balloon pump removal
Immediate action can result in the successful removal of the device before the development of dense clot. Intra-aortic Balloon Pump: Assessing the Pressure Waveform ). The length of time elapsed from balloon rupture to recognition of entrapment along with balloon location are important factors that will dictate management options. Other factors, like an obese or distended abdomen, pre-existent hematoma or compromised distal pulses, can add further adversity to line withdrawal. Thrombus aspiration and stenting was performed with good result and TIMI 3 flow. JW Intra-Aortic Balloon Pump (IABP) or intra-aortic counterpulsation device the balloon is inflated during diastole to increase coronary perfusion and then deflated during systole to decrease afterload This aims to improve myocardial oxygenation, increase cardiac output and organ perfusion with a reduction in left ventricular workload FG Manual and mechanical external compression remain the primary methods for achieving hemostasis. 2 No. Helium should be the only thing within the helium tubing and blood can only enter if the balloon surface has been damaged. 2 Intra aortic balloon counter pulsation( IABP): Most common and widely available methods of mechanical circulatory support Temporary support for the left ventricle by mechanically displacing blood within the aorta Concepts: - Systolic unloading - Diastolic augmentation Traditionally used in surgical and non surgical patients with cardiogenic shock , Buerke M, de Waha A, Haerting J, Pietzner D, Seyfarth M, Thiele H, Werdan K, Zeymer U, Prondzinsky R. Frederiksen The optimal removal strategy of an entrapped IABP is still unclear, given its rarity. Insertion of IABP. 10. An intra-aortic balloon pump condensation prevention system comprising a water vapor extraction element, such as a Nafion tube (made by Dupont Inc.), or a condensation element, such as a cold trap or Good distal pulses were present following the procedure. IABP 1. Helium is used as it is a low-viscosity gas that facilitates its quick introduction and removal to the balloon in diastole and systole, respectively.6, Complications associated with balloon perforation such as in this case can be catastrophic. , Hand M, Smith SC Jr, King SB3rd, Anderson JL, Antman EM, Bailey SR, Bates ER, Blankenship JC, Casey DJJr, Green LA, Hochman JS, Jacobs AK, Krumholz HM, Morrison DA, Ornato JP, Pearle DL, Peterson ED, Sloan MA, Whitlow PL, Williams DO. Essentially, the balloon deflates during systole to reduce afterload and inflates during diastole to increase blood flow through the coronary arteries. A femoral arteriotomy was performed after achieving proximal and distal control of the common femoral artery. The challenge of achieving and maintaining femoral arterial hemostasis following Intra-aortic Balloon Pump (IABP) counterpulsation therapy can be daunting. The most May be required to replace the balloon. Management of heart failure in the setting of a reduced ejection fraction is ongoing. N.H. and N.S. H If the balloon … The use of intraluminal thrombolytic administration can be used to aid removal; however, its use in cases where the balloon thrombus has been present for a period of >1 h, such as in this case, is debatable, given the solid consistency of the clot.12–15. Balloon length & diameter increases with larger size. Patient improving—reducing dobutamine requirements. Tel: +353 87 9009907, Email: Search for other works by this author on: Department of Cardiology. It consists of two parts: a balloon inserted into the aorta, one of the large arteries through which blood passes from the heart to the rest of the body; and a machine outside the body. Background medical history was significant for hyper-cholesterolaemia and a spontaneous intracranial bleed 4 years previously. An electrocardiogram was performed, which showed normal sinus rhythm with ST-elevation in leads I and aVL. The vascular surgery team was contacted and a computed tomography angiogram was performed, which showed the tip of the balloon to lie within the distal right common iliac artery (Figures 1–3). The Intra-Aortic Balloon Pump (IABP) is frequently used to mechanically support the heart. Intra-aortic balloon pump is used frequently to support a failing myocardium in cardiac patients. The patient was then transferred for primary PCI. Intra-aortic balloon pump (IABP) use following myocardial infarction is now infrequent and reserved for cases of cardiogenic shock. It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide, This PDF is available to Subscribers Only. Tip of intra-aortic balloon pump within distal right common iliac artery. Wide ranges of complication rates with the use of the IABP have been reported. The patient had a 10 pack-year smoking history; however, they had not smoked for the past 10 years. The aorta is the very large artery leaving your heart. It is removed when the heart can pump enough blood on its own or another heart assist device is needed. In this video, Dr Ray Raper outlines the background, physiology and indications for intra-aortic balloon pump. Please check for further notifications by email. In general, the complication rate with the use of IABPs is low, given the cohort of patients involved. Physiology of Balloon Pumping. Intra-aortic Balloon Pump Kanchi, Chandran 73 Journal of Cardiac Critical Care TSSVol. 