Sheathless Insertion of the Percutaneous Intraaortic Balloon Pump: An Alternate Method Steven J. Phillips, MD, Mark Tannenbaum, MD, Robert H. Zeff, MD, L. A. Iannone, MD, Magdi Ghali, MD, and Chamnahn Kongtahworn, MD Mercy Hospital Medical Center, Des Moines, Iowa
A technique is described that allows insertion of a standard percutaneous intraaortic balloon without use of the larger 12F sheath. Standard 9.5-cm. Percor balloons were inserted in a series of patients without using the provided sheath. Elimination of the sheath reduced the potential vascular complications related to the extra bulk placed in the femoral artery by the sheath. No serious complications were noted in more than 25 patients. (Ann Thorac Surg 1992;53:162)
guidewire through the subcutaneous tissue into the vessel. Care was taken to gently rotate the tip of the balloon through the subcutaneous tissues into the common femoral artery so that it did not twist or buckle. The guidewire was held taut as it exited from the central port of the balloon. With adequate placement of the balloon through the femoral artery into the descending thoracic aorta, the guidewire was removed and the central lumen connected for pressure monitoring. Balloon pumping was then initiated.
C
Comment
linical application of the intraaortic balloon pump was introduced by Kantrowitz and associates [l]in 1968. Intraaortic balloon pumping is widely accepted as a first-line mechanical modality for the treatment of left ventricular power failure. The clinical application of balloon pumping was limited by the fact that it required a surgical team to implant. The introduction of the percutaneous balloon pump in 1978 [2] permitted wider application of this device. The percutaneous balloon is usually inserted by a modified Seldinger technique [3] through a 12F sheath. In a subgroup of patients with small or diseased arteries, the intraaortic balloon pump combined with a 12F sheath can obstruct the femoral artery with resultant vascular complications [4]. This report describes a technique for sheathless insertion of the percutaneous intraaortic balloon pump.
Material and Methods The Percor balloon is a 40-mL polyurethane balloon folded in such a way as to provide easy introduction through a sheath or over a guidewire. All balloons were off-the-shelf items and were not modified in any manner. To reduce the potential vascular complication related to the 12F sheath, a series of Percor balloons was purposely inserted in a sheathless fashion as follows: All insertions were through the common femoral artery. The groin was prepared, draped, and anesthetized in the usual fashion. The common femoral artery was punctured, and a guidewire was passed through the needle and directed into the thoracic aorta. The skin and subcutaneous tissue were dilated with the two graduated dilators down to the artery. The central wire stylet of the intraaortic balloon was removed, and the balloon was passed over the Accepted for publication Aug 12, 1991. Address reprint requests to Dr Phillips, Mercy Hospital Medical Center, 6th and University Ave, Des Moines, IA 50314. 0 1992 by The Society of Thoracic Surgeons
Since its first clinical application by Kantrowitz and coworkers [l] in 1966, the intraaortic balloon pump has been the most commonly used mechanical therapy for ventricular power failure. The insertion techniques have evolved from the surgical cut-down [5] to percutaneous insertion with a sheath [2] to the described technique of sheathless insertion. No serious complications have been noted in more than 25 patients when sheathless insertion was used. In addition, no serious bleeding or retroperitoneal hematoma has been experienced. The absence of peripheral vascular complications distal to the balloon have led us to adopt this as our primary technique for balloon pump insertions. We use a pursestring suture around the puncture site to seal it on the balloon shaft, which limits any bleeding from the arteriotomy through the skin puncture site. Bleeding was experienced in 1 patient and was easily controlled by placement of a second pursestring suture. We suggest other physicians consider using the sheathless insertion technique as an alternative to the method of inserting the balloon through the sheath.
References 1. Kantrowitz A, Tjonneland S, Freed PS, Phillips SJ, Butner AN, Sherman JL. Initial clinical experience with intra-aortic balloon pumping in cardiogenic shock. JAMA 1968;203:113-8. 2. Subramanian VA, Paul J, Sos TA. Percutaneous intra-aortic balloon counterpulsation: a new technique. 14th Annual Meeting of the AAMI, May 1978. 3. Conahan TJ, Schwartz AJ, Geer RT. Percutaneous catheter introduction: the Seldinger technique [Letter]. JAMA 1977; 237446-7. 4. Alpert J, Bhakton EG, Bielschinsky I, et al. Vascular complications of intra-aortic balloon pumping. Arch Surg 1976;3: 1190. 5. Kantrowitz A, Phillips SJ, Butner AN, Tjonnelands S, Haller JD. Techniques of femoral artery cannulation for phase shift balloon pumping. J Thorac Cardiovasc Surg 1968;56219-20.
