Case Report

Intra-Aortic Balloon Pump Insertion Through the RightSubclavian Artery in a Patient of Anterior Wall

Myocardial Infarction With Ventricular Septal Ruptureand Severe Peripheral Artery Obstruction Disease

Kamal H. Sharma,1 MD, DNB (Medicine), DM, DNB (Cardiology), MNAMS, Bhavik S. Shah,2* andNikhil D. Jadhav,1 MD, DM (Cardiology)

Intra-aortic balloon pump (IABP) is used in cardiogenic shock of different etiologies.Routinely, it is inserted through the transfemoral access, but in the patients with severeperipheral artery obstruction disease (PAOD), use of alternative approach is needed. Inthis case report, IABP insertion through the right subclavian artery with the help of cardi-othoracic surgeon in a patient of anterior wall myocardial infarction (AWMI) with severePAOD has been described. A 60-years-old male patient, with the history of chronicsmoking, presented with progressing chest pain for last 3 days. On the basis of clinicalexamination and radiological findings, he was diagnosed with AWMI along with the ven-tricular septal rupture and PAOD. The patient was advised to undergo coronary arterybypass graft with VSR repair, but to stabilize the patient, it was necessary to put him onIABP. Because of the severe PAOD, femoral access was not suitable to insert the IABP,and hence, the right subclavian route was accessed. Then, the patient was operated andno other complications were encountered. Subclavian arterial IABP insertion under localanesthesia is easier and safer to perform and allows increased patient mobility. Otherroutes, such as, ascending aorta and axillary artery have also been discussed in otherliteratures, but subclavian arterial IABP insertion was found to be the best in the patientswith severe PAOD. Trans-subclavian route is an effective approach in extended IABPutilization even in patients with severe PAOD. VC 2014 Wiley Periodicals, Inc.

Key words: IABP; myocardial infarction; PVD; subclavian route; VSR; mechanicalcirculatory support; PAOD; catheterization, acute MI

INTRODUCTION

Intra-aortic balloon pump (IABP) is the mechanicalassist device most frequently used in cardiac surgery[1]. It is used in cardiogenic shock of different etiolo-gies in an effort to reduce left ventricular afterload andimprove diastolic coronary and subendocardial perfu-sion [2]. Conventionally, IABPs are placed using femo-ral artery access. However, this approach is associatedwith a number of important limitations [3]. Elderlyhigh-risk patients present frequently with severe co-morbidities, including severe peripheral artery obstruc-tion disease (PAOD) which usually contraindicate rou-tinely transfemoral IABP insertion. Use of alternativeapproaches in such patients with clinical indication toIABP insertion has to be, therefore, encouraged [4].Here, we report a case of a patient with severe PAOD,

in which IABP insertion through the right subclavianartery was carried out successfully by combined effortsof cardiologist and cardiothoracic surgeon.

1Department of Cardiology, U. N. Mehta ICRC, Ahmedabad,Gujarat, India2B. J. Medical College, Ahmedabad, Gujarat, India

Conflict of interest: Nothing to report.

*Correspondence to: Bhavik S. Shah, 147/Extension, B Block, U.

G. Hostel, B. J. Medical College, Civil Hospital Campus, Asarwa,

Ahmedabad – 16, Gujarat, India. E-mail: bhavikshah7@hotmail.com

Received 15 August 2013; Revision accepted 5 February 2014

DOI: 10.1002/ccd.25425

Published online 00 Month 2014 in Wiley Online Library

(wileyonlinelibrary.com)

VC 2014 Wiley Periodicals, Inc.