19. S Careful monitoring of these devices should be stressed at all times while insitu. 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On inspection following removal, a significantly sized solid thrombus was visible within the lumen of the balloon (Figure 4). A coronary angiogram was performed that confirmed a LAD/D1 occlusion caused by a stent thrombosis. Small holes visible when water is introduced under pressure. In the case reported herein, it was possible to gain both proximal and distal control of the involved vessels to ensure any bleeding could be controlled quickly and adequately should the need arise. Close monitoring of the balloon pump at ward level to allow for swift extraction in the event of complication and therefore obviating the need for surgical intervention is crucial. The balloon is inserted into your aorta. Groin cut down to allow proximal and distal artery control followed by arteriotomy is a relatively non-invasive and safe method of device removal. 8. Niall Hardy, Neasa Starr, John Cosgrave, Prakash Madhavan, Intra-aortic balloon pump entrapment and surgical removal: a case report, European Heart Journal - Case Reports, Volume 1, Issue 1, August 2017, ytx002, https://doi.org/10.1093/ehjcr/ytx002. Methods of Insertion and Removal of Intra . , Hudson HM, Woodson J, Menzoian JO. III All Rights Reserved. If there is clinician anxiety, the presence of another experienced provider is optimal These vary from as low as 7% up to 50%.4,5 The Japanese multi-institutional IABP Balloon Study group noted a 1.7% balloon rupture rate on the use of the IABP in 2803 patients.5 Rupture was indicated by either the presence of blood within the pump tubing or activation of the pump’s rupture alarm system. 7. Kantrowitz This skill set, combined with a patient first mindset, will ensure patient safety and comfort for all persons involved, regardless of one’s hemostasis methodology. PRINCIPAL PARTS A flexible catheter – 2 lumen • For distal aspiration/ flushing or pressure monitoring • For periodic delivery and removal of helium gas to a closed The device used in this case involved a 40 cm3 polyurethane balloon, which can be easily inflated and deflated with helium. , Smith J, Brown P, Zinetti C. Richter Arterial helium embolism is a documented complication of larger perforations in the balloon membrane allowing a sudden introduction of a large volume of helium into the systemic circulation and resulting in significant neurological deficit and even death.7,8 The use of carbon dioxide in place of helium significantly lowers the risk of embolus, given its increased solubility in blood; however, its higher density means a slower diffusion coefficient and it is therefore not commonly used.9, Smaller micro-perforations such as in this case tend to result in the entry of blood into the lumen of the catheter. heart attack, heart failure, etc.) Angiogram performed: stent thrombosis causing left anterior descending/first diagonal (LAD/D1) occlusion—thrombus aspirated and stenting performed—TIMI 3 flow, Hypotensive: dobutamine 5 μg/kg/min infusion commenced, Worsening hypotension—increasing dobutamine requirements. This is because pressure inside the balloon is not sufficient enough to overcome the surface tension at the balloon—blood interface and as a result blood moves into the cavity.10 As blood is drawn into the balloon on deflation, it results in the formation of clot within the balloon, which is particularly hard and can prevent withdrawal of the catheter through the vasculature, as was the case in this report. Know the fundamentals of IABP technology. Manual compression, while the oldest approach, requires tactile precision to palpate the femoral pulse while applying vice-like pressure to achieve hemostasis. Axial computed tomography image showing intra-aortic balloon pump lodged within right common iliac artery. Krishna M, Zacharowski K. Principles of Intra-Aortic Balloon Pump Counterpulsation. The restlessness and agitation which parallels long hours of positional discomfort and mechanical ventilation creates a scenario set up for bleeding. These two effects correspond to the two movements that the balloon makes, namely: inflation and deflation. A Normal fill pressure is typically 0–2.5 mmHg Sign up to receive ATOTW weekly - email email@example.com ATOTW 220 – Intra-Aortic Balloon Pump Counterpulsation 25/04/2011 Page 4 of 8 Successful IABP removal requires enough external compression to overcome these conditions while achieving a precise balance of hemostasis with continuity of distal perfusion. Learn more about the procedure, benefits and risks, and recovery. It is therefore essential to use the right tools and techniques to overcome the potential risks of vascular complications associated with prolonged IABP dwells and their aggressive anticoagulation. Your healthcare provider will insert the balloon pump catheter into an artery in your leg. 3. The potential stress to both patient and clinician when dealing with these large bore endovascular devices, however, cannot be understated. Swan Ganz catheter located in right femoral vein. Dobutamine requirements increased to 10 μg/kg/min, and the decision was made to insert an IABP and Swan Ganz catheter for management of the persistent hypotension in the setting of a reduced ejection fraction. Your comment will be reviewed and published at the journal's discretion. 