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CASE REPORT
Year : 2023 | Volume
: 9
| Issue : 1 | Page : 73-75
Successful surgical extraction of an entrapped intra-aortic balloon pump
Jayarama Pai1, Shivaprasad Babu Mukkannavar1, Bharat Siddharth1, R Geethika1, D Krishna Shriram2
1 Department of Cardiovascular Surgery, Vijayawada, Andhra Pradesh, India
2 Dr. Ramesh Cardiac and Multispecialty Hospitals Private Limited, Vijayawada, Andhra Pradesh, India
Correspondence Address:
Bharat Siddharth
Department of Cardiovascular Surgery, Dr. Ramesh Cardiac and Multispecialty Hospitals Private Limited, Doctor Ramesh Hospital Road, Near ITI College Bus Stop, Vijayawada - 520 008, Andhra Pradesh
India
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/jpcs.jpcs_84_22
Intra-aortic balloon pump use is an approach for the provision of mechanical support to improve cardiac output and perfusion in the perioperative period in patients undergoing coronary intervention. Despite its beneficial use, rupture of the balloon and entrapment of blood clots in the lumen may occur in very rare cases. We discuss a postoperative presentation, plan, and operative management for the removal of an entrapped balloon catheter.
Keywords: Angina, aortotomy, balloon rupture, entrapment, intra-aortic balloon pump
Intra-aortic balloon pump (IABP) is a mechanical circulatory assist device that has been widely used for hemodynamic management in critically ill patients with low cardiac output.[1],[2] Most commonly, it is placed percutaneously under the guidance of fluoroscopic imaging through the femoral artery.[2] The complications of IABP use include fever, thrombocytopenia, lower limb ischemia, hemorrhage, balloon rupture, and entrapment.[3],[4] Rupture of the balloon is almost rare, which may lead to entrapment and cause severe life-threatening injury.[4] The rupture is indicated either by the presence of blood within the pump tubing or by the activation of the pump's alarm system. A Japanese multi-institutional study noted a 1.7% incidence of balloon rupture in its use in 2803 patients.[5] We report the surgical management of an IABP rupture and entrapment in a patient postcoronary artery bypass grafting (CABG).
Case ReportA 65-year-old male, known hypertensive for 20 years, presented with a sudden onset of central chest pain, with recurrent on-and-off episodes persisting for the past month. On examination, he was comfortable with a heart rate of 100 bpm, blood pressure of 110/70 mmHg, and normal heart sounds (Cardiovascular System (CVS): S1 S2+) on auscultation. Electrocardiography showed normal sinus rhythm with ST elevations on leads V3-V5. He had a left ventricular ejection fraction of 45% and was hemodynamically stable during the presentation.
Critical lesions were seen on coronary angiogram with stenosis of about 99% in the mid-left anterior descending artery (LAD), 90% in the ostio-proximal ramus, and 80% in mid-obtuse marginal (OM). The mid-right coronary artery had a long segment lesion of about 50% stenosis. IABP was inserted through the right common femoral artery due to unstable angina to stabilize the patient. The next day, he was subjected to emergency CABG due to persisting angina and ST-segment elevations. Surgical revascularization with four grafts was done with the left internal mammary artery to diagonals and LAD sequential, followed by reverse saphenous vein graft to the ramus and OM. The patient was extubated 6 h postsurgery as he met the extubation criteria.
Later, a small amount of blood was noticed in the tube connecting the balloon to the console. The alarm signaled balloon leakage, and no more deviation in balloon inflation or waveform was noticed. As the patient was hemodynamically stable on the postoperative day 1, an attempt to remove the IABP was made in the intensive care unit. The balloon was removed easily up to 10 cm, beyond which resistance was encountered that indicated balloon entrapment. The patient was brought to the operation theater for cut-down and removal of IABP, surgically.
Under sedation and local anesthesia, a vertical incision was made into the right groin. Exposing the femoral artery, a femoral arteriotomy was performed after achieving proximal and distal control of the femoral artery. The existing arterial puncture site with a catheter in situ was extended, and the distal part of the balloon was seen, but still failed to be extracted.
Due to the difficulty in shifting the patient to the catheterization laboratory to identify the exact location of IABP, a measurement with a demo IABP from the surface confirmed that the tip of the balloon was present at the junction of the aorta and the right common iliac artery. A median laparotomy was done under general anesthesia. The tip of the balloon was stuck at the proximal part of the right common iliac artery very firmly like a stone on palpation. Hence, both the abdominal aorta and the left common iliac artery were cross-clamped, and a transverse aortotomy was made distal to the inferior mesenteric artery. The IAB catheter was cut on the right common femoral artery level and pulled out retrogradely from the aortotomy.
The aortic bifurcation was cross-clamped, the aortotomy was sutured, and then, the cross-clamp was released. The layers of the abdominal wall were closed. The right femoral arteriotomy was repaired using an polytetrafluoroethylene patch. The tip of the balloon was found thrombosed with a small stone-like hard clot as shown in [Figure 1] and [Table 1]. The patient's recovery following the revision surgery was eventful with postoperative ileus, which was managed conservatively with nil per oral, total parental nutrition, potassium supplementation, and Ryle's tube drainage. He was discharged in a hemodynamically stable condition and allowed oral feeds on the postoperative day 9.
Figure 1: Extracted IABP entrapped with hard clot within the lumen. IABP: Intra-aortic balloon pump Discussion The use of IABP is crucial for managing hemodynamic stability in some cases during a cardiac interventional or surgical procedure.[5],[6] The complications of IABP use include thrombocytopenia, fever, and arterial injury, whereas acute limb ischemia, hemorrhage, and entrapment of thrombus occur in rare cases, and their occurrence rates remain inconsistent.[3],[4],[7],[8] However, entrapment of the balloon is very rare that occurs only in <0.5%.[9],[10]
In our case (post-CABG), the blood in the tubing signaled an IABP rupture indicating a need for removal. The attempt of percutaneous extraction failed due to resistance that indicated balloon entrapment. The lower limb peripheral pulses were also less palpable indicating a risk for lower limb ischemia. A forceful extraction of the entrapped IAB catheter may cause vascular damage or further complicate the injury.[1],[8] Hence, we opted for surgical extraction for the safe removal of the entrapped IABP catheter. The location of entrapment was measured and detected using the guidewire technique from the external surface. The atherosclerotic lesions might also be a risk factor for IAB rupture in our case.[10] In case of resistance due to entrapment, removal by surgical exploration is the choice of treatment in most cases.[6],[7],[8] In our case, a midline laparotomy was performed, following transverse aortotomy, to remove the IAB catheter.
In conclusion, using an IABP as a mechanical assist device to stabilize the patient needs a critical observation. Although the risk of complications is low in IABP use, balloon rupture can occur rarely despite careful monitoring. Hence, an immediate intervention to remove the IAB catheter should be driven out to avoid thrombus entrapment. In case of entrapment, surgical removal of the ruptured IAB catheter should be done to avoid further complications.
Ethical clearance
Not applicable.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
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