Catheterization and Cardiovascular Interventions 00:00–00 (2014)

CASE REPORT

A 60-years-old male patient, who was also a chronicsmoker, presented with progressing chest pain for last3 days. On clinical examination, the blood pressure(BP) was found to be of 96/66 mm Hg, with the pulserate of 112/min. Jugular venous pressure (JVP) wasfound to be elevated on examination. On auscultation,Grade IV pansystolic murmur in left parasternal areaand bilateral basal crepitation were positive. Routinelaboratory investigations were within the normal range.The electrocardiogram (EKG) was suggestive of heal-ing extensive anterior wall myocardial infarction(AWMI). Transthoracic echocardiography was also car-ried out and the patient was found to be having ven-tricular septal rupture (VSR).

The patient was taken to the CathLab and coronaryangiography (CAG) was carried out. On CAG, 50%lesion was found in the left main coronary artery(LMCA) with 100% block in left anterior descendingartery (LAD) and 70% block in the obtuse marginal-1(OM1) branch of the left circumflex artery (LCX).Right coronary artery (RCA) was found to be the dom-inant artery, with plaque in the mid portion.

The patient underwent coronary artery bypass graft(CABG) with VSR repair. Since the patient was hemo-dynamically unstable with signs of biventricular dys-function, to stabilize the patient, it was necessary toput the patient on IABP before surgery, but the femoralaccess was not possible because of the severe PAODin the form of 100% occluded right common iliac ar-tery and 80% occluded left common iliac artery andatherosclerotic changes in abdominal aorta with boththe femoral arteries non-palpable. Figure 1 illustratesfluoroscopy image with right common iliac artery totalocclusion, left common iliac artery significant stenosiswith diseased infrarenal abdominal aorta.

Hence, it was planned to insert IABP through sub-clavian access. Although left subclavian artery haseasy accessibility and less chances of cardiovascularstroke as compared to right subclavian artery, left sub-clavian artery was not considered for IABP with aview of utilizing the left internal mammary artery forgrafting, if the need arises, as per cardiothoracic sur-geon’s decision.

The patient was shifted to Hybrid OT (OperationTheatre), as it was necessary to check position of theIABP under fluoroscopy guidance. With the help ofcardiothoracic surgeon, standard sterile antiseptic pro-cedures were used to prepare the anterior chest wall.Local anesthesia was infiltrated along a small obliqueline below middle third of the right clavicle. The rightaxillary-subclavian artery junction was dissected outthrough a small oblique incision in the right anterior

chest wall, about 2–3 cm below the middle third of theclavicle. The pectoralis major muscle fibers were splitto gain access to the lateral border of the pectoralisminor. The clevipectoral fascia was incised; the subcla-vian vein was mobilized enough so that clamps couldbe put on this vessel. A 4 mm polytetrafluoroethylenegraft was anastomosed to subclavian artery, open endof graft was connected to one way valve, and graftwas tunneled in subcutaneous space and then IABPsheath of 7 Fr size was introduced into it and the guidewire was guided through it, over which IABP balloonof 40 cm size was inserted under fluoroscopic guidanceand then, the position was verified. And the patientwas taken for surgery where the VSR was repairedthrough the left ventriculotomy and a graft was put tomajor OM. Figures 2 and 4 illustrate images afterIABP insertion, balloon passed through right subcla-vian artery to innominate artery, to arch of aorta, andfinally to descending aorta; radio opaque marker wasadjusted so that inflatable part of balloon lies just distalto left subclavian artery. Figure 3 illustrates fluoros-copy image with distal marker of balloon in descend-ing abdominal aorta with inflated balloon.

Post-operatively, the patient improved hemodynami-cally in the form of improved BP and peripheral perfu-sion with good urine output, the patient was extubatedon day 2, and the balloon was removed in the adultcardiothoracic recovery room on day 3. During re-moval of balloon, initially guide wire was inserted inthe lumen of balloon, balloon was deflated and

Fig. 1. Peripheral angiogram showing total occlusion of rightcommon iliac artery and significant occlusion of left commoniliac artery.

