**17. Insertion techniques**


Intra-Aortic Balloon Counterpulsation Therapy

post-procedure day.

Fig. 13. Transbrachial Insertion

and Its Role in Optimizing Outcomes in Cardiac Surgery 57

6. Transthoracic Insertion- In instances where the IAB insertion is precluded due to severe PVD or has been tried and failed, The IAB catheter can be introduced down the aorta in operative room situations. We had one such patient- a 65 year old male with active smoking history, no hypertension/daibetic history and a history of pericarditis in 2003. He had a history of severe PVD with bilateral femoral claudication and severe pain in his legs. Angiogram was facilitated through the right radial approach. He underwent CPB and uneventful CABG to his LAD and PIV (posterior interventricular artery). The patient had a hypotensive episode during sternal closure, CPB was re-initiated, mammary spasm suspected and a vein graft anastomosed distal to the previous mammary artery anastomosis. We were unable to separate from CPB, at this time a decision was made to insert an IAB transfemorally. Transfemoral insertion failed and an IAB catheter (Fig 14) was placed antegrade down the thoracic aorta. At this point the patient was able to separate from CPB. Due to suspicion of myocardial edema, late sternal closure was decided upon, the skin closed, dressing placed and patient transported to the CVICU. The patient was taken back to the OR post-op day 3, the IAB

should be taken to insert the IAB on the left rather than the right side. As right sided insertion would not give the IAB enough length to cross the aortic arch and lie in the descending Aorta. We came across a 74 years female diagnosed with coronary artery disease (CAD) and triple vessel disease (TVD) who had aorto-bifemoral grafts inserted in 2004. Her risk factors included hypertension, active smoking history, type 2 Diabetes and previous MI. Her EF was only 28%, she had moderate MR, moderate PAH and left carotid bruit. She was turned down for surgery. She presented in emergency with angina. Had a syncopal episode with rapid atrial fibrillation. She was cardioverted twice and transported to the cath lab for IAB insertion. An IAB (Fig 13) was initially inserted through the right brachial artery and was observed via fluoroscopy to lie in the aortic arch. The IAB was then removed and re-inserted via the left brachial artery and inserted antegrade down the thoracic aorta. Augmentation was initiated, the patient survived the hypotensive episode, was placed in the CCU and discharged on the 9th

puncture is then dilated by the dilator provided in the IAB catheter set. The introducerdilator set is advanced over the guidewire. Finally the dilator is removed and the IAB catheter advanced over the guidewire. The IAB is introduced over the guide wire and placed in the second or third intercostal space. It is recommended to maintain a continuous flush of the IAB catheter with heparinized saline (1000u in 500ml) after placement. It is also recommended to periodically flush the arterial line from the IAB in order to prevent clotting of the arterial line coming from the IAB catheter. The manufacturer recommends the IAB catheter to be anchored with two sutures to the subcutaneous tissue of the thigh (Fig 12) at the anchors provided on the side of the base of the catheter or by the sutureless securement device provided.

Fig. 12. Proper Anchoring of the IAB Catheter


3. Sheathless insertion- Initially IAB catheters were enveloped by sheaths with bigger French sizes. E.g. The 8Fr IAB catheter has a sheath whose outer diameter is 10Fr. By not using the sheath, the practitioner is reducing trauma to the groin and femoral artery. Current IAB catheters of 7 and 7.5Fr are inserted in our institution without the sheath. Sheathless insertion also reduces the length of catheter indwelling in the tissue,

4. Subclavian insertion- Currently the manufacturer and FDA (Food and Drug Administration) recommends (in their IFU-instruction for use manual) femoral insertion of all IAB catheters. IAB catheters have regulatory clearance for femoral insertion and are labeled as such. There are situations where the subclavian artery has been used in order to avoid an aorto-iliac stenosis. A subclavicular incision is done and the subclavian artery isolated via cut down. An IAB catheter is placed antegrade down

5. Brachial insertion- The brachial artery can be used as a point of insertion where the patients have bilateral obstructive femoral and iliac disease and/or the patient has bilateral femoro-popliteal graft. Due to discomfort associated with positioning, the authors would recommend only in patients who are intubated and on a ventilator. Care

of the catheter or by the sutureless securement device provided.

