Insertion Of Intra-aortic Balloon Research Articles

Anesthesia Management in Patient with Placenta Percreta Performed Intra-aortic Ballooning Caesarean Section

<p>Placenta accreta spectrum is one of maternal mortality’s causes which is related with severe obstetric bleeding that requires hysterectomy. The incidence rate of the spectrum placenta increases with increasing caesarean section. Placenta accreta spectrum is also close-related to placenta previa. The aim of this study is to understand perioperative management in patient with placenta percreta performed with intra-aortic ballooning in caesarean section. We are following a case on a 36 year old female patient, multigravida at term pregnant with placenta percreta and history of caesarean section 5 and 2 years ago. The surgeries performed were caesarean section surgery as well as intra-aortic ballooning. Anesthetic technique used was general anesthesia. Operation duration approximately ± 180 minutes, bleeding 1500 cc. After the operation, the patient was admitted to the ICU. The patient going well and discharged from ICU to ward on the second day. After three days in ward, the patient discharged to home. Hemodynamic changes during balloon intra-aortic procedures are of particular concern to anesthetists. This is because the stopping of blood flow to the aorta in this case can cause an increase in blood vessel pressure, where the administration of nitroglycerin at low doses can reduce venous tone resulting in venous vasodilation which will maintain hemodynamic stability during the process of blocking blood vessels with a balloon. From the case we may conclude that anesthesia in pregnant women with placenta accreta spectrum should be carried out with caution and involve a multidisciplinary specialist given its high risk of bleeding. The intra-aortic balloon insertion technique can be an option used to reduce the risk of bleeding in patients with placenta accreta spectrum.</p>

Trans-Aortic Counterpulsation: A Viable Alternative?

Transthoracic intra-aortic balloon pump (IABP) insertion has been a relatively rare and uncommon procedure. However, it is an established beneficial option in patients with severe peripheral vascular disease (PVD) accompanied with bi-lateral femoral arterial occlusion. There are several viable alternatives to trans-aortic IABP insertion, including trans-axillary or in abdominal aorta (requiring a laparotomy). Cardiac surgery has the advantage of an open sternum, facilitating effortless direct intraaortic balloon (IAB) insertion into the aorta. The IAB can be inserted either through a 9-mm graft or directly into the ascending aorta. During cardiac surgery, direct insertion into the ascending aorta with the balloon tip lying distally in the abdominal aorta is facilitated with an open sternum. The base of the balloon lies ∼2 cm below the left subclavian and can be confirmed through a trans-esophageal echocardiogram (TEE). Elimination of a graft insertion saves the team from time-consuming maneuvers and additional hemorrhagic complications. In our experience, postoperative vasoplegic syndrome coupled with myocardial edema contributed to patent instability and was treated with vasopressin and transthoracic IAB insertion. The CS 100 (Datascope Corp., Mahwah, NJ) console allowed the ability to time the balloon accurately. This case report details our experience with one such patient and establishes trans-aortic counter-pulsation as a safe and viable option in patients with severe PVD, where percutaneous insertion is precluded or has failed.

Critical Left Main Coronary Artery Stenosis Diagnosed by Computed Tomographic Coronary Angiography

