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A simple technique for repositioning the intra-aortic balloon catheter associated with ipsilateral limb ischemia
A Simple Technique for Repositioning the Intra-Aortic Balloon Catheter Associated With Ipsilateral Limb Ischemia Jonathan
D. Gates, MD, Boston, Massachusem
Occasionally, ipsilateral ischemia develops following the groin insertion of an intra-aortic balloon catheter. Various treatment options have evolved, and include replacing the catheter in the opposite groin, removing it completely, or performing a femorofemoral bypass to deliver blood flow below the catheter. Outlined in this paper is a simple method to restore blood flow to a threatened limb, during femoral artery exploration, in the presence of an intra-aortic balloon. This method is also appropriate for optimal positioning of the balloon catheter prior to femorofemoral bypass. Am J Surg. 1996;171:371-373.
event there has been a localized dissection of the artery that may require a femoral artery exploration, thrombectomy, and patch angioplasty. If the balloon has been relocated and both limbs develop ischemia, then a more extensive inflow procedure involving an axillobifemoral bypass is in order. The continued manipulation of the intra-aortic balloon may increase the chances for a localized dissection, distal or vis-
T
he percutaneous and open insertion of intra-aortic balloons for the support of the failing heart may be periodically associated with ischemic complications in the ipsilateral limb in as many as 8.8% to 25% of cases.‘,* Peripheral ischemia may arise from reduced flow of arterial blood around the catheter in a small or damaged common femoral artery or from an improperly positioned balloon catheter in the superficial femoral artery, which is characteristically smaller in caliber than the common femoral artery. Alle et al3 reported the two risk factors for intra-aortic balloon complications as female gender and concomitant peripheral vascular disease. Miller et al4 noted that in those patients with preexisting peripheral vascular disease, the percutaneous insertion of the balloon carries a vascular complication rate of 38.9%, in contrast to the surgical cut-down technique with its 17.9% complication rate. In the event that hemodynamic parameters dictate the continued need for the intra-aortic balloon, alternatives must be found to augment blood flow to the ischemic limb. Repositioning of the balloon may be done initially, requiring its removal and reinsertion into the contralateral femoral artery. The contralateral femoral artery may have preexisting occlusive disease, and thus repositioning potentially places both lower limbs at risk. Occasionally, removal of the balloon is insufficient to establish adequate inflow in the
From the Department of Surgery, Harvard Medical School, and Brigham and Women’s Hospital, Boston, Massachusetts. Requests for reprints should be addressed to Jonathan D. Gates, MD, 75 Francis Street, Division of Trauma and Critical Care, Boston, Massachusetts 02115. Manuscript submitted February 1, 1995 and accepted in revised form May 1, 1995.
Figure 1. The intra-aortic balloon catheter entrance is placed in the superficial femoral artery; even if the cathetelr enters the distal common femoral artery, there is insufficient space for insertion of a femorofemoral graft below it. An umbilical tape is secured around the vessel for proximal control of the intravascular catheter.
THE AMERICAN JOURNAL OF SURGERY@ VOLUME 171 MARCH 1996
371
Figure 2. After inflow occlusion, the arteriotomy is made and the catheter advanced into the common femoral artery. The arteriotomy is partially closed in preparation for the femorofemoral bypass.
Figure 3. The femorofemoral bypass is secured to the common femoral artery to augment blood flow distal to the ballooncatheter insertion site.
ceral emboli, or balloon rupture. In addition, during the removal of the intra-aortic balloon, the patient is potentially hemodynamically unstable, until counterpulsation is once again achieved. Occasionally, maneuvers such as removal or withdrawal of the insertion sheath have been attempted in an effort to reduce the diameter of the catheter. Some investigators have reported limited success with these efforts5 Withdrawal of the sheath may be complicated by extravasation of blood, and sheath excision has occasionally resulted in damage and hence dysfunction of the balloon catheter. Alternatively, a femorofemoral bypass below the insertion site of the catheter will suffice to deliver additional blood from the contralateral femoral artery, assuming that there are no contralateral iliac artery stenoses.‘s5 During femoral artery exploration for leg ischemia, the catheter may be found to have been inserted low into a small common femoral artery with insufficient room to anchor the graft below the insertion of the intra-aortic balloon catheter. Alternatively, the catheter may have been inserted into the
smaller caliber superficial femoral artery. In each of these scenarios, the ideal placement of the femorofemoral bypass is in the distal common femoral artery below the intra-aortic balloon.