2 Sharma et al.

Catheterization and Cardiovascular Interventions DOI 10.1002/ccd.Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).

removed after applying negative pressure with 50 ccsyringe. The sheath was removed and the graft wasligated at its base close to the anastomosis and the restof the graft was excised. The patient was dischargedon day 7 postoperatively. The patient was managedsuccessfully for other morbidities as well.

DISCUSSION

The American College of Cardiology (ACC)/Ameri-can Heart Association (AHA) guidelines suggest the useof IABP in patients with ST elevation myocardial infarc-tion and cardiogenic shock unresponsive to pharmaco-logical therapy, acute mitral regurgitation or ventricularseptal rupture, recurrent ischemia or intractable ventricu-lar arrhythmias with hemodynamic instability, and inpatients with refractory pulmonary congestion [5].

Patients with severe peripheral vascular disease whorequire IABP support are not infrequently encounteredin clinical practice. In such patients it is often impossi-ble to pass even a guide wire retrograde from the fem-oral artery, in which case an alternative approach is toplace an IABP through the ascending aorta [6]. Thismethod requires a median sternotomy under generalanesthesia. Complications of ascending aortic IABPinsertion such as graft infection, aberrant cannulationof the left subclavian artery, left coronary artery embo-lism, and inability to close the sternum due to mechan-ical temponade have been described [6].

On the other hand, subclavian arterial IABP insertionunder local anesthesia is easier and safer to perform

and allows increased patient mobility [7]. In decidingwhich subclavian artery to use for IABP access, onehas to consider the presence of signs and symptoms ofsubclavian stenosis (difference between BP measure-ments in the arms, presence of vertebral steal syndromeor arm claudication), if needed obtain a computed to-mographic or magnetic resonance angiogram of theaortic arch vessels [7]. It will be advisable to performaortogram prior to inserting IABP sheath to access theaorta and brachiocephalic vessels to select between left

Fig. 3. Distal marker of balloon and inflated IABP balloon.

Fig. 4. IABP balloon proximal part during inflation.

Fig. 2. Proximal marker of IABP balloon in arch of aorta, partof 7 Fr sheath.

IABP Inserted Through Right Subclavian Artery 3

Catheterization and Cardiovascular Interventions DOI 10.1002/ccd.Published on behalf of The Society for Cardiovascular Angiography and Interventions (SCAI).

or right subclavian after doing coronary angiogram. Ifthe left internal thoracic artery is to be used forCABG, one might consider placing the IABP throughthe right subclavian artery and avoid, at least in theory,interfering with the left thoracic artery blood flow [7].

Complications associated with IABP insertion arelimb ischemia, vascular injury ranging from 8% to42% and less common are aortic dissection, bleeding,infection, stroke, embolic complications including para-plegia, balloon leak, and death have been explained[8]. Similar case reports have also been described.According to Zattera et al. [4], the axillary artery is asuitable alternative to allow IABP positioning inpatients with severe PAOD and axillary arteryapproach, being more invasive has to be preferred,especially in the theatre for patients who cannot beweaned from cardiopulmonary bypass.

In this case, the patient had an AWMI along withthe VSR and the PAOD. The patient was suitable forthe IABP, according to the ACC/AHA guidelines. Butbecause of the persisting PAOD, the IABP couldn’t beinserted through the traditional transfemoral route.Hence, the attending cardiologist with the help of car-diothoracic surgeon inserted it through the right subcla-vian artery successfully. This can be routinelyperformed in patients with severe PAOD who requireIABP support prior to surgery.

CONCLUSION

As we’ve already discussed, the patients suitable forIABP with other co-morbidities like PAOD are notuncommon, but the routine transfemoral insertion ofIABP is contraindicated in such patients. So, other suit-able and less invasive routes for IABP have to beexplored. Right subclavian artery was found to be the

most suitable route to insert the IABP in this presentcase by the attending cardiologist. In conclusion, theauthors think that this approach has to be added to car-diac interventional and surgical armamentarium as itcan be effective in extended IABP utilization even inpatients with peripheral vessel diseases.

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