Interesting Image—Intra-aortic Balloon Pump: Axillary Approach (Ambulatory Intra-aortic Balloon Pump)

Abhishek Samprathi¹ https://orcid.org/0000-0001-8525-2482, Bagirath Raghuraman²

¹Department of Critical Care Medicine, Narayana Institute of Cardiac Sciences, Bengaluru, Karnataka, India

²Department of Cardiology, Narayana Institute of Cardiac Sciences, Bengaluru, Karnataka, India

Corresponding Author: Abhishek Samprathi, Department of Critical Care Medicine, Narayana Institute of Cardiac Sciences, Bengaluru, Karnataka, India, Phone: +91 8056738436, e-mail: abhisamprati@gmail.com

Received: 26 September 2023; Accepted: 18 October 2023; Published on: 19 February 2024

How to cite this article: Samprathi A, Raghuraman B. Interesting Image—Intra-aortic Balloon Pump: Axillary Approach (Ambulatory Intra-aortic Balloon Pump). J Acute Care 2023;2(3):166–167.

Source of support: Nil

Conflict of interest: None

Patient consent statement: The author(s) have obtained written informed consent from the patient for publication of the case report details and related images.

CASE SUMMARY

A 47-year-old gentleman was admitted to the cardiac intensive care unit with a history of worsening breathlessness and pedal edema for 3 months. On examination, he was conscious and alert, hemodynamically stable, and had bilateral crepitation on auscultation. He was on regular medications for chronic heart failure due to dilated cardiomyopathy. Previously, he had undergone an implantable cardioverter-defibrillator (ICD) and a Bentall procedure for aortic root aneurysm and severe aortic regurgitation. Echocardiography on current admission reported an ejection fraction of 10%. He was listed for a heart transplant after counseling. He underwent percutaneous intra-aortic balloon pump (IABP) insertion via the left axillary artery (Figs 1 and 2) for pretransplant optimization. He subsequently underwent a successful heart transplant.

Fig. 1: (Without labels): Chest X-ray showing a widened mediastinum due to cardiomegaly (cardiothoracic ratio 0.8)

Fig. 2: (With labels): Chest X-ray showing a widened mediastinum due to cardiomegaly (cardiothoracic ratio 0.8), 1 = implantable cardioverter defibrillator (ICD); 2 = peripherally inserted central catheter inserted through the right cubital vein; 3 = IABP catheter inserted through the left axillary artery, the tip of the IABP balloon is below the diaphragm, and hence, not visualized; 4 = poststernotomy midline sternal wire sutures

TECHNIQUE OF INSERTION

After obtaining informed consent, access to the axillary artery was obtained using a micropuncture needle by fluoroscopy. Initially, a 4-french (4-F) catheter sheath was inserted by the Seldinger technique and the distal end of the guide wire was positioned in the abdominal aorta. The catheter sheath was later exchanged for the IABP sheath. Care was taken to make a nick and dilate the insertion site to avoid damage to the IABP balloon. Axillary IABP was placed in an inverted position as compared with the femoral approach. Though the radiologic positioning is similar to that of femoral IABP, the tip of the IABP may be visualized in the abdomen below the diaphragm.

DISCUSSION

Percutaneous IABP insertion through the left axillary artery is a feasible strategy for temporary mechanical circulatory support in patients with advanced heart failure as a bridge to definitive care.¹ IABP insertion has varied indications and the femoral route is most commonly used. However, the femoral venous approach not only has a higher incidence of infection; but also impedes ambulation and recuperation of patients who require long-term mechanical support devices. Complications of IABP insertion include ischemia (cerebrovascular or limb or mesenteric), malpositioning, bleeding, pseudo aneurysm, and balloon rupture. Axillary IABP offers better management of patients requiring long-term mechanical circulatory support by reducing the incidence of infections and offering better ambulation. This case highlights the use of IABP through the axillary artery route as a bridge to heart transplantation.

ORCID

Abhishek Samprathi https://orcid.org/0000-0001-8525-2482

REFERENCES

1. Bhimaraj A, Agrawal T, Duran A, et al. Percutaneous left axillary artery placement of intra-aortic balloon pump in advanced heart failure patients. JACC Heart Fail 2020;8(4):313–323. DOI: 10.1016/j.jchf.2020.01.011

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