372
THE AMERICAN JOURNAL OF SURGERY~
TECHNIQUE Herein is described a method for repositioning the catheter during femoral artery exploration without rmemoving it from the artery. In some cases of catheter-induced limb ischemia, the intra-aortic balloon is inadvertently inserted percutaneously into the superficial femoral artery (Figure 1). Distal ischemia is more likely, given the smaller caliber and possible atherosclerosis of the artery at this level. Proximal control is obtained using an umbilical tape passed around the external iliac vessel twice to provide a firm occlusion around the catheter when the tape is cinched up. If a soft-jawed vascular clamp is applied, blood flow continues around the catheter to obscure the field. With clamps applied to the femoral artery branches, an anterior incision is made beginning above the catheter and ending high in the common
VOLUME 171 MARCH 1996
femoral artery. This allows the balloon catheter to be advanced higher into the common femoral artery. The arteriotomy is then closed below the catheter with fine Prolene sutures (Ethicon, Somerville, New Jersey) (Figure 2). In the event that the superficial femoral artery is of small caliber or extensively diseased, a patch-graft angioplasty would be performed. If simple repositioning of the balloon catheter into the larger caliber commornfemoral artery is insufficient to relieve the ischemia, then additional inflow is required and a femorofemoral bypass limb from the contralateral groin may be incorporated into the anteriorly placed suture line of the common femoral artery (Figure 3). This would not be possible if the balloon had not been repositioned to allow exposure of an adequate length of,distal common femoral artery. Naturally, surgical manipulation of the balloon catheter in the femoral artery mandates chat in the future, as counterpulsation is weaned, the catheter be removed under direct visualization.
COMMENTS Ipsilateral leg ischemia in the presence of the intra-aortic balloon should initially be managed through relocation of the intra-aortic balloon into the opposite groin or sheath removal. In the event that these maneuvers fail or are contraindicated, femoral artery exploration is indicated. When the catheter is found to enter the superficial femoral artery, advancing the catheter higher up into the common femoral artery may be sufficient to relieve the distal ischemia. When the catheter is placed distally in the common femoral artery
THE AMERICAN
REPOSITIONING
INTRA-AORTIC
BALLOON
CATHETER/GATE!
and the caliber of this vessel is insufficient to maintain adequate distal flow around the catheter, cephalad advancement of the catheter exposes sufficient area for insertion of the femorofemoral bypass graft to allow antegrade flow into both the profunda femoris and the superficial femoral artery without actually removing the balloon and reinserting it in a different location. Direct flow of the femorofemoral bypass graft into the profunda may be critical to maintaining patency of the bypass in the event of preexisting atherosclerotic disease or occlusion of the superficial femoral artery. The advantages of this approach are an easy, rapid method that allows the catheter to be relocated into a larger caliber artery or to move the catheter cephalad to provide sufficient space for a femorofemoral bypass limb without actually removing the balloon.
REFERENCES 1. Alpert J, Parsonnet V, Goldenkranz RJ, et al. Limb ischemia during intra-aorric balloon pumping: indication for femorofemoral crossover graft. .J Thorac Cardiovasc Surg. 1980;79:729-734. 2. Mackenzie DJ, Wagner WH, Kulber DA, et al. Vascular omplications of the intra-aortic balloon pump. Am J Surg. 1992; 1645 17-52 1. 3. Alle KM, White GH, Harris JP, et al. Iatrogenic vascular trauma associated with intra-aortic balloon pumping: identification of risk factors. Am Surg. 1993;59:813417. 4. Miller JS, Dodson TF, Salam AA, Smith RB. Vascular complications following intra-aortic balloon pump insertion. Am .I Surg. 1992;58:232-238. 5. Gold JP, Cohen J, Shemin RJ, et al. Femorofemoral bypass to relieve acute leg ischemia during intra-aortic balloon pump cardiac support. J Vast Surg. 1986;3:351-354.