A technique is described that allows insertion of a standard percutaneous intraaortic balloon without use of the larger 12F sheath. Standard 9.5-cm. Percor balloons were inserted in a series of patients without using the provided sheath. Elimination of the sheath reduced the potential vascular complications related to the extra bulk placed in the femoral artery by the sheath. No serious complications were noted in more than 25 patients. (Ann Thorac Surg 1992;53:162)
guidewire through the subcutaneous tissue into the vessel. Care was taken to gently rotate the tip of the balloon through the subcutaneous tissues into the common femoral artery so that it did not twist or buckle. The guidewire was held taut as it exited from the central port of the balloon. With adequate placement of the balloon through the femoral artery into the descending thoracic aorta, the guidewire was removed and the central lumen connected for pressure monitoring. Balloon pumping was then initiated.
C
Comment
linical application of the intraaortic balloon pump was introduced by Kantrowitz and associates [l]in 1968. Intraaortic balloon pumping is widely accepted as a first-line mechanical modality for the treatment of left ventricular power failure. The clinical application of balloon pumping was limited by the fact that it required a surgical team to implant. The introduction of the percutaneous balloon pump in 1978 [2] permitted wider application of this device. The percutaneous balloon is usually inserted by a modified Seldinger technique [3] through a 12F sheath. In a subgroup of patients with small or diseased arteries, the intraaortic balloon pump combined with a 12F sheath can obstruct the femoral artery with resultant vascular complications [4]. This report describes a technique for sheathless insertion of the percutaneous intraaortic balloon pump.
Material and Methods The Percor balloon is a 40-mL polyurethane balloon folded in such a way as to provide easy introduction through a sheath or over a guidewire. All balloons were off-the-shelf items and were not modified in any manner. To reduce the potential vascular complication related to the 12F sheath, a series of Percor balloons was purposely inserted in a sheathless fashion as follows: All insertions were through the common femoral artery. The groin was prepared, draped, and anesthetized in the usual fashion. The common femoral artery was punctured, and a guidewire was passed through the needle and directed into the thoracic aorta. The skin and subcutaneous tissue were dilated with the two graduated dilators down to the artery. The central wire stylet of the intraaortic balloon was removed, and the balloon was passed over the Accepted for publication Aug 12, 1991. Address reprint requests to Dr Phillips, Mercy Hospital Medical Center, 6th and University Ave, Des Moines, IA 50314. 0 1992 by The Society of Thoracic Surgeons
Since its first clinical application by Kantrowitz and coworkers [l] in 1966, the intraaortic balloon pump has been the most commonly used mechanical therapy for ventricular power failure. The insertion techniques have evolved from the surgical cut-down [5] to percutaneous insertion with a sheath [2] to the described technique of sheathless insertion. No serious complications have been noted in more than 25 patients when sheathless insertion was used. In addition, no serious bleeding or retroperitoneal hematoma has been experienced. The absence of peripheral vascular complications distal to the balloon have led us to adopt this as our primary technique for balloon pump insertions. We use a pursestring suture around the puncture site to seal it on the balloon shaft, which limits any bleeding from the arteriotomy through the skin puncture site. Bleeding was experienced in 1 patient and was easily controlled by placement of a second pursestring suture. We suggest other physicians consider using the sheathless insertion technique as an alternative to the method of inserting the balloon through the sheath.
References 1. Kantrowitz A, Tjonneland S, Freed PS, Phillips SJ, Butner AN, Sherman JL. Initial clinical experience with intra-aortic balloon pumping in cardiogenic shock. JAMA 1968;203:113-8. 2. Subramanian VA, Paul J, Sos TA. Percutaneous intra-aortic balloon counterpulsation: a new technique. 14th Annual Meeting of the AAMI, May 1978. 3. Conahan TJ, Schwartz AJ, Geer RT. Percutaneous catheter introduction: the Seldinger technique [Letter]. JAMA 1977; 237446-7. 4. Alpert J, Bhakton EG, Bielschinsky I, et al. Vascular complications of intra-aortic balloon pumping. Arch Surg 1976;3: 1190. 5. Kantrowitz A, Phillips SJ, Butner AN, Tjonnelands S, Haller JD. Techniques of femoral artery cannulation for phase shift balloon pumping. J Thorac Cardiovasc Surg 1968;56219-20.
