HOW TO DO IT
Improved Technique of Intraaortic Balloon Insertion Jonathan R. Merrill, M.D., David McClusky, M.D., arid William D. Logan, Jr., M.D.
ABSTRACT Routine insertion of an intraaortic balloon through the femoral artery may be difficult in the face of obstructive aortoiliac atherosclerosis. Perioperatively, the balloon catheter may be guided through diseased vessels by transabdominal palpation.
Intraaortic balloon counterpulsation has proved effective in salvaging patients with acute left ventricular failure subsequent to myocardial infarction or cardiotomy and pulmonary bypass [61. The technique of balloon catheter insertion through the femoral artery is familiar to the cardiac surgeon [3]. Occasionally, severe aortoiliac atherosclerosis prevents cannulation by conventional means [l]. Several cases of subintimal aortic dissection have been reported [l, 21. We are aware of 1 instance of perforation of the iliac artery following attempts to pass the balloon, and we suspect that others have observed this same complication. Wolfson and associates [7] failed in 17 of 287 attempted cannulations because of the presence of severe peripheral vascular disease. For those 17 difficult patients they employed a modified balloon with an extra central lumen for guidewire placement and contrast injection using fluoroscopy to navigate tortuous vessels. Ascending aortotomy has been advocated when groin entry is unsuccessful [4, 51. A more simple maneuver was suggested by one of us (J. R. M.) and has been used with success in 2 patients requiring intraaortic balloon insertion immediately following cardiac surgery. If resistance or obstruction to the catheter is encountered at the iliac or lower abdominal aortic area, the peritoneum is opened From the Department of Surgery, Georgia Baptist Medical Center, Atlanta, GA. Accepted for publication Dec 5, 1977. Address reprint requests to Dr. Logan, Atlanta Heart and Lung Clinic, 272 Boulevard, NE, Atlanta GA 30312.
The balloon catheter is guided by palpation transabdominally with access through the inferior aspect of the median sternotomy incision.
at the inferior aspect of the sternotomy exposure. The surgeon can insert one hand into the peritoneal cavity and palpate the aortoiliac area directly. With this bimanual method, one hand advances the catheter while the other guides it through the diseased vessel (Figure). This technique probably cannot be used in patients with numerous intraperitoneal adhesions who have had previous abdominal surgery. The technique presented here has been successful in the 2 patients in whom it was used. It adds little time to the procedure and does not contribute to morbidity.
261 0003-497517810026-0313$01.00@ 1978 by Jonathan R. Merrill
262 The Annals of Thoracic Surgery Vol 26 No 3 September 1978
References
4. Krause AH, Jr, Bigelow JC, Page US: Transthoracic
1 . Cleveland JC, Lefemine AA, Madoff I, et al: The
intraaortic balloon cannulation to avoid repeat sternotomy for removal. Ann Thorac Surg 21:562, 1976 5. Shirkey AL, Loughridge BP, Lain KC: Insertion of the intraaortic balloon through the aortic arch. Ann Thorac Surg 21:560, 1976 6. Webb WR: Intraaortic balloon pumping. Ann Thorac Surg 21:571, 1976 7. Wolfson S, Geha AS, Graeme LH, et al: Preliminary report: modification of intraaortic balloon for pressure measurement, contrast injection and guidewire passage (abstract). Am J Cardiol39:260, 1977
role of intra-aortic balloon counterpulsation in patients undergoing cardiac operations. Ann Thorac Surg 20:652, 1975 2. Duckman WB, Leinback RC, Buckley MJ, et al: Clinical and hemodynamic results of intra-aortic balloon pumping and surgery for cardiogenic shock. Circulation 46:465, 1972 3 . Kantrowitz A, Phillips SJ, Butner AN, et al: Technique of femoral artery cannulation for phase-shift balloon pumping. J Thorac Cardiovasc Surg 56:219, 1968
Improved Technique of Intraaortic Balloon Insertion Jonathan R. Merrill, M.D., David McClusky, M.D., arid William D. Logan, Jr., M.D.
ABSTRACT Routine insertion of an intraaortic balloon through the femoral artery may be difficult in the face of obstructive aortoiliac atherosclerosis. Perioperatively, the balloon catheter may be guided through diseased vessels by transabdominal palpation.
Intraaortic balloon counterpulsation has proved effective in salvaging patients with acute left ventricular failure subsequent to myocardial infarction or cardiotomy and pulmonary bypass [61. The technique of balloon catheter insertion through the femoral artery is familiar to the cardiac surgeon [3]. Occasionally, severe aortoiliac atherosclerosis prevents cannulation by conventional means [l]. Several cases of subintimal aortic dissection have been reported [l, 21. We are aware of 1 instance of perforation of the iliac artery following attempts to pass the balloon, and we suspect that others have observed this same complication. Wolfson and associates [7] failed in 17 of 287 attempted cannulations because of the presence of severe peripheral vascular disease. For those 17 difficult patients they employed a modified balloon with an extra central lumen for guidewire placement and contrast injection using fluoroscopy to navigate tortuous vessels. Ascending aortotomy has been advocated when groin entry is unsuccessful [4, 51. A more simple maneuver was suggested by one of us (J. R. M.) and has been used with success in 2 patients requiring intraaortic balloon insertion immediately following cardiac surgery. If resistance or obstruction to the catheter is encountered at the iliac or lower abdominal aortic area, the peritoneum is opened From the Department of Surgery, Georgia Baptist Medical Center, Atlanta, GA. Accepted for publication Dec 5, 1977. Address reprint requests to Dr. Logan, Atlanta Heart and Lung Clinic, 272 Boulevard, NE, Atlanta GA 30312.
The balloon catheter is guided by palpation transabdominally with access through the inferior aspect of the median sternotomy incision.
at the inferior aspect of the sternotomy exposure. The surgeon can insert one hand into the peritoneal cavity and palpate the aortoiliac area directly. With this bimanual method, one hand advances the catheter while the other guides it through the diseased vessel (Figure). This technique probably cannot be used in patients with numerous intraperitoneal adhesions who have had previous abdominal surgery. The technique presented here has been successful in the 2 patients in whom it was used. It adds little time to the procedure and does not contribute to morbidity.
261 0003-497517810026-0313$01.00@ 1978 by Jonathan R. Merrill
262 The Annals of Thoracic Surgery Vol 26 No 3 September 1978
References
4. Krause AH, Jr, Bigelow JC, Page US: Transthoracic
1 . Cleveland JC, Lefemine AA, Madoff I, et al: The
intraaortic balloon cannulation to avoid repeat sternotomy for removal. Ann Thorac Surg 21:562, 1976 5. Shirkey AL, Loughridge BP, Lain KC: Insertion of the intraaortic balloon through the aortic arch. Ann Thorac Surg 21:560, 1976 6. Webb WR: Intraaortic balloon pumping. Ann Thorac Surg 21:571, 1976 7. Wolfson S, Geha AS, Graeme LH, et al: Preliminary report: modification of intraaortic balloon for pressure measurement, contrast injection and guidewire passage (abstract). Am J Cardiol39:260, 1977
role of intra-aortic balloon counterpulsation in patients undergoing cardiac operations. Ann Thorac Surg 20:652, 1975 2. Duckman WB, Leinback RC, Buckley MJ, et al: Clinical and hemodynamic results of intra-aortic balloon pumping and surgery for cardiogenic shock. Circulation 46:465, 1972 3 . Kantrowitz A, Phillips SJ, Butner AN, et al: Technique of femoral artery cannulation for phase-shift balloon pumping. J Thorac Cardiovasc Surg 56:219, 1968