2. FemoStop® Intra-aortic Balloon Pump Removal Protocol Approach 1. We report successful removal of a ruptured and entrapped intra-aortic balloon pump catheter after use of streptokinase solution to clear clots from the device.  Datascope’s IABP elearning modules Gomersall C. Intra-aortic balloon pumping. As the use of balloon pump becomes less common in the era of PCI via a radial approach, this case report should serve to highlight the importance of close observation and rapid action to remove the IABP in the event of perforation. FH General Criteria, Contraindications and Guidelines for Balloon Pumping. An intra-aortic balloon pump is a device that basically does two good things for a heart in trouble. A serious but rare complication of IABP insertion is balloon entrapment within the arterial tree. Blood noted in tubing at the time of attempted removal—balloon entrapment, Groin cut down and surgical removal of pump, Copyright © 2020 European Society of Cardiology. , Hückstädt T, Aksakal D, Klitscher D, Wowra T, Till H, Schier F, Kampmann C. Fukushima NEVER allow the pump to be paused for >30 minutes. Care guide for Intra-Aortic Balloon Counterpulsation Pump (Aftercare Instructions). A Fogarty catheter was used to perform an iliac embolectomy, which resulted in the removal of a small clot. Clinical Editor's Corner Live, International Symposium on Endovascular Therapy, Symposium on Clinical Interventional Oncology. 8, 22-25 Traditionally, 2 forms of weaning have been recognized. The pump was removed without difficulty to 10 cm, at which point significant resistance was encountered suggesting balloon entrapment. All health care professionals involved in IABP use and monitoring should familiarize themselves with their potential complications. Over the next 48 h, the patient’s condition improved with a reduction in ionotropic requirements and stable renal function. Cath Lab Digest is a trademark of HMP. Occlusion of right external iliac artery due to intra-aortic balloon pump entrapment. Surgical extraction under local anesthesia was performed and the patient h… Surgical removal of the balloon may be required to ensure complete removal. Four of the 5 patients had no serious hemodynamic … Clopidogrel was switched to ticagrelor following the procedure. , Tjonneland S, Freed P. Kushner Right lower limb pulses were not palpable, however, Doppler signals were present distally. These findings are a direct contrast to previously described literature, which traditionally have advocated gradual weaning of balloon pump prior to removal. The patient was brought to the operating theatre for cut down and removal under general anaesthesia. Balloon rupture, although it occurs rarely, may lead to entrapment if diagnosis delays. Oxford University Press is a department of the University of Oxford. On examination, the patient was dyspnoeic with a heart rate of 100 beats/min and blood pressure of 110/70 mmHg. Intra‐aortic balloon pump (IABP) is often used to support patients in decompensated heart failure. The balloon may have ruptured, requiring immediate removal. IABP = intraaortic balloon pump; (6.2%) had rupture of the balloon pump necessitating urgent removal of the device. were involved in compilation of data and writing of this piece. , Koyanagi H, Abe T, Arai H, Hirayama H, Hirayama T. Unverzagt If pump operation can't be restored within 15 minutes, the balloon becomes dormant. In this report, we share our experience of a case of balloon entrapment within the right common iliac artery and successful removal of the device via groin cut down under general anaesthesia. , Yoshioka M, Hirayama N, Kashiwagi T, Onitsuka T, Koga Y. Horowitz For full access to this pdf, sign in to an existing account, or purchase an annual subscription. We suggest this procedure as a … Depending on which of the intra-aortic balloon pump injuries afflicting the patient, the outlook can range from benign to fatal. The potential for benefit of 6. Millham et al.15 reported two cases of entrapment in 1991 at the end of which they concluded that the abdominal aorta should be controlled proximally in cases where the catheter tip resides above the inguinal ligament. Perirectal Fascial Anatomy: New Insights Into an Old Problem. You must manually inflate and deflate the balloon optimally every 5 minutes; at a minimum, at least several times per hour. S lntraaortic balloon pump and vascular tourniquet have been removed in the intensive care unit and suture has been secured. 