A 60-year-old man with previous cerebrovascular accident, hypercholesterolemia, and tobacco use presented with a several-month history of worsening exertional dyspnea. Immediate catheterization was considered unsafe, as the patient was taking warfarin (international normalized ratio, 2.9), and nonemergent, as the patient's symptoms were relatively stable. Warfarin was stopped, and multislice computed tomographic coronary angiography (CTCA) was performed (Lightspeed 16, GE Systems) after obtaining appropriate consent. CTCA demonstrated a high-grade narrowing at the ostium of the left main coronary artery (Figure ​(Figure1,1, arrowheads). The ostium of the left main coronary artery had a tapered appearance and a large plaque in its ostial and proximal portions (Figure ​(Figure1b,1b, black arrow). A large amount of plaque was seen in all coronary distributions. Figure 1 Computed tomographic coronary angiogram demonstrating critical left main coronary artery stenosis. (a, b) The multiplanar reformat views clearly demonstrate a high-grade stenosis (arrowheads). (b) The plaque contains both soft and calcified components ... Cardiac catheterization was performed using a 4F system in an attempt to avoid excessive trauma to the artery. In addition, an intraaortic balloon pump and console were positioned inside the cardiac catheterization suite. Invasive coronary angiography demonstrated a critical stenosis of the left main coronary artery (Figure ​(Figure2,2, arrowhead), with pressure damping upon engagement of the 4F Judkins left catheter. The intraaortic balloon was placed, and the patient went on to have successful 5-vessel coronary artery bypass grafting that afternoon. Figure 2 Conventional invasive angiography confirmed the critical stenosis (arrowhead). CTCA allowed us to “preview” the coronary anatomy in a patient whose invasive catheterization was delayed due to anticoagulation. Demonstration of the critical stenosis prior to the catheterization allowed us to change the timing of the catheterization (which was originally planned for the next week) as well as the strategy. Normally, 6F catheters would have been used, which might have been more traumatic given the severity of the ostial left main artery stenosis. In addition, foreknowledge of the severity of the stenosis allowed us to plan for likely intraaortic balloon insertion.

Cardiac Munchausen Syndrome

To examine the reports on cardiac Munchausen syndrome for clinical characteristics. Cases, case series, and related articles on the subject in all languages were identified through a comprehensive literature search. Fifty-eight cases of cardiac Munchausen syndrome were identified. Mean +/- SD patient age was 44 +/- 12 years (range, 23 to 71 years). Fifty-four patients (93%) were men. The most common presenting complaint was chest pain simulating acute coronary syndrome (86%). Syncope and dyspnea were also reported. Mostly, these patients were admitted directly from the emergency department to the coronary care unit. Acute myocardial infarction was the most common admitting diagnosis. The other admitting diagnoses were cardiac arrest and arrhythmia. The average number of hospital admissions for cardiac symptoms was 6 per patient (range, 1 to > 29 admissions). Numerous procedures including cardiac catheterization, coronary angiography, peripheral arteriography, permanent pacemaker placement, electrophysiological studies, intra-aortic balloon insertion, pulmonary artery catheter insertion, and electrical cardioversion have been performed in these patients. Twenty-four patients (41%) had history of undergoing prior multiple invasive procedures, but only 10 of these patients admitted having undergone these procedures. Ninety-five percent of patients altered their stories, with many leaving the hospital against medical advice when confronted with possibility of cardiac Munchausen syndrome as the correct unifying diagnosis. None of the patients reported for follow-up. Cardiac Munchausen syndrome results in unnecessary investigations and organ damage from unneeded aggressive procedures. There is scarce information available on the prognosis of these patients, especially in the long term.

Gastric tonometry in patients with cardiogenic shock and intra-aortic balloon counterpulsation.

To study the course of gastric regional PCO2 (PrCO2) in patients with cardiogenic shock requiring intra-aortic balloon (IAB) counterpulsation and the prognostic value of PrCO2 in this patient population. A prospective, observational clinical study. Medical intensive care unit in a university hospital. Twenty-six consecutive patients with cardiogenic shock requiring mechanical support with an IAB counterpulsation undergoing mechanical ventilation None. Hemodynamic variables, tonometric variables, arterial blood gases, and arterial lactate were assessed before insertion of IAB (baseline), and 1, 2, 3, 8, 16, 24, and 48 hrs thereafter. A subset of these patients (n = 14) were studied just before and 1, 8, 24, and 32 hrs after IAB removal; 12/26 patients (46.2%) died. Cardiac index increased from baseline to 1 hr after insertion of IAB (1.7 +/- 0.3 to 2.6 +/- 0.8 L/min/m2, p < .05). PrCO2 did not change between admission (47 +/- 13 torr [6.3 +/- 1.7 kPa]) and 8 hrs after placement of IAB but increased to 63 +/- 22 torr (8.4 +/- 2.9 kPa) at 16 hrs (p < .05) without any further alteration until 48 hrs. CO2 gap showed a similar pattern with 15 +/- 11 torr (2.0 +/- 1.5 kPa) at baseline and an increase to 28 +/- 22 torr (3.7 +/- 2.9 kPa) 16 hrs later. PrCO2 and CO2 gap remained at high levels (59 +/- 11 torr [7.7 +/- 1.5 kPa] and 22 +/- 10 torr [2.9 +/- 1.3 kPa], respectively), before IAB removal without further improvement or deterioration thereafter. PrCO2 values showed no difference between survivors and nonsurvivors at any time point. Patients with cardiogenic shock developed high PrCO2 within the first 24 hrs, which reflects gastric mucosal ischemia. Persistently high levels of PrCO2 were indicative for prolonged hypoperfusion of the gut. Gastric tonometry failed to discriminate between survivors and nonsurvivors.

