. . 217–219. 4. Ferguson J III, Cohen M, Freedman JR, Stone GW, Miller M, Joseph DL, Ohman 11. Parissis H, Soo A, Al-Alao B. Intra aortic balloon pump: literature review of risk M. The current practice of intra-aortic balloon counterpulsation: results from factors related to complications of the intraaortic balloon pump. J Cardiothorac the Benchmark Registry. J Am Coll Cardiol. 2001;38:1456–1462. Surg 2011;6:147 5. Nishida H, Koyanagi H, Abe T, Arai H, Hirayama H, Hirayama T Comparative . 12. Lambert CJ. Intra aortic balloon entrapment. Ann Thorac Surg 1987;44:446. study of five types of IABP balloons in terms of incidence of balloon rupture and 13. Fukushima Y, Yoshioka M, Hirayama N, Kashiwagi T, Onitsuka T, Koga Y. other complications: a multi-institutional study. Artif Organs 1994;18:746–51 Management of intraaortic balloon entrapment. Ann Thorac Surg 1995;60:1109–11. 6. Unverzagt S, Buerke M, de Waha A, Haerting J, Pietzner D, Seyfarth M, Thiele H, . 14. Horowitz MD, Otero M, de Marchena EJ, Neibart RM, Novak S, Bolooki H. Intra Werdan K, Zeymer U, Prondzinsky R. Intra-aortic balloon pump counterpulsa- aortic balloon entrapment. Ann Thorac Surg 1993;56:368–70. tion (IABP) for myocardial infarction complicated by cardiogenic shock. Cochrane 15. Millham FH, Hudson HM, Woodson J, Menzoian JO. Intra aortic balloon pump Database Syst Rev 2015;3:CD007398. entrapment. Ann Vasc Surg 1991;5:381–4. Downloaded from https://academic.oup.com/ehjcr/article-abstract/1/1/ytx002/4092766 by Ed 'DeepDyve' Gillespie user on 10 April 2018 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png European Heart Journal - Case Reports Oxford University Press

Intra-aortic balloon pump entrapment and surgical removal: a case report

Download PDF
5 pages

Loading next page...
 
/lp/oxford-university-press/intra-aortic-balloon-pump-entrapment-and-surgical-removal-a-case-W1ZWuE9C8q

References (19)

Publisher
Oxford University Press
Copyright
© The Author 2017. Published on behalf of the European Society of Cardiology
eISSN
2514-2119
DOI
10.1093/ehjcr/ytx002
Publisher site
See Article on Publisher Site

