A Safe and Simple Method for Ambulatory Iabp Placement Using Left Axillary-radial Technique

Abstract

In patients with severe heart failure, a percutaneous axillary intra-aortic balloon pump (axIABP) may permit ambulation while awaiting destination therapy. Traditionally, an “axillary-femoral” approach has been used with femoral access for axillary angiography during insertion. Here we describe an “axillary-radial” technique for axIABP insertion and removal using left radial artery for second access. Insertion: Draping is performed to allow access to left axillary and radial arteries. A 5 Fr sheath is placed in the radial artery. Heparin is withheld until axillary access is obtained. Left distal subclavian angiography is performed via 4 French Pigtail to identify optimal IABP sheath insertion site avoiding major branches (Fig 1). A 0.018” wire via the radial sheath aids target artery identification with US (Fig 2A and B). A 5 Fr sheath is inserted into the axillary artery and the J-tipped 0.032” IABP guidewire is then advanced into the descending aorta using a JR4 diagnostic catheter to navigate the aortic arch. Sequential dilations allow easy insertion of the 8 Fr sheath. The proximal tip of the axIABP is placed near the level of the carina (Fig 4); a lower position may be considered if significant subclavian tortuosity is present. The external device is stabilized to the forearm with mild slack allowed to limit displacement during restricted arm movement. Anticoagulation is started after radial hemostasis is achieved. Removal: The axIABP is manually removed through the sheath, which remains in place, to simplify site sterilization. A 6 Fr sheath is placed in the left radial artery and an uninflated 7 mm x 40 mm balloon is positioned proximal to axillary sheath. If required, the balloon is repositioned over the arteriotomy and low-pressure inflation performed, assisting hemostasis should standard techniques fail. A Perclose device is deployed, and if successful, no balloon inflation is required. Final angiography through the balloon wire lumen is needed to confirm hemostasis without vascular complication. Generally, A 50cc Maquet Sensation Plus IABP is removable through the 8 Fr sheath. However, the 40cc IABP requires insertion of an 0.018” guidewire to maintain arterial access because the IABP cannot be easily removed through the 7.5 Fr sheath and they are often removed as a unit. Prior wire placement allows insertion of an 8 Fr sheath prior to suture closure. Periprocedural antibiotics are recommended in this instance. Conclusion: The left “axillary-radial” technique described here simplifies axIABP placement, post procedure hemostasis, overall procedural ergonomics and facilitates immediate ambulation.