Reduction in ischemic vascular complications with a hydrophilic-coated intra-aortic balloon catheter.

Hydrophilic coatings improve the handling characteristics of angioplasty equipment, but until recently this technology has not been available for intra-aortic balloon (IAB) catheters. To determine whether a new hydrophilic coating is associated with a reduction in IAB-related complications, we prospectively evaluated 188 patients undergoing insertion of this new IAB catheter. Complications related to IAB insertion were recorded and compared to data from 682 patients previously treated with an uncoated IAB catheter of the same shaft diameter and balloon size. By multivariate analysis the hydrophilic-coated IAB catheter was associated with a 72% reduction in ischemic vascular complications (relative risk 0.28, 95% CI 0.08-0.96, P= 0.04). There were also trends toward reductions in IAB rupture and the need for vascular surgical repair for bleeding or ischemia. While further investigation is warranted, hydrophilic coatings that reduce the coefficient of friction during IAB catheter insertion may also reduce subsequent ischemic vascular complications.

Influence of catheter and arterial diameter on flow distal to an intra-aortic balloon insertion site: a theoretic examination and in vitro assessment.

Percutaneous placement of an intra-aortic balloon (IAB) through a femoral artery of a patient is associated with a risk of reduction of blood flow distal to the balloon insertion site. If this reduction is severe, it ultimately causes limb ischemia and necessitates IAB removal. Although clinicians intuitively know that larger catheters cause higher flow restrictions, very few studies have examined this situation quantitatively. The authors theoretically analyzed the insertion site geometry in relationship to the catheter diameter and other factors effecting distal flow. To verify the findings, in vitro flow tests were conducted with various IAB catheters currently available on the market, as well as their respective sheaths and hemostasis plugs. This was done using a blood analog solution in an array of polyvinyl chloride tubing sizes. Diameters of the vessel and catheter have a profound and nonlinear effect on the distal flow. For example, a 12.2 Fr catheter in a 0.187 in. vessel only allows 19.9% of normal flow, whereas a 6.1 Fr catheter in the same size vessel allows a 92.0% flow. As the catheter diameter increases, the physical resistance suddenly grows, which causes a significant drop in distal flow. These results are accurately predicted by a mathematical model that gives flow percentage results to within 15% of those measured experimentally. In general, vessels larger than 5 mm in diameter do not exhibit substantial flow reduction for most IABs with and without sheaths. In smaller vessels, however, this reduction may be significant. Sheathless insertion is extremely effective in improving distal blood flow in such a situation. Hemostasis plugs restrict the distal flow similar to respective sheaths, thus diminishing the benefits of sheathless insertion.

Changes of intraaortic balloon volume during pumping in a mock circulation system.

The effects of hemodynamic changes on intraaortic balloon (IAB) volumes were studied experimentally using a helium tachometer in a mock circulatory system. The IAB volume decreased with increases in the heart rate and mean aortic pressure, but the degree of reduction in the IAB volume was different among 4 commercially available IAB drivers. Improvements in IAB consoles are needed to compliment the progress made in percutaneous techniques for IAB insertion resulting in smaller balloons.