1999. Fukushima et al.13 describe a case of entrapment within the aorta of a 68-year-old gentleman, where removal was carried out using a guidewire with fluoroscopy via the axillary artery. Removal of the Balloon The balloon pump is used for short amounts of time. Unfractionated heparin was commenced at 1000 IU/h. Should You Cancel the Cardiac Catheterization This Morning? A FemoStop® Plus Femoral Compression System is often a useful instrument over manual compression when performing IABP removal because it can achieve hemostatic harmony while freeing the operator of potential repetitive stress injury. If blood is noted—it should prompt the removal of the balloon within 30 min, as the longer it is left after its rupture the drier the clot becomes and the less likely it is to extract at the bedside. The arteriotomy site was closed uneventfully as was the skin. A number of different approaches have been referenced in the literature with varying degrees of success. Ensure that the standby advisory tone is on. A transverse incision was made in the right groin and extended inferiorly to form a T shape. At the time of removal, however, it was noticed that there was blood within the helium tubing suggesting device perforation. Antihelical Auricular Reconstruction With Adipoperichondrial Turnover Flap and Full-thickness Skin Graft. The patient encountered no post-operative complications from the surgery and was discharged home. The balloon itself looks H The Swan Ganz catheter was left in situ. Corresponding author. Testing of the balloon post-removal showed a number of small holes and a very solid thrombus that could not be fragmented with finger pressure (Figures 5 and 6). Introduction The intra-aortic balloon pump (IABP) was first introduced in the 1960s as a means to provide extra haemodynamic support to those in cardiogenic shock. The intra aortic balloon pump (IABP), also called the balloon pump, is a machine that helps the heart pump blood throughout the body. This is even more crucial now that they are encountered less commonly. MD , Cohen M, Freedman JR, Stone GW, Miller M, Joseph DL, Ohman M. Nishida , Otero M, de Marchena EJ, Neibart RM, Novak S, Bolooki H. Millham Increased to 10 μg/kg/min. Despite successful intervention, the patient remained persistently hypotensive and an echo revealed a reduced ejection fraction of 10–15% with anterior apicoseptal hypokinesis, a dilated left atrium and moderate functional mitral regurgitation. Characteristics of the balloon pressure waveform to be assessed include –the baseline pressure. Informed consent was obtained from this patient for publication of this case history and associated images in line with COPE recommendations. This case report should serve to highlight the importance of strict vigilance of IABPs by ward staff that may be less familiar with their use and complications as balloon pump use becomes more infrequent. Thiele Intra-aortic balloon pump entrapment and surgical removal: a case report August 2017 European Heart Journal - Case Reports 1(1) DOI: 10.1093/ehjcr/ytx002 Authors: Niall P … Take ownership of the task. 2 More recent studies, however, have called into question the … Unfractionated heparin was re-commenced at 1000 IU/h. The patient was on aspirin and clopidogrel 75mg along with atorvastatin 40 mg at night. 9. 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( helium leak ), connecting tubing or the IABP console dyspnoeic with a heart rate of 100 beats/min blood... Rupture, 10 cases subsequently required surgical removal bore endovascular devices, however, it should prompt swift of... Margin Status as a Predictive Factor for Recurrence in Preoperative MRI for lower. The existing arterial puncture site with catheter in situ was extended transversely, and balloon pump removal was. Of a ruptured and entrapped intra-aortic balloon pump 9009907, Email: Search for works. The invasive nature of this piece Dr Ray Raper outlines the background physiology! Rare ; however, it should prompt swift extraction of the balloon pressure Waveform ) achieving proximal and artery. And support device, usage is accompanied by consistent risk of complications about the procedure benefits. For hyper-cholesterolaemia and a spontaneous intracranial bleed 4 years previously you must manually inflate and deflate the balloon optimally 5... Long-Term Outcome data ) counterpulsation Therapy can be easily inflated and deflated helium... Hematoma or compromised distal pulses, can not be understated restlessness and agitation which parallels long hours positional. Site with catheter in situ was extended transversely, and recovery Press a. Informed consent was obtained from this, there have been a number different. Of care and support discharged home of data and writing of this piece pump ’ s,... Requires enough external compression to overcome these conditions while achieving a precise balance hemostasis! All times while insitu s condition improved with a reduction in ionotropic requirements and stable function. Cases subsequently required surgical removal of the case 30 minutes examination, the balloon pump afflicting. The two movements that the balloon pump sign in to an existing account, or purchase an annual subscription the... Restored within 15 minutes, the patient encountered no post-operative complications from the surgery was... Ca n't be restored within 15 minutes, the patient was dyspnoeic with a heart rate of beats/min.