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Transaxillary Intra-aortic Balloon Pump Placement: A New Approach With Great Potential

      To the Editor:
      The intra-aortic balloon pump (IABP) was initially developed for management of cardiogenic shock in the setting of acute myocardial infarction.
      • Kantrowitz A.
      • Tjonneland S.
      • Freed P.S.
      • Phillips S.J.
      • Butner A.N.
      • Sherman Jr., J.L.
      Initial clinical experience with intraaortic balloon pumping in cardiogenic shock.
      Over ensuing years, the IABP became a therapeutic strategy for bridging critically ill patients to left ventricular assist device (LVAD) implantation or heart transplant. Because of the nature of femoral access, prolonged use of an IABP has been associated with infection, peripheral artery complications, and restricted patient mobility. Therefore, the IABP oftentimes is removed after a few days of insertion, which deprives patients of prolonged mechanical hemodynamic support. Percutaneous transaxillary access has evolved as an alternative approach for prolonged mechanical hemodynamic support as a bridge to target therapy. Additionally, in many centers, the transaxillary approach for placement of the IABP has been the primary access for patients with occlusive peripheral artery disease.
      The first IABP placement via axillary artery was performed in 1989 by McBride et al,
      • McBride L.R.
      • Miller L.W.
      • Naunheim K.S.
      • Pennington D.G.
      Axillary artery insertion of an intraaortic balloon pump.
      who used a simplified surgical technique for IABP placement. A Dacron side-arm graft or vein cuff is used as a conduit to avoid trauma to the axillary artery and to facilitate decannulation by simply transecting the graft.
      • Sabik J.F.
      • Lytle B.W.
      • McCarthy P.M.
      • Cosgrove D.M.
      Axillary artery: an alternative site of arterial cannulation for patients with extensive aortic and peripheral vascular disease.
      Currently, transaxillary access can be obtained percutaneously under sonographic guidance, which is less invasive and does not require general anesthesia. Once access is obtained, the sheath is inserted to cannulate the left axillary artery. The advancement of the IABP through the axillary sheath can be performed under fluoroscopic guidance until the distal end of the catheter is positioned in the proximal abdominal aorta just above the ostia of renal arteries.
      Patients presenting with decompensated end-stage heart failure often require urgent placement of an LVAD as bridging or destination therapy. However, because of multiple comorbidities such as active bleeding, previous sternotomy, acute kidney injury, or ongoing infection, LVAD implantation is often delayed.
      • Estep J.D.
      • Cordero-Reyes A.M.
      • Bhimaraj A.
      • et al.
      Percutaneous placement of an intra-aortic balloon pump in the left axillary/subclavian position provides safe, ambulatory long-term support as bridge to heart transplantation.
      • Umakanthan R.
      • Hoff S.J.
      • Solenkova N.
      • et al.
      Benefits of ambulatory axillary intra-aortic balloon pump for circulatory support as bridge to heart transplant.
      Thus, the transaxillary approach for IABP placement has evolved as an alternative access that provides prolonged hemodynamic support without interfering with early ambulation and physical therapy.
      • Estep J.D.
      • Cordero-Reyes A.M.
      • Bhimaraj A.
      • et al.
      Percutaneous placement of an intra-aortic balloon pump in the left axillary/subclavian position provides safe, ambulatory long-term support as bridge to heart transplantation.
      • Umakanthan R.
      • Hoff S.J.
      • Solenkova N.
      • et al.
      Benefits of ambulatory axillary intra-aortic balloon pump for circulatory support as bridge to heart transplant.
      Umakanthan et al
      • Umakanthan R.
      • Hoff S.J.
      • Solenkova N.
      • et al.
      Benefits of ambulatory axillary intra-aortic balloon pump for circulatory support as bridge to heart transplant.
      described a series of 18 patients who underwent transaxillary IABP placement as a bridge to heart transplant (median of 19 days). The IABP was placed successfully through the left axillary artery in all patients with no reported IABP-related vascular or embolic complications. Three patients required IABP replacement because of device migration, kinking, and rupture without any further complications. There was marked improvement in ambulatory potential, and the longest distance walked in a day was 2654.58±2425.52 feet compared with 411.4±247.7 feet before IABP placement (P=.008). In a large retrospective cohort of 50 patients supported by axillary IABP placement as bridge to heart transplant (median of 18 days), IABP implantation was successful in all patients, and only 4 patients (8%) had significant thromboembolic or bleeding complications, without long-term sequelae.
      • Estep J.D.
      • Cordero-Reyes A.M.
      • Bhimaraj A.
      • et al.
      Percutaneous placement of an intra-aortic balloon pump in the left axillary/subclavian position provides safe, ambulatory long-term support as bridge to heart transplantation.
      However, IABP malposition was common and occurred in 22 patients (44%). All patients were able to sit upright and ambulate, and 16 of them underwent physical therapy. Despite prolonged IABP placement in the aforementioned studies, the rate of infection was negligible.
      • Estep J.D.
      • Cordero-Reyes A.M.
      • Bhimaraj A.
      • et al.
      Percutaneous placement of an intra-aortic balloon pump in the left axillary/subclavian position provides safe, ambulatory long-term support as bridge to heart transplantation.
      • Umakanthan R.
      • Hoff S.J.
      • Solenkova N.
      • et al.
      Benefits of ambulatory axillary intra-aortic balloon pump for circulatory support as bridge to heart transplant.
      Given the large insertion sheath, transfemoral access is associated with increased risk of peripheral vascular complications and limitation of patient mobility. Further, long-term use of a femoral IABP in those requiring extended support is also associated with increased risk of infection. Previous studies reported a 42% increase in the rate of infection related to femoral placement of an IABP in patients who required mechanical support for 20 days or more.
      • Barnett M.G.
      • Swartz M.T.
      • Peterson G.J.
      • et al.
      Vascular complications from intraaortic balloons: risk analysis.
      • Freed P.S.
      • Wasfie T.
      • Zado B.
      • Kantrowitz A.
      Intraaortic balloon pumping for prolonged circulatory support.
      Malposition of the IABP is one complication that is more common with transaxillary access; however, it only requires simple bedside repositioning.
      • Estep J.D.
      • Cordero-Reyes A.M.
      • Bhimaraj A.
      • et al.
      Percutaneous placement of an intra-aortic balloon pump in the left axillary/subclavian position provides safe, ambulatory long-term support as bridge to heart transplantation.
      • Umakanthan R.
      • Hoff S.J.
      • Solenkova N.
      • et al.
      Benefits of ambulatory axillary intra-aortic balloon pump for circulatory support as bridge to heart transplant.
      Moreover, the axillary artery is more prone to injury during sheath insertion because it has higher elastic properties and thinner walls compared with the femoral artery. Also, the anatomic location precludes effective manual compression at the puncture site and thus higher risk of hemorrhagic shock if bleeding occurs.
      In conclusion, ultrasound-guided transaxillary IABP placement is an alternative technique that can be useful in patients with severe occlusive peripheral artery disease and acute limb ischemia and allows ambulation in those requiring prolonged IABP support. Further studies are needed to evaluate the safety and clinical outcomes of this relatively new approach.