Intra-aortic Balloon Counterpulsation as a ‘Bridge’ to Cardiac Transplantation: Effects in Nonischemic and Ischemic Cardiomyopathy

Intra-aortic balloon (IAB) counterpulsation has been utilized as an effective "bridge" to transplantation in patients with end-stage heart failure. To determine if patients with heart failure with nonischemic cardiomyopathy (NICM) derive the same benefit from IAB support as those with ischemic cardiomyopathy (ISCM), we evaluated 27 patients with NICM and 16 patients with ISCM who required IAB support while awaiting transplantation. Hemodynamic changes, effects on organ function (renal and hepatic), frequency of complications, and clinical outcomes were analyzed. Baseline demographics and hemodynamics were comparable in both groups (p = NS). Hemodynamics improved in both groups, immediately (15 to 30 min) following IAB insertion, with greater improvement (p < 0.05) in cardiac index and a trend toward greater reduction in filling pressures in the NICM group. Systemic vascular resistance fell to a similar degree in both groups. During continued IAB support (0.13 to 38 days in NICM, 1 to 54 days in ISCM), all hemodynamic changes persisted in both groups, with larger decrease (p < 0.05) in systemic vascular resistance and greater increase (p < 0.05) in cardiac index in the patients with NICM. The reduction in filling pressures, however, tended to be greater in patients with ISCM. Renal and hepatic function parameters improved to a similar extent in both groups. The frequency of complications and clinical outcome during IAB support were also similar in the two groups. These data confirm that IAB counterpulsation is a safe and effective "bridge" in patients with both NICM and ISCM with end-stage heart failure. The mechanism of sustained benefit in the two groups, however, may be different; afterload reduction appears to be more important in patients with NICM whereas reduction in filling pressures (increased coronary perfusion pressure) may be the main mechanism in patients with ISCM.

Intraaortic balloon pumping in patients requiring cardiac operations: Risk analysis and long-term follow-up

The intraaortic balloon pump is usually the first mechanical device inserted for perioperative cardiac failure; however, little current information is available regarding short- and long-term effectiveness. From January 1983 through November 1990, 6856 adult patients underwent cardiac surgical procedures, 580 of whom (8.5%) had an intraaortic balloon inserted preoperatively (107 patients), intraoperatively (419 patients), or postoperatively (54 patients). There were 374 men and 206 women with a mean age of 63.9 years (range 19 to 88). Operations included 376 coronary artery bypass grafts, 100 mitral valve replacements (with or without bypass grafting), 70 aortic valve replacements (with or without bypass grafting), 15 double valve replacements (with or without bypass grafting), and 32 other procedures. There were 72 (12.4%) complications related to the balloon pump, of which 42 necessitated surgical intervention including thrombectomy (21), vascular repair (13), fasciotomy (2), aortic repair (1), and amputation (4). Operative mortality for patients supported by the balloon pump was 44%. Multivariate stepwise analysis of 27 parameters revealed six independent predictors of mortality: preoperative New York Heart Association class, transthoracic intraaortic balloon insertion (both p < 0.0001), preoperative administration of intravenous nitroglycerin, age, female gender, and preoperative balloon insertion (p < 0.001). Balloon-related complications were not predictive of death. Of the 326 hospital survivors, only 34 were lost to follow-up. There were 75 late deaths, the cause of which was cardiac in 41 (55%), noncardiac in 20 (27%), and unknown in 14 (19%). Actuarial survivals at 1, 5, and 9 years are 51%, 42%, and 33%. Of the 217 hospital survivors still alive and contacted, 81% were in class I (114) or II (60). These data demonstrate (1) operative mortality for patients requiring an intraaortic balloon in the perioperative period remains high, (2) perioperative risk factors can be identified, (3) complications related to the balloon pump do not affect survival, (4) operative survivors can achieve prolonged survival with excellent functional results, and (5) consideration for alternative methods of circulatory support is justified.

Aortic dissection following intraaortic balloon insertion: Recognition by transesophageal echocardiography

Aortic dissection following intraaortic balloon insertion: Recognition by transesophageal echocardiography

Portable intraaortic balloon counterpulsation: clinical experience and guidelines for use.

