Insertion of the Intraaortic Balloon through the Aortic Arch A. L. Shirkey, M.D., B . P. Loughridge, M.D., and K. C. Lain, M.D. ABSTRACT A method for rapidly inserting the balloon catheter of the intraaortic balloon pump directly into the aortic arch in patients undergoing cardiac operations is described.
A new technique for insertion of the intraaortic balloon catheter has been developed for use in patients undergoing various cardiac procedures that necessitate opening the chest and who require mechanical circulatory assistance using the intraaortic balloon pump. * The intraaortic balloon has normally been inserted through the femoral artery and passed into position in the descending thoracic aorta. This new technique takes advantage of the accessibility of the aorta for inserting the balloon into the aortic arch, directing it down through the descending thoracic aorta, and establishing it in the identical location achieved with femoral insertion, though in reverse position. The Figure shows the essentials of the technique, which was adapted from that of Morris for use with the Morris arch cannula. The catheter is inserted well above the aortic valve and the
From the Department of Surgery, University of Oklahoma College of Medicine, Oklahoma City, OK. Accepted for publication Sept 16, 1975. Address reprint requests to Dr. Shirkey, 2600 Center, Suite 312, 2705 E Skelly Dr, Tulsa, OK 74105. *Avco intraaortic balloon pump, Hoffmann-LaRoche Inc, Cranbury, NJ 08512.
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area for any potential vein graft anastomoses and below the area of the innominate vein and artery. Because the balloon passes by the great vessels, it is recommended that the patient be totally heparinized during the entire time the balloon is in place. We have used this arch insertion method in 12 patients with 10 survivors. Only once have we had to switch from arch insertion to femoral insertion. In this case, the patient could not be weaned from cardiopulmonary bypass. Arch insertion offers several advantages. The intraaortic balloon can be inserted in approximately one minute by this technique, so it is useful in patients who suddenly deteriorate before cardiopulmonary bypass is instituted. In patients who have occlusion of the iliac arteries or the aorta, this provides an alternative to insertion through the femoral artery. Patients with aortoiliac disease who need extended support can have a 10 mm woven Dacron graft sutured directly to the aortic arch and brought out into a cervical subcutaneous position for later removal under local anesthesia. In patients with severely depressed left ventricular function, the intraaortic balloon pump may only be needed during the course of the operation to produce pulsatile flow, through weaning from cardiopulmonary bypass, to perhaps30 to 60 minutes after bypass. Insertion by way of the aortic arch in this case is quick and avoids the more time consuming procedure of femoral artery insertion.
561 How to Do It: Shirkey, Loughridge, and Lain: Intraaortic Balloon Insertion through Aortic Arch
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lnsertion of the balloon catheter through the aortic arch: (1) T w o mattress sutures of 0 silk are placed, and Teflon pledget buttresses are spaced approximately 7 mm apart in a radial direction. (2) A stab wound is made in the aorta perpendicular to the mattress sutures. A N o . 11 blade should be used, with penetration halfway u p the bevel. (3) If it is necessary to dilate the stab wound, this is done first. The balloon catheter is then inserted into the incision. (4)After the balloon is inserted, the sutures are drawn through a rubber ligature tube and clamped to hold the balloon catheter in place. (5)After the procedure the catheter is removed and the mattress sutures are tied.
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A new technique for insertion of the intraaortic balloon catheter has been developed for use in patients undergoing various cardiac procedures that necessitate opening the chest and who require mechanical circulatory assistance using the intraaortic balloon pump. * The intraaortic balloon has normally been inserted through the femoral artery and passed into position in the descending thoracic aorta. This new technique takes advantage of the accessibility of the aorta for inserting the balloon into the aortic arch, directing it down through the descending thoracic aorta, and establishing it in the identical location achieved with femoral insertion, though in reverse position. The Figure shows the essentials of the technique, which was adapted from that of Morris for use with the Morris arch cannula. The catheter is inserted well above the aortic valve and the
From the Department of Surgery, University of Oklahoma College of Medicine, Oklahoma City, OK. Accepted for publication Sept 16, 1975. Address reprint requests to Dr. Shirkey, 2600 Center, Suite 312, 2705 E Skelly Dr, Tulsa, OK 74105. *Avco intraaortic balloon pump, Hoffmann-LaRoche Inc, Cranbury, NJ 08512.
560
area for any potential vein graft anastomoses and below the area of the innominate vein and artery. Because the balloon passes by the great vessels, it is recommended that the patient be totally heparinized during the entire time the balloon is in place. We have used this arch insertion method in 12 patients with 10 survivors. Only once have we had to switch from arch insertion to femoral insertion. In this case, the patient could not be weaned from cardiopulmonary bypass. Arch insertion offers several advantages. The intraaortic balloon can be inserted in approximately one minute by this technique, so it is useful in patients who suddenly deteriorate before cardiopulmonary bypass is instituted. In patients who have occlusion of the iliac arteries or the aorta, this provides an alternative to insertion through the femoral artery. Patients with aortoiliac disease who need extended support can have a 10 mm woven Dacron graft sutured directly to the aortic arch and brought out into a cervical subcutaneous position for later removal under local anesthesia. In patients with severely depressed left ventricular function, the intraaortic balloon pump may only be needed during the course of the operation to produce pulsatile flow, through weaning from cardiopulmonary bypass, to perhaps30 to 60 minutes after bypass. Insertion by way of the aortic arch in this case is quick and avoids the more time consuming procedure of femoral artery insertion.
561 How to Do It: Shirkey, Loughridge, and Lain: Intraaortic Balloon Insertion through Aortic Arch
4
lnsertion of the balloon catheter through the aortic arch: (1) T w o mattress sutures of 0 silk are placed, and Teflon pledget buttresses are spaced approximately 7 mm apart in a radial direction. (2) A stab wound is made in the aorta perpendicular to the mattress sutures. A N o . 11 blade should be used, with penetration halfway u p the bevel. (3) If it is necessary to dilate the stab wound, this is done first. The balloon catheter is then inserted into the incision. (4)After the balloon is inserted, the sutures are drawn through a rubber ligature tube and clamped to hold the balloon catheter in place. (5)After the procedure the catheter is removed and the mattress sutures are tied.
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