Abstract

CASE REPORT European Heart Journal - Case Reports (2017) 1, 1–5 doi:10.1093/ehjcr/ytx002 Coronary heart disease Intra-aortic balloon pump entrapment and surgical removal: a case report 1 2 2 1 Niall Hardy *, Neasa Starr , John Cosgrave , and Prakash Madhavan 1 2 Department of Vascular Medicine and Surgery, St James’s Hospital, James’s Street, Dublin 8, Ireland; and Department of Cardiology. St James’s Hospital, James’s Street, Dublin 8, Ireland Received 28 July 2017; accepted 29 July 2017 Abstract Intra-aortic balloon pump (IABP) use following myocardial infarction is now infrequent and reserved for cases of cardiogenic shock. As their use declines, so does our ability to promptly recognize and manage potential problems that may arise. A serious but rare complication of IABP insertion is balloon entrapment within the arterial tree. In this report, we share our experience of a case of balloon entrapment within the right common iliac artery and suc- cessful removal of the device via groin cut down under general anaesthesia. Keywords Intra-aortic balloon pump Entrapment Intra-aortic balloon pump management Case report � � � Introduction Learning points . The intra-aortic balloon pump (IABP) was first introduced in the Serious intra-aortic balloon pump (IABP) complications are . 1960s as a means to provide extra haemodynamic support to those . 1 rare; however, they may have major consequences. . in cardiogenic shock. Over the next 40 years, the insertion of an Prompt recognition of blood within the balloon pump’s helium . . IABP became a common occurrence in cases of cardiogenic shock tubing is crucial as it indicates balloon rupture. This should . 2 . not reversed with the use of pharmacological agents. More recent then prompt immediate removal to reduce the risk for . . studies, however, have called into question the mortality benefit of entrapment. IABP use in myocardial infarction, and this has seen a sharp decline in • . All health care professionals involved in IABP use and monitor- 3 their use in recent years. Their use is still widespread, however, and ing should familiarize themselves with their potential complica- the balloon pump remains a viable tool in the management of cardio- tions. This is even more crucial now that they are genic shock. encountered less commonly. Wide ranges of complication rates with the use of the IABP have There have been a number of extrication methods described 4,5 been reported. These vary from as low as 7% up to 50%. The when dealing with balloon pump entrapment. Groin cut down Japanese multi-institutional IABP Balloon Study group noted a 1.7% to allow proximal and distal artery control followed by arterio- 5 balloon rupture rate on the use of the IABP in 2803 patients. tomy is a relatively non-invasive and safe method of device Rupture was indicated by either the presence of blood within the removal. pump tubing or activation of the pump’s rupture alarm system. Of the 43 cases of rupture, 10 cases subsequently required surgical removal. As the use of the balloon pump continues to decline, famili- arity in dealing with their rare, but serious, complications also decreases. Careful monitoring of these devices should be stressed at all times while in situ. * Corresponding author. Tel: þ353 87 9009907, Email: niall.hardy@gmail.com. This case report was reviewed by A. John Camm and C. Fielder Camm. V The Author 2017. Published on behalf of the European Society of Cardiology. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com Downloaded from https://academic.oup.com/ehjcr/article-abstract/1/1/ytx002/4092766 by Ed 'DeepDyve' Gillespie user on 10 April 2018 2 N. Hardy et al. Timeline Day Events ................................................................................................. 1 Patient presents acutely with chest pain 3 weeks post- percutaneous coronary intervention (PCI) and stent- ing to left anterior descending artery (LAD). Angiogram performed: stent thrombosis causing left anterior descending/first diagonal (LAD/D1) occlu- sion—thrombus aspirated and stenting performed— TIMI 3 flow Figure 1 Axial computed tomography image showing intra-aortic Hypotensive: dobutamine 5 lg/kg/min infusion balloon pump lodged within right common iliac artery. Swan Ganz commenced catheter located in right femoral vein. 2 Worsening hypotension—increasing dobutamine requirements. Increased to 10 lg/kg/min. Insertion of IABP 4 (p.m.) Patient improving—reducing dobutamine require- ments. Decision made to remove pump. Blood noted in tubing at the time of attempted removal—balloon entrapment 5 (a.m.) Groin cut down and surgical removal of pump Case presentation A 56-year-old woman presented with sudden onset central chest pain and shortness of breath on a background of PCI and stenting for worsening angina 3 weeks before. Figure 2 Occlusion of right external iliac artery due to intra- On examination, the patient was dyspnoeic with a heart rate of aortic balloon pump entrapment. 