JOURNAL
OF SURGERY”
VOLUME
171
MARCH
1996
373
D. Gates, MD, Boston, Massachusem
Occasionally, ipsilateral ischemia develops following the groin insertion of an intra-aortic balloon catheter. Various treatment options have evolved, and include replacing the catheter in the opposite groin, removing it completely, or performing a femorofemoral bypass to deliver blood flow below the catheter. Outlined in this paper is a simple method to restore blood flow to a threatened limb, during femoral artery exploration, in the presence of an intra-aortic balloon. This method is also appropriate for optimal positioning of the balloon catheter prior to femorofemoral bypass. Am J Surg. 1996;171:371-373.
event there has been a localized dissection of the artery that may require a femoral artery exploration, thrombectomy, and patch angioplasty. If the balloon has been relocated and both limbs develop ischemia, then a more extensive inflow procedure involving an axillobifemoral bypass is in order. The continued manipulation of the intra-aortic balloon may increase the chances for a localized dissection, distal or vis-
T
he percutaneous and open insertion of intra-aortic balloons for the support of the failing heart may be periodically associated with ischemic complications in the ipsilateral limb in as many as 8.8% to 25% of cases.‘,* Peripheral ischemia may arise from reduced flow of arterial blood around the catheter in a small or damaged common femoral artery or from an improperly positioned balloon catheter in the superficial femoral artery, which is characteristically smaller in caliber than the common femoral artery. Alle et al3 reported the two risk factors for intra-aortic balloon complications as female gender and concomitant peripheral vascular disease. Miller et al4 noted that in those patients with preexisting peripheral vascular disease, the percutaneous insertion of the balloon carries a vascular complication rate of 38.9%, in contrast to the surgical cut-down technique with its 17.9% complication rate. In the event that hemodynamic parameters dictate the continued need for the intra-aortic balloon, alternatives must be found to augment blood flow to the ischemic limb. Repositioning of the balloon may be done initially, requiring its removal and reinsertion into the contralateral femoral artery. The contralateral femoral artery may have preexisting occlusive disease, and thus repositioning potentially places both lower limbs at risk. Occasionally, removal of the balloon is insufficient to establish adequate inflow in the
From the Department of Surgery, Harvard Medical School, and Brigham and Women’s Hospital, Boston, Massachusetts. Requests for reprints should be addressed to Jonathan D. Gates, MD, 75 Francis Street, Division of Trauma and Critical Care, Boston, Massachusetts 02115. Manuscript submitted February 1, 1995 and accepted in revised form May 1, 1995.
Figure 1. The intra-aortic balloon catheter entrance is placed in the superficial femoral artery; even if the cathetelr enters the distal common femoral artery, there is insufficient space for insertion of a femorofemoral graft below it. An umbilical tape is secured around the vessel for proximal control of the intravascular catheter.
THE AMERICAN JOURNAL OF SURGERY@ VOLUME 171 MARCH 1996
371
Figure 2. After inflow occlusion, the arteriotomy is made and the catheter advanced into the common femoral artery. The arteriotomy is partially closed in preparation for the femorofemoral bypass.
Figure 3. The femorofemoral bypass is secured to the common femoral artery to augment blood flow distal to the ballooncatheter insertion site.
ceral emboli, or balloon rupture. In addition, during the removal of the intra-aortic balloon, the patient is potentially hemodynamically unstable, until counterpulsation is once again achieved. Occasionally, maneuvers such as removal or withdrawal of the insertion sheath have been attempted in an effort to reduce the diameter of the catheter. Some investigators have reported limited success with these efforts5 Withdrawal of the sheath may be complicated by extravasation of blood, and sheath excision has occasionally resulted in damage and hence dysfunction of the balloon catheter. Alternatively, a femorofemoral bypass below the insertion site of the catheter will suffice to deliver additional blood from the contralateral femoral artery, assuming that there are no contralateral iliac artery stenoses.‘s5 During femoral artery exploration for leg ischemia, the catheter may be found to have been inserted low into a small common femoral artery with insufficient room to anchor the graft below the insertion of the intra-aortic balloon catheter. Alternatively, the catheter may have been inserted into the
smaller caliber superficial femoral artery. In each of these scenarios, the ideal placement of the femorofemoral bypass is in the distal common femoral artery below the intra-aortic balloon.
