**16. Complications of IAB insertion**

1. Loss of pedal pulses- Occurs in 15 – 25% of patients (*funk M et al.,1989*). Asymptomatic loss occurs transiently without resulting in limb ischemia and usually returns spontaneously or after IAB removal.

Intra-Aortic Balloon Counterpulsation Therapy

and Its Role in Optimizing Outcomes in Cardiac Surgery 55

8. IAB rupture/entrapment- IAB rupture is rare but immediate removal/replacement is required. Rupture is more likely in women and patients with smaller size and usually occurs because of the constant contact between IAB membrane and atherosclerotic plaque on the femoral arterial/Aorta walls. The most common sign of IAB leak is blood in the drive line (fig 11). IAB leak can cause either a helium embolus (in instants of patient hypotension where helium pressure within the IAB exceeds blood pressure in the aorta) or entrapment of the catheter. The leak can cause a clot to form within the catheter resulting in prevention of removal of the catheter at the time of IAB removal.

9. Hematologic effects- Long term use of IAB has been associated with increased destruction of red cells and thrombocytopenia. The degree of decrease appears to be

10. Malposition of the IAB catheter- If positioned too high, the IAB may occlude blood flowing to the head vessels causing cerebral ischemia and or embolism. If positioned too low it may occlude the renal arteries thereby causing renal ischemia/perfusion and

1. Cut down technique- By 1978 the IAB was a 12fr catheter and prior to that year, cut down insertion was common. Initially, the common femoral artery is dissected and the vascular fascia is opened. With a retractor the femoral artery can be dissected up to a length of 5 cms and umbilical tapes are placed around and behind the femoral artery. Heparin 5000u is administered and the IAB catheter is introduced at an angle to the femoral artery. Placement is confirmed and augmentation initiated. This technique can also be used in patients where femoral pulse is not palpable or where difficulty of

2. Percutaneous (Seldinger) technique: An 18 gauge cannula is introduced into the common femoral artery at a 45 degree angle or less. The guide wire is advanced through the needle and the needle removed. The tissue tract around the arterial

This may necessitate a cut down removal of the IAB catheter.

Fig. 11. IAB Catheter with Blood in Drive Line and Balloon

related to the duration of therapy (*McCabe 1978*)

**17. Insertion techniques** 

non-optimal coronary perfusion/afterload reduction.

insertion is anticipated as in patients suffering from PVD.


2. Limb ischemia- Occurs in 12 – 47% patients and is the most frequently reported complication (*Curtis JJ et al., 1988).* This may result from decreased cardiac output subsequent to heart failure, elevated SVR, low output syndrome, intimal injury or dissection, vessel catheter discrepancy, catheter occlusion or distal thrombo-embolism. Limb ischemia usually preceded by pain in the affected limb, change in pallor, cyanotic color changes, mottling, decreases in sensation, motor function loss, decrease in temperatures in extremity and loss of pedal pulses. Treatment is usually done by removal of IAB, thrombectomy, femoro-popiteal grafting and/or papaverine

3. Thromboembolism- Percutaneous insertion/removal of IAB may result in dislodging of plaques or clots into the renal, splanchnic, hepatic or peripheral arteries. Clots can be seen while removing IAB catheters. It is our institutional policy to have some sort of anti-coagulation during IAB therapy. Although Low molecular weight Dextran has been used, heparin is preferable as it can be reversed with protamine. Generally maintaining the **aPTT 1.5 – 2** times normal is sufficient to prevent formation of thrombin, thereby protecting from subsequent embolism. It is also recommended to flush the IAB catheter with heparinized saline prior to insertion. The only incidence where this may not be necessary is when the patient is fully heparinized and on CPB. It is always a good practice even in this situation to flush with heparinized saline. At Southlake we use pre-mixed heparinized saline bags with 5000 units of heparin in

4. Compartment syndrome- The legs and thighs of humans are made up of compartments containing bone, muscle, nerve tissue and blood vessels, surrounded by a fibrous membrane or fascia. Compartment syndrome is caused by an increased pressure within the non-distensible fascial space reducing capillary blood flow which in turn compromises enclosed fascial tissue. A fasciotomy can be performed to relieve the

5. Aortic Dissection- Is the most serious of complications from IAB insertion. Often unrecognized until removal or until IAB therapy is discontinued resulting in hemodynamic instability and death. Diagnosis is confirmed upon autopsy. Isner in 1980 found an incidence of aortic dissection in 36% of IAB patients (*Isner JM et al,. 1980).*With the advent of smaller French sizes in IAB catheters and better techniques and training, incidence of aortic dissection as a direct consequence of IAB insertion has drastically reduced .Symptoms of aortic dissection include severe back and/or abdominal pain, falling hematocrit and mediastinal enlargement. Aortic Dissection has to be treated aggressively and immediately by attempting to repair the dissection in the operating

6. Local injury- False aneurysm formation, hematoma, lymphedema, lymph fistula, wound hemorrhage, laceration of the femoral/iliac artery or the aorta are common

7. Infective complication- Local wound infection is possible necessitating debridement, drainage, systemic antibiotics and rare cases removal. Sterility is very important while inserting the IAB whether in the peri-operative setting or otherwise. Generally the thigh is prepared by applying betadine prior to insertion and is covered by sterile dressing

complications and can be treated by evacuation and/or arterial repair.

after insertion and anchorage of the catheter by two sutures.

administration.

500ml of saline.

pressure.

room.

8. IAB rupture/entrapment- IAB rupture is rare but immediate removal/replacement is required. Rupture is more likely in women and patients with smaller size and usually occurs because of the constant contact between IAB membrane and atherosclerotic plaque on the femoral arterial/Aorta walls. The most common sign of IAB leak is blood in the drive line (fig 11). IAB leak can cause either a helium embolus (in instants of patient hypotension where helium pressure within the IAB exceeds blood pressure in the aorta) or entrapment of the catheter. The leak can cause a clot to form within the catheter resulting in prevention of removal of the catheter at the time of IAB removal. This may necessitate a cut down removal of the IAB catheter.

Fig. 11. IAB Catheter with Blood in Drive Line and Balloon