100 beats/min and blood pressure of 110/70 mmHg. Normal S1 and S2 heart sounds were present on auscultation. An electrocardiogram was performed, which showed normal sinus rhythm with ST- Over the next 48 h, the patient’s condition improved with a reduc- elevation in leads I and aVL. The patient was haemodynamically stable . . tion in ionotropic requirements and stable renal function. Due to this on presentation; however, the condition of the patient deteriorated . marked improvement in haemodynamic parameters, the decision to and a dobutamine infusion was commenced at a rate of 5 ug/kg/min. . remove the device was made. The patient was then transferred for primary PCI. The patient was . At the time of removal, however, it was noticed that there on aspirin and clopidogrel 75mg along with atorvastatin 40 mg at . was blood within the helium tubing suggesting device perforation. night. . The pump was removed without difficulty to 10 cm, at which point The patient had a 10 pack-year smoking history; however, they significant resistance was encountered suggesting balloon entrap- had not smoked for the past 10 years. Background medical history ment. Right lower limb pulses were not palpable, however, Doppler was significant for hyper-cholesterolaemia and a spontaneous intra- signals were present distally. cranial bleed 4 years previously. The vascular surgery team was contacted and a computed tomog- A coronary angiogram was performed that confirmed a LAD/D1 raphy angiogram was performed, which showed the tip of the balloon occlusion caused by a stent thrombosis. Thrombus aspiration and to lie within the distal right common iliac artery (Figures 1–3). stenting was performed with good result and TIMI 3 flow. Unfractionated heparin was re-commenced at 1000 IU/h. Clopidogrel was switched to ticagrelor following the procedure. The patient was brought to the operating theatre for cut down Despite successful intervention, the patient remained persistently and removal under general anaesthesia. hypotensive and an echo revealed a reduced ejection fraction of A transverse incision was made in the right groin and extended 10–15% with anterior apicoseptal hypokinesis, a dilated left atrium inferiorly to form a T shape. A femoral arteriotomy was performed and moderate functional mitral regurgitation. Dobutamine require- after achieving proximal and distal control of the common femoral ments increased to 10 lg/kg/min, and the decision was made to insert . artery. The existing arterial puncture site with catheter in situ was an IABP and Swan Ganz catheter for management of the persistent . extended transversely, and the balloon was extracted without diffi- hypotension in the setting of a reduced ejection fraction. This was . culty. On inspection following removal, a significantly sized solid done percutaneously via the right groin. Unfractionated heparin was . thrombus was visible within the lumen of the balloon (Figure 4). commenced at 1000 IU/h. . Downloaded from https://academic.oup.com/ehjcr/article-abstract/1/1/ytx002/4092766 by Ed 'DeepDyve' Gillespie user on 10 April 2018 Intra-aortic balloon pump entrapment and surgical removal 3 Figure 4 Solid thrombus within balloon lumen. Figure 3 Tip of intra-aortic balloon pump within distal right com- mon iliac artery. Figure 5 Solid intraluminal thrombus. A Fogarty catheter was used to perform an iliac embolectomy, The device used in this case involved a 40 cm polyurethane bal- which resulted in the removal of a small clot. The arteriotomy site . loon, which can be easily inflated and deflated with helium. Helium is was closed uneventfully as was the skin. The Swan Ganz catheter was . used as it is a low-viscosity gas that facilitates its quick introduction left in situ. Good distal pulses were present following the procedure. . and removal to the balloon in diastole and systole, respectively. Testing of the balloon post-removal showed a number of small . Complications associated with balloon perforation such as in this holes and a very solid thrombus that could not be fragmented with case can be catastrophic. Arterial helium embolism is a documented finger pressure (Figures 5 and 6) complication of larger perforations in the balloon membrane allowing The patient encountered no post-operative complications from a sudden introduction of a large volume of helium into the systemic the surgery and was discharged home. Management of heart failure in circulation and resulting in significant neurological deficit and even the setting of a reduced ejection fraction is ongoing. 