372
THE AMERICAN JOURNAL OF SURGERY~
TECHNIQUE Herein is described a method for repositioning the catheter during femoral artery exploration without rmemoving it from the artery. In some cases of catheter-induced limb ischemia, the intra-aortic balloon is inadvertently inserted percutaneously into the superficial femoral artery (Figure 1). Distal ischemia is more likely, given the smaller caliber and possible atherosclerosis of the artery at this level. Proximal control is obtained using an umbilical tape passed around the external iliac vessel twice to provide a firm occlusion around the catheter when the tape is cinched up. If a soft-jawed vascular clamp is applied, blood flow continues around the catheter to obscure the field. With clamps applied to the femoral artery branches, an anterior incision is made beginning above the catheter and ending high in the common
VOLUME 171 MARCH 1996
femoral artery. This allows the balloon catheter to be advanced higher into the common femoral artery. The arteriotomy is then closed below the catheter with fine Prolene sutures (Ethicon, Somerville, New Jersey) (Figure 2). In the event that the superficial femoral artery is of small caliber or extensively diseased, a patch-graft angioplasty would be performed. If simple repositioning of the balloon catheter into the larger caliber commornfemoral artery is insufficient to relieve the ischemia, then additional inflow is required and a femorofemoral bypass limb from the contralateral groin may be incorporated into the anteriorly placed suture line of the common femoral artery (Figure 3). This would not be possible if the balloon had not been repositioned to allow exposure of an adequate length of,distal common femoral artery. Naturally, surgical manipulation of the balloon catheter in the femoral artery mandates chat in the future, as counterpulsation is weaned, the catheter be removed under direct visualization.
COMMENTS Ipsilateral leg ischemia in the presence of the intra-aortic balloon should initially be managed through relocation of the intra-aortic balloon into the opposite groin or sheath removal. In the event that these maneuvers fail or are contraindicated, femoral artery exploration is indicated. When the catheter is found to enter the superficial femoral artery, advancing the catheter higher up into the common femoral artery may be sufficient to relieve the distal ischemia. When the catheter is placed distally in the common femoral artery
THE AMERICAN
REPOSITIONING
INTRA-AORTIC
BALLOON
CATHETER/GATE!
and the caliber of this vessel is insufficient to maintain adequate distal flow around the catheter, cephalad advancement of the catheter exposes sufficient area for insertion of the femorofemoral bypass graft to allow antegrade flow into both the profunda femoris and the superficial femoral artery without actually removing the balloon and reinserting it in a different location. Direct flow of the femorofemoral bypass graft into the profunda may be critical to maintaining patency of the bypass in the event of preexisting atherosclerotic disease or occlusion of the superficial femoral artery. The advantages of this approach are an easy, rapid method that allows the catheter to be relocated into a larger caliber artery or to move the catheter cephalad to provide sufficient space for a femorofemoral bypass limb without actually removing the balloon.
REFERENCES 1. Alpert J, Parsonnet V, Goldenkranz RJ, et al. Limb ischemia during intra-aorric balloon pumping: indication for femorofemoral crossover graft. .J Thorac Cardiovasc Surg. 1980;79:729-734. 2. Mackenzie DJ, Wagner WH, Kulber DA, et al. Vascular omplications of the intra-aortic balloon pump. Am J Surg. 1992; 1645 17-52 1. 3. Alle KM, White GH, Harris JP, et al. Iatrogenic vascular trauma associated with intra-aortic balloon pumping: identification of risk factors. Am Surg. 1993;59:813417. 4. Miller JS, Dodson TF, Salam AA, Smith RB. Vascular complications following intra-aortic balloon pump insertion. Am .I Surg. 1992;58:232-238. 5. Gold JP, Cohen J, Shemin RJ, et al. Femorofemoral bypass to relieve acute leg ischemia during intra-aortic balloon pump cardiac support. J Vast Surg. 1986;3:351-354.
JOURNAL
OF SURGERY”
VOLUME
171
MARCH
1996
373