Fig. 12. Proper Anchoring of the IAB Catheter

thereby reducing limb ischemia.

the descending thoracic aorta.

puncture is then dilated by the dilator provided in the IAB catheter set. The introducerdilator set is advanced over the guidewire. Finally the dilator is removed and the IAB catheter advanced over the guidewire. The IAB is introduced over the guide wire and placed in the second or third intercostal space. It is recommended to maintain a continuous flush of the IAB catheter with heparinized saline (1000u in 500ml) after placement. It is also recommended to periodically flush the arterial line from the IAB in order to prevent clotting of the arterial line coming from the IAB catheter. The manufacturer recommends the IAB catheter to be anchored with two sutures to the subcutaneous tissue of the thigh (Fig 12) at the anchors provided on the side of the base should be taken to insert the IAB on the left rather than the right side. As right sided insertion would not give the IAB enough length to cross the aortic arch and lie in the descending Aorta. We came across a 74 years female diagnosed with coronary artery disease (CAD) and triple vessel disease (TVD) who had aorto-bifemoral grafts inserted in 2004. Her risk factors included hypertension, active smoking history, type 2 Diabetes and previous MI. Her EF was only 28%, she had moderate MR, moderate PAH and left carotid bruit. She was turned down for surgery. She presented in emergency with angina. Had a syncopal episode with rapid atrial fibrillation. She was cardioverted twice and transported to the cath lab for IAB insertion. An IAB (Fig 13) was initially inserted through the right brachial artery and was observed via fluoroscopy to lie in the aortic arch. The IAB was then removed and re-inserted via the left brachial artery and inserted antegrade down the thoracic aorta. Augmentation was initiated, the patient survived the hypotensive episode, was placed in the CCU and discharged on the 9th post-procedure day.

Fig. 13. Transbrachial Insertion

6. Transthoracic Insertion- In instances where the IAB insertion is precluded due to severe PVD or has been tried and failed, The IAB catheter can be introduced down the aorta in operative room situations. We had one such patient- a 65 year old male with active smoking history, no hypertension/daibetic history and a history of pericarditis in 2003. He had a history of severe PVD with bilateral femoral claudication and severe pain in his legs. Angiogram was facilitated through the right radial approach. He underwent CPB and uneventful CABG to his LAD and PIV (posterior interventricular artery). The patient had a hypotensive episode during sternal closure, CPB was re-initiated, mammary spasm suspected and a vein graft anastomosed distal to the previous mammary artery anastomosis. We were unable to separate from CPB, at this time a decision was made to insert an IAB transfemorally. Transfemoral insertion failed and an IAB catheter (Fig 14) was placed antegrade down the thoracic aorta. At this point the patient was able to separate from CPB. Due to suspicion of myocardial edema, late sternal closure was decided upon, the skin closed, dressing placed and patient transported to the CVICU. The patient was taken back to the OR post-op day 3, the IAB

Intra-Aortic Balloon Counterpulsation Therapy

(Fig 16).

hearts afterload.

to the groin and resulted in fewer complications post-insertion.

Fig. 16. Chest X-ray Confirmation of IAB Placement

WAVE console (fig 20) marketed by Arrow international.

and Its Role in Optimizing Outcomes in Cardiac Surgery 59

The IAB is connected by a driveline to a helium chamber or pressurized gas reservoir which is connected to the IAB catheter via a solenoid valve. The inflation or helium supply is linked to a trigger for the balloon which is usually a synchronized ECG (Electrocardiogram) or the patient's blood pressure. Earlier on in IAB development CO2 was used due to its high solubility and safety in case of balloon leak/rupture and gas embolization. Helium started being used due to its smaller Reynold's number (lower density), thereby allowing a smaller drive line/catheter. Smaller balloon catheters improved gas shuttle speeds, reduced trauma

The balloon is usually placed 2 cms below the subclavian artery in the second to third intercostals space. This optimizes coronary perfusion and decreases the chances for renal artery occlusion. Balloon placement is verified in the OR by TEE or post-operatively by CXR

Synchronization of the IAB is achieved usually by using the R wave of the QRS complex to deflate the IAB catheter. In the operating room some practitioners tend to use pressure trigger to circumvent electrical interference from the cautery or other devices. If the patient is pacer dependent, the pacer spike can also be use to trigger IAB deflation. Correct timing is verified by observing the dicrotic notch on the arterial pressure waveform on the balloon console and making sure that balloon inflation takes place just after the dicrotic notch (aortic valve closure) and deflates prior to LV ejection (R wave on QRS complex-Fig 17 & Fig 18) While using the pressure trigger, it's important to use the dicrotic notch as the marker for inflation. This will prevent the balloon from impinging on LV ejection and adding to the

At Southlake we use the Maquet IAB console (fig 19) CS 100 which has an auto feature for timing. Another IAB console which the reader may come across would be the ACAT II

The console uses a unique algorithm to establish the initial timing using the ECG or arterial pressure waveforms. It will also automatically readjust the inflation and deflation timing for changes in heart rate or rhythm. This allows for ease of nursing care post-operatively and decreases the necessity of the perfusionist except for troubleshooting. The IAB has three choices for augmentation. 1:1, 1:2 and 1:3. The IAB is generally initiated at 1:2 in order to be

removed and the chest closed. The patient was extubated post-op day 9 and discharged after 25 days. No post-operative morbidity noted other than associate with his history of peripheral vascular disease (*Datt B 2007*)

Fig. 14. Trans-thoracic Insertion of IAB Catheter