Intraaortic balloon (IAB) counterpulsation is a proven treatment for patients with refractory ischemia or cardiogenic shock; however its use has been largely limited to tertiary centers due to the difficulties and risks encountered in transporting patients with this device in place. We report our initial experience with 11 patients who underwent IAB counterpulsation at a community hospital utilizing a portable transport IAB system. All 11 patients had successful IAB insertion, resulting in prompt stabilization. Immediate transportation during uninterrupted IAB counterpulsation was successfully accomplished in each case using routine ambulance vehicles, allowing for the prompt initiation of further tertiary care. The role of portable IAB counterpulsation in the community hospital and guidelines for the implementation of this portable IAB system are outlined.

Interhospital transport of patients with ongoing intraaortic balloon pumping

During a 5-year period (1979 to 1983), 50 consecutive patients undergoing continuous intraaortic balloon (IAB) pumping were transferred from Evanston Hospital to Northwestern Memorial Hospital (16 miles), where they underwent cardiac operation. All patients had cardiac catheterization before transfer. Indications for IAB were cardiogenic shock (9 patients), postinfarction angina (18 patients), unstable angina (9 patients), evolving myocardial infarction (3 patients), accelerating angina or hemodynamic instability during cardiac catheterization (9 patients) and prophylactic insertion for high-grade left main stenosis (2 patients). Transportation after stabilization was uneventful in all patients. All patients underwent operative coronary revascularization. There was concomitant mitral valve replacement in 3 patients, acute ventricular septal defect repair in 1 patient, aortic valve replacement in 1, and ventricular aneurysmectomy in 1. Three patients (5%) died postoperatively. Nine patients (20%) had complications directly related to IAB insertion. One patient required femoral-femoral arterial bypass preoperatively, 4 patients had postoperative lower limb ischemia treated by IAB removal or thrombectomy and 1 patient had thrombocytopenia (< 60,000/mm 3), 1 false aneurysm, 1 anterior compartment syndrome and 1 prolonged bleeding at the insertion site. Interhospital transfer with IAB pumping in progress should not be restricted to patients with cardiogenic shock, but can be effectively used for all patients who require preoperative IAB insertion. It should be a therapeutic adjunct in any hospital treating acute cardiac patients where there are physicians skilled in IAB insertion and management and may be instituted without regard for the necessity to transport to another facility.

Hospital Readmissions Among Survivors Six Months After Myocardial Revascularization

One neglected but important measure of early morbidity after coronary artery bypass graft (CABG) operations is rehospitalization. As part of a prospective study of recovery after elective CABG procedures conducted at four academic medical centers, data from all readmissions occurring within the first six postoperative months were collected for 326 patients. A total of 24% of patients had readmissions. The most common categories of readmission discharge diagnoses were cardiac (57%), noncardiac (26%), and surgical sequelae (17%). Factors from the initial hospitalization identified as risk factors for rehospitalization included: length of stay in intensive care unit after surgery, severe noncardiac complications, duration of preoperative cardiac symptoms, intra-aortic balloon insertion, and preoperative resting angina. These findings help to identify a subset of at risk patients for whom more careful surveillance might be beneficial.

Surgical versus percutaneous removal of the intra-aortic balloon

In order to determine the best method for removal of the percutaneous intra-aortic balloon (IAB), we divided 38 patients into two groups. The IAB was removed percutaneously in Group I and surgically in Group II. There were two hemorrhagic and four thrombotic complications sufficiently severe to necessitate vascular surgical intervention in Group I. There were no vascular complications in Group II (p less than 0.1). Among the 19 patients in Group II, eight were found to have acute thrombosis of the superficial or deep femoral artery at the time of operation. It is concluded that thrombus development at the site of IAB insertion is a common event and often leads to acute ischemia. Surgical removal of a percutaneously placed IAB is recommended because it provides an opportunity for the detection and removal of thrombotic material, as well as careful closure of the puncture site.

Mechanical Techniques of Circulation Support: A Percutaneous Intra‐aortic Balloon Device

As medical indications for intra-aortic balloon (IAB) pumping expand, many physicians without surgical expertise are faced with the decision to institute circulatory support. Accordingly, to facilitate rapid establishment of cardiac assist and to obviate the need for operative insertion and removal, a 40-cc single-chambered device was designed for percutaneous insertion by the Seldinger technique. Hemodynamic augmentation produced by the percutaneous balloon is similar to that obtained with conventional IAB. It appears that complications related to IAB insertion may be decreased by the percutaneous method.

