Migration of Intraaortic Balloon Pump Placed Via the Axillary Artery

J INVASIVE CARDIOL 2018;30(1):E11.

Key words: cardiac imaging, intraaortic balloon pump, migration, PCI, complications

Heart failure (HF) is the most common indication for intraaortic balloon pump (IABP) placement either for acute cardiac decompensation or as a bridge to cardiac transplantation in chronic HF patients.¹ The most common location for IABP placement is the femoral artery, although the axillary artery has grown in popularity because femoral artery use will make the patient bedridden and immobility may increase patient morbidity and mortality before and after cardiac transplantation. Moreover, using the femoral artery for a long period will increase both vascular and septic complication rates. Axillary artery IABP placement enables the cardiac patient awaiting transplantation to ambulate and get stronger; however, the increased motion increases the risk of IABP migration.²

A 44-year-old man was admitted for cardiogenic shock after a large anterolateral ST-elevation myocardial infarction requiring emergency IABP placement. Veno-arterial extracorporeal membrane oxygenation (ECMO) support was also initiated after cardiac arrest during percutaneous coronary intervention (drug-eluting stent to the circumflex artery) and aspiration thrombectomy of the left anterior descending artery. Hemodynamics stabilized on ECMO support, and he underwent decannulation with reconfiguration of the femoral IABP to the right axillary artery; 3 days after insertion, it was noted that the IABP had migrated. An initial attempt to reposition the IABP using bedside fluoroscopy failed and the patient was taken to the catheterization lab. Using fluoroscopy, the IABP was found to have migrated to the ascending aorta (Figure 1; Video 1), increasing the risk for ventricular migration, vascular perforation, arrhythmias, and intermittent occlusion of the head vessels. 

We considered snaring the distal tip of the IABP from a femoral approach, but were concerned about kinking the catheter. The axillary IABP was removed and a left femoral IABP was placed. The patient underwent axillary IABP sheath removal in the operating room in a stable condition. A left ventricular assist device was subsequently implanted, and the patient was discharged home and is doing well. Despite sheath stabilization and daily radiographic monitoring, ambulation with an axillary IABP can lead to migration, highlighting the need for vigilance in assessing the position and arterial waveforms.

References

1.    Cochran RP, Starkey TD, Panos AL, Kunzelman KS. Ambulatory intraaortic balloon pump use as bridge to heart transplant. Ann Thorac Surg. 2002;74:746-751. 

2.    Estep JD, Cordero-Reyes AM, Bhimaraj A, et al. Percutaneous placement of an intraaortic balloon pump in the left axillary/subclavian position provides safe, ambulatory long-term support as bridge to heart transplantation. JACC Heart Fail. 2013;1:382-388. 

From the ¹Division of Thoracic and Cardiovascular Surgery and ²Division of Cardiology, Duke University Medical Center, Durham, North Carolina.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.

Manuscript accepted June 15, 2017. 

Address for correspondence: Yaron D. Barac, MD, PhD, Division of Cardiothoracic Surgery, Duke University Medical Center, 10 Duke Medicine Circle, Durham, NC 27710. Email: yaron.barac@duke.edu