7,8 death. The use of carbon dioxide in place of helium significantly . lowers the risk of embolus, given its increased solubility in blood; . however, its higher density means a slower diffusion coefficient and it Discussion . 9 . is therefore not commonly used. . Smaller micro-perforations such as in this case tend to result in the Although their use is decreasing, IABPs are the most commonly used . entry of blood into the lumen of the catheter. This is because pres- mechanical assist devices in the management of haemodynamic insta- . sure inside the balloon is not sufficient enough to overcome the sur- bility, which is not amenable to less invasive strategies. It is an effec- . face tension at the balloon—blood interface and as a result blood tive way to increase both diastolic blood pressure and coronary . 6 . moves into the cavity. As blood is drawn into the balloon on defla- perfusion while reducing afterload. . tion, it results in the formation of clot within the balloon, which is par- In general, the complication rate with the use of IABPs is low, given . ticularly hard and can prevent withdrawal of the catheter through the the cohort of patients involved. Analysis of just under 17 000 balloon . vasculature, as was the case in this report. Entrapment is seen more pump insertions from 1996 to 2000 showed a 7% incidence of all com- . commonly within the female vasculature, and this is felt to be due to plications with the use of an IABP. Major complication rates were the narrower calibre of the female femoral artery. The presence of 2.6% and a mortality rate of 0.5% as a direct result of IABP use. Other atherosclerosis is also a known risk factor for entrapment. studies have suggested higher complication rates ranging from 20% to As the use of balloon pump becomes less common in the era of 50%. When complications arise, however, they have the potential to PCI via a radial approach, this case report should serve to highlight be extremely serious including the loss of limbs and even death. Downloaded from https://academic.oup.com/ehjcr/article-abstract/1/1/ytx002/4092766 by Ed 'DeepDyve' Gillespie user on 10 April 2018 4 N. Hardy et al. controlled proximally in cases where the catheter tip resides above the inguinal ligament. . 13 . Fukushima et al. describe a case of entrapment within the aorta . of a 68-year-old gentleman, where removal was carried out using a . guidewire with fluoroscopy via the axillary artery. . As is evident from this, there have been numerous techniques . used since the late 1980s for the removal of entrapped aortic balloon . pumps. In the case reported herein, it was possible to gain both prox- imal and distal control of the involved vessels to ensure any bleeding could be controlled quickly and adequately should the need arise. The technique used here did not require the need for retro perito- neal aortic exposure, and the associated morbidity that comes with this, as suggested by Millham et al. Pre-operative imaging to delin- eate anatomy and identify the location of obstruction is vital in plan- ning the most appropriate approach on a case-by-case basis, as it helps determine the most appropriate method for its removal. If blood is noted within the external tubing supplying the balloon pump, it should prompt swift extraction of the balloon. Helium should be the only thing within the helium tubing and blood can only enter if the balloon surface has been damaged. Often an alarm will sound on the IABP console if blood gets in this tubing, but this is unre- liable and often will not sound, as was the situation in this case. Vigilance in monitoring this tubing is therefore paramount in the overall care of patients under IABP support. If blood is noted—it . should prompt the removal of the balloon within 30 min, as the lon- . ger it is left after its rupture the drier the clot becomes and the less . likely it is to extract at the bedside. . Close monitoring of the balloon pump at ward level to allow for . swift extraction in the event of complication and therefore obviating . the need for surgical intervention is crucial. This case report should serve to highlight the importance of strict vigilance of IABPs by ward staff that may be less familiar with their use and complications as bal- loon pump use becomes more infrequent. . Author Contributions Figure 6 Small holes visible when water is introduced under pressure. . N.H. and N.S. were involved in compilation of data and writing of this . piece. J.C. and P.M. were lead consultants/senior authors involved in . the management of the case. the importance of close observation and rapid action to remove the Consent IABP in the event of perforation. Immediate action can result in the successful removal of the device Informed consent was obtained from this patient for publication of before the development of dense clot. The use of intraluminal throm- this case history and associated images in line with COPE bolytic administration can be used to aid removal; however, its use in recommendations. cases where the balloon thrombus has been present for a period of . >1 h, such as in this case, is debatable, given the solid consistency of . Conflicts of interest: none declared. 