Retrograde Intra-Aortic Balloon Pump Placement via Brachial Access for Hemodynamic Support in Complex Coronary Intervention with Distal Aortic Occlusion

Disclosures: Dr. Cox, Dr. Van Hise, and Dr. Varghese report no conflicts of interest regarding the content herein. Dr. George reports he is a consultant for Maquet and Abiomed.

The authors can be contacted via Dr. Jon George at georgej@deborah.org.

Case

A 64-year-old male with history of 40 pack-year tobacco use presented to an outside facility with complaint of sub-sternal chest pain of approximately 6 hours duration. An electrocardiogram was noted to have ST-segment elevations in the anterior leads, prompting urgent coronary angiography. However, due to the concern about aortic dissection, the patient underwent a computed tomography angiogram of the chest, abdomen, and pelvis, revealing a chronic total occlusion of the infra-renal aorta with significant collateral flow. The patient was transferred to our facility to undergo coronary angiography via a radial or brachial approach. Upon arrival to our facility, the patient appeared to be hemodynamically stable, with chest pain controlled on a nitroglycerin drip and resolution of ST-segment changes on anticoagulation therapy with heparin infusion, and dual antiplatelet therapy of aspirin and prasugrel.

Coronary angiography via transradial access revealed severe multi-vessel disease: left anterior descending artery (LAD) with tubular 80% stenosis in mid-vessel (Figure 1), left circumflex with 100% occlusion after a small obtuse marginal branch with faint left-to-left collaterals, and right coronary artery with 100% mid-vessel occlusion after an acute marginal branch and collateralized by LAD septals.  Left ventriculography demonstrated significantly diminished function, with ejection fraction estimated at 15%, and akinesis of the apical and posterobasal walls. Abdominal aortography confirmed occlusion of the aorta just below the level of the renal arteries (Figure 2). 

Based on the results of coronary angiography, it was recommended that the patient undergo a viability study and cardiothoracic surgical evaluation. The inferior wall and apex were non-viable, with some evidence of viability in the anterior, lateral, and septal walls. Cardiac enzymes during this period peaked with a troponin level of 69.71, corroborating a large myocardial infarction. An echocardiogram confirmed diminished ejection fraction without visualization of intracavitary thrombus. The patient was quoted an operative risk of 10% based on Society of Thoracic Surgery criteria, and after extensive multidisciplinary discussion, the patient was deemed a poor surgical candidate and referred for percutaneous coronary intervention (PCI).

The patient was brought back to the catheterization laboratory for a planned PCI of the LAD via a right radial approach. Hemodynamic support with retrograde insertion of an intra-aortic balloon pump (IABP; Maquet) from the left brachial artery was planned. Access was obtained in the right radial artery with a 6 French sheath, and in the left brachial artery under ultrasound guidance and placement of an 8 French sheath. From the brachial access, a Judkins right (JR) 4 and Grand Slam guide wire (Abbott Vascular) were used to direct the wire into the descending aorta. The smallest available IABP was positioned between the aortic arch and distal occlusion (Figure 3). After initiation of hemodynamic support, an Extra Back Up (EBU) 3.5 guide (Medtronic) was used to engage the left main coronary artery via the right radial artery access. A Balanced Middle Weight (BMW) wire (Abbott) was then used to cross the LAD lesion into the distal vessel. The mid-vessel lesion was pre-dilated serially with a 2.0 mm compliant balloon, followed by a 2.5 mm non-compliant balloon. A Promus 2.5 x 38 mm stent (Boston Scientific) was deployed in the mid vessel, followed by a second Promus 2.75 x 20 mm stent in overlapping fashion from the mid to proximal LAD. The proximal stented segment was post-dilated with a 3.0 mm non-compliant balloon. The final angiogram revealed an excellent angiographic result, with TIMI-3 flow into the LAD territory (Figure 4). The IABP was weaned and removed at the completion of the case. A TR Band (Terumo) was placed for hemostasis at the radial artery access site. The brachial sheath was sutured in place and removed when the activated clotting time (ACT) was <180, with hemostasis achieved via manual compression.

The patient was discharged home with a LifeVest (Zoll Medical Corp.) for primary prevention of sudden death from ventricular fibrillation in the setting of ischemic cardiomyopathy. He has since successfully undergone placement of an intracardiac defibrillator and in follow-up, with no recurrence of anginal symptoms and improvement in his ejection fraction to 25%. 

Discussion

An IABP has been the most common device for circulatory support used to date, but randomized evidence on survival has been lacking.¹ Identifying appropriate patients for use of circulatory support during PCI is an important patient management issue, which must include a cost-benefit analysis.  A recent study from Germany found that the Impella (Abiomed), as compared with the IABP, was a cost-effective alternative for circulatory support during high-risk PCI.² Comorbidities such as peripheral artery disease, valvular heart disease, and left ventricular thrombus may limit the type of hemodynamic support that can be used.³

Several recent trials have compared the Impella to the IABP. Boudoulas et al found that the Impella can be used as safely as an IABP with similar vascular and bleeding complications.⁴ The study also reported that one-third of the bleeding was from the gastrointestinal tract, with the remaining two-thirds related to access site bleeding.⁴ This finding outlines the importance of appropriate prophylactic measures and monitoring in the use of hemodynamic support devices.   

Based on registry data, the use of IABP for cardiogenic shock complicating acute myocardial infarction has been downgraded from class I to class IIa and IIb in the American and European guidelines, respectively. In the largest randomized trial to date, IABP-SHOCK II, the use of IABP did not reduce 30-day all-cause mortality compared with control. Patients undergoing early revascularization and optimal medical therapy were assigned to IABP versus control. Final 12-month results demonstrated no improvement in all-cause mortality out to 1 year.⁵    

The PROTECT II study randomly assigned 452 patients with complex multi-vessel disease or unprotected left main coronary artery disease with severely depressed left ventricular systolic dysfunction to IABP or Impella.⁶ The patients underwent non-emergent, high-risk PCI with hemodynamic support. The primary end point of adverse events at 30 days was not statistically different between the two groups, although the Impella 2.5 provided superior hemodynamic support when compared to IABP. At 90 days, there was a strong trend, although not statistically significant, toward decreased major adverse events in the patients supported with Impella 2.5 as compared with the IABP.⁶

The use of IABP via transbrachial approach has been previously described⁷ in patients with unsuitable femoral or iliac anatomy for traditional insertion. The catheter is positioned under fluoroscopic guidance down the descending aorta with the proximal tip of the balloon beyond the aortic arch⁸.  Since the pressure transducer at the distal tip of the balloon points away from the aortic valve, the balloon timing is not synchronized on the arterial tracing but on the ECG tracking mode only⁹.  Forearm perfusion should be monitored with pulse oximetry throughout the duration of hemodynamic support.  In a series that evaluated the transbrachial approach for IABP insertion¹⁰, there were no complications despite a mean duration of 72 hours of IABP support.

In summary, there has not been overwhelming positive data supporting the use of IABP in cardiogenic shock or complex PCI. However, in patients that require high risk, complex, coronary interventions in the setting of severe peripheral arterial disease with absence of vascular access for large-bore catheters, the use of retrograde IABP from a brachial approach can offer a feasible option.

References

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