IP139. Management Recommendations for Arterial Entrapment of an Intra-Aortic Balloon Pump Caused by Balloon Rupture and Helium-Hemoglobin Clot

Abstract

Intra-aortic balloon pumps (IABPs) are lifesaving left ventricular assist devices placed in patients with heart failure to augment cardiac output and coronary perfusion. However, their use is not without complications, reported to be up to 30%. Many of these require a vascular surgeon to be familiar with the device and to repair the complications. We present the case of a 63-year-old man with severe heart failure necessitating IABP placed through the left axillary artery, necessitating removal open. The patient was brought to the operating room for routine open removal of the IABP when there was suspicion that the balloon was ruptured. The only sign of rupture was a small amount of blood in the pump tubing. The balloon and catheter could not be removed, so removal was attempted by axillary cutdown. An attempt was made to snare the balloon and to pull it into a large sheath in the iliac artery. The balloon was found to be so full of solid blood that an aortotomy had to be performed for removal. Entrapment of the IABP was due to formation of a compact, inflexible clot within the balloon after its rupture (a known complication of the mixing of the blood with helium). Ultimately, the device was removed by open retroperitoneal exposure and aortotomy. Because of the dense nature of the thrombus material within the balloon, it was necessary to perform a transection of the balloon and to remove the thrombus piecemeal using rongeurs. The balloon was able to be removed with as little trauma to the vessels as possible. The retroperitoneal exposure was used to reduce the morbidity associated with transperitoneal exposure and because the distal aorta exposure was needed. Although rupture and subsequent entrapment of IABPs is rare, reported to have an incidence of <2%, there are a handful of reports in the literature that describe open removal approaches. Most case reports describe removal by femoral arteriotomy, so the severity of this IABP rupture was rare in the need for aortotomy to remove the IABP secondary to the abundance of dense clot material within the balloon. Recommendation for removal at the first sign of rupture as well as avoidance of larger balloons than are needed will reduce the incidence of this problem. A review of the literature and subsequent recommendations for the surgical management of IABP entrapment are discussed in the context of our case.