Complications of percutaneous intra-aortic balloon insertion

Early studies reported that percutaneous intra-aortic balloons can be placed quickly and easily with minimal complications. To assess our experience with this technique, the records of the first 100 consecutive percutaneous intra-aortic balloon insertion attempts at our hospital were reviewed. In 21 insertion attempts, the balloon could not be passed retrograde into the thoracic aorta. Of the 79 patients in whom the balloon could be passed, 61 had no subsequent complications of balloon insertion. Ten patients, including three in whom insertion was unsuccessful, developed an ischemic limb or false aneurysm requiring surgical correction; among these, amputation was required in two extremities. One patient died as a result of iliac artery perforation by the balloon, and another patient required small bowel resection for mesenteric infarction during counterpulsation. The specific vascular injuries included six instances of femoral artery thrombosis related to laceration with intimal plaque elevation and one case of femoral artery thrombosis without laceration. There were three cases of false aneurysm of the femoral artery, with thrombosis in one. There was one case of iliac artery perforation. Techniques of repair included thrombectomy with lateral repair, vein or prosthetic-patch angioplasty, and simple suture repair of false aneurysm. Excluding five patients who died within 3 hours after balloon insertion and thus had no follow-up, major complications requiring surgical intervention occurred in 12 of 95 attempted insertions (12.6%). This complication rate prompted us to examine indications, risk factors that might predict complications, and potentially preventive techniques such as preinsertion aortography and the use of a wire guide or long sheath for insertion. Although percutaneous intra-aortic balloon insertion has proved to be a valuable technique, a significant number of complications have been seen. Careful selection of patients and insertion by experienced hands should minimize complications.

Percutaneous intraaortic balloon insertion in patients with aortoiliac disease

A new technique for percutaneous insertion of intraaortic balloon catheters in patients with tortuous or narrowed external iliac arteries is described. This method uses a long (45 cm) 12F sheath, which extends up to the descending aorta and protects the iliac artery and aorta from injury during insertion of the balloon catheter. Insertion of intraaortic balloon catheters was not possible by conventional percutaneous technique in six patients with severe acute myocardial ischemia. Use of the long sheath approach permitted rapid and successful institution of circulatory support in these patients.

Percutaneous intraaortic balloon insertion

A new single chambered percutaneous intraaortic balloon has been constructed around a central guidewire. The balloon can be wrapped around the guidewire, enabling its insertion into the femoral artery through a 12F sheath inserted with the conventional Seldinger technique. Percutaneous intraaortic balloon insertion has been performed in 27 patients (mean age 58 years) for a variety of medical and surgical indications. Percutaneous balloons could not be advanced into the aorta in two patients (7.4 percent) with severe bilateral aortoillac occlusive disease. In all 25 patients undergoing intraaortic balloon pumping satisfactory circulatory support was achieved, and 21 (84 percent) of the patients survived to be discharged from the hospital. The mean duration of intraaortic balloon pumping was 3.5 days. Percutaneous intraaortic balloon insertion requires less than 5 minutes and has been successfully performed in the cardiac catheterization laboratory, coronary care unit, operating room and recovery room. After direct balloon removal, external pressure was applied for 30 minutes. No patient experienced hematoma of the groin, aortic dissection, compromised distal pulses or late wound complications. Percutaneous balloon insertion permits the rapid institution of circulatory support and broadens the medical and surgical applications of intraaortic balloon pumping.

Subclavian artery approach for insertion of intra-aortic balloon

Subperiosteal clavicular resection for access to the subclavian artery is described. In those patients requiring intra-aortic balloon placement in the nonsurgical setting, such an approach provides a reasonably benign alternative when aortoiliac atherosclerosis prevents the usual retrograde femoral placement. Little morbidity or functional compromise is associated with clavicular wedge resections, and the anatomic availability of a large artery without the need for major surgical maneuvers in these gravely ill patients is a distinct advantage.