12–15 . the clot. . The optimal removal strategy of an entrapped IABP is still unclear, . References given its rarity. A number of different approaches have been refer- . 1. Kantrowitz A, Tjonneland S, Freed P. Intra aortic balloon pumping. JAMA 1968; 203:988. enced in the literature with varying degrees of success. The length of . 2. Kushner FG, Hand M, Smith SC Jr, King SB 3rd, Anderson JL, Antman EM, Bailey time elapsed from balloon rupture to recognition of entrapment . SR, Bates ER, Blankenship JC, Casey DJ Jr, Green LA, Hochman JS, Jacobs AK, along with balloon location are important factors that will dictate Krumholz HM, Morrison DA, Ornato JP, Pearle DL, Peterson ED, Sloan MA, Whitlow PL, Williams DO. 2009 Focused updates: ACC/AHA guidelines for the management options. management of patients with ST-elevation myocardial infarction (updating the Millham et al. reported two cases of entrapment in 1991 at the . 2004 guideline and 2007 focused update) and ACC/AHA/SCAI guidelines on end of which they concluded that the abdominal aorta should be percutaneous coronary intervention (updating the 2005 guideline and 2007 Downloaded from https://academic.oup.com/ehjcr/article-abstract/1/1/ytx002/4092766 by Ed 'DeepDyve' Gillespie user on 10 April 2018 . focused update): a report of the American College of Cardiology Foundation/ . 7. Frederiksen JW, Smith J, Brown P, Zinetti C. Arterial helium embolism from a American Heart Association Task Force on Practice Guidelines. Circulation. 2009; ruptured intraaortic balloon. Ann Thorac Surg 1988;46:690–692. 120:2271–2306 8. Richter S, Hu ¨cksta ¨dt T, Aksakal D, Klitscher D, Wowra T, Till H, Schier F, 3. Thiele H, Zeymer U, Neumann FJ, Ferenc M, Olbrich HG, Hausleiter J, Waha A, Kampmann C. Embolism risk analysis—helium versus carbon dioxide. J Laparoendosc Richardt G, Hennersdorf M, Empen K, Fuernau G, Desch S, Eitel I, Hambrecht R, Adv Surg Tech A 2012;22:824–829. Lauer B, Bohm M, Ebelt H, Schneider S, Werdan K, Schuler G. Intra-aortic bal- 9. Wolf JS Jr. Gas embolis: helium is more lethal than carbon dioxide. loon counterpulsation in acute myocardial infarction complicated by cardiogenic J Laparoendosc Surg 1994;4:173–7. shock (IABP-SHOCK II): final 12 month results of a randomised, open-label trial. 10. Intra Aortic Balloon Perforations. Hazard update. Health Devices 1997;26: Lancet. 2013;382:1638–1645. . 217–219. 4. Ferguson J III, Cohen M, Freedman JR, Stone GW, Miller M, Joseph DL, Ohman 11. Parissis H, Soo A, Al-Alao B. Intra aortic balloon pump: literature review of risk M. The current practice of intra-aortic balloon counterpulsation: results from factors related to complications of the intraaortic balloon pump. J Cardiothorac the Benchmark Registry. J Am Coll Cardiol. 2001;38:1456–1462. Surg 2011;6:147 5. Nishida H, Koyanagi H, Abe T, Arai H, Hirayama H, Hirayama T Comparative . 12. Lambert CJ. Intra aortic balloon entrapment. Ann Thorac Surg 1987;44:446. study of five types of IABP balloons in terms of incidence of balloon rupture and 13. Fukushima Y, Yoshioka M, Hirayama N, Kashiwagi T, Onitsuka T, Koga Y. other complications: a multi-institutional study. Artif Organs 1994;18:746–51 Management of intraaortic balloon entrapment. Ann Thorac Surg 1995;60:1109–11. 6. Unverzagt S, Buerke M, de Waha A, Haerting J, Pietzner D, Seyfarth M, Thiele H, . 14. Horowitz MD, Otero M, de Marchena EJ, Neibart RM, Novak S, Bolooki H. Intra Werdan K, Zeymer U, Prondzinsky R. Intra-aortic balloon pump counterpulsa- aortic balloon entrapment. Ann Thorac Surg 1993;56:368–70. tion (IABP) for myocardial infarction complicated by cardiogenic shock. Cochrane 15. Millham FH, Hudson HM, Woodson J, Menzoian JO. Intra aortic balloon pump Database Syst Rev 2015;3:CD007398. entrapment. Ann Vasc Surg 1991;5:381–4. Downloaded from https://academic.oup.com/ehjcr/article-abstract/1/1/ytx002/4092766 by Ed 'DeepDyve' Gillespie user on 10 April 2018

Journal

European Heart Journal - Case Reports – Oxford University Press

Published: Aug 1, 2017

There are no references for this article.