      References

        • Kantrowitz A.
        • Tjonneland S.
        • Freed P.S.
        • Phillips S.J.
        • Butner A.N.
        • Sherman Jr., J.L.
        Initial clinical experience with intraaortic balloon pumping in cardiogenic shock.
        JAMA. 1968; 203: 113-118
        • McBride L.R.
        • Miller L.W.
        • Naunheim K.S.
        • Pennington D.G.
        Axillary artery insertion of an intraaortic balloon pump.
        Ann Thorac Surg. 1989; 48: 874-875
        • Sabik J.F.
        • Lytle B.W.
        • McCarthy P.M.
        • Cosgrove D.M.
        Axillary artery: an alternative site of arterial cannulation for patients with extensive aortic and peripheral vascular disease.
        J Thorac Cardiovasc Surg. 1995; 109: 885-890
        • Estep J.D.
        • Cordero-Reyes A.M.
        • Bhimaraj A.
        • et al.
        Percutaneous placement of an intra-aortic balloon pump in the left axillary/subclavian position provides safe, ambulatory long-term support as bridge to heart transplantation.
        JACC Heart Fail. 2013; 1: 382-388
        • Umakanthan R.
        • Hoff S.J.
        • Solenkova N.
        • et al.
        Benefits of ambulatory axillary intra-aortic balloon pump for circulatory support as bridge to heart transplant.
        J Thorac Cardiovasc Surg. 2012; 143: 1193-1197
        • Barnett M.G.
        • Swartz M.T.
        • Peterson G.J.
        • et al.
        Vascular complications from intraaortic balloons: risk analysis.
        J Vasc Surg. 1994; 19: 81-87
        • Freed P.S.
        • Wasfie T.
        • Zado B.
        • Kantrowitz A.
        Intraaortic balloon pumping for prolonged circulatory support.
        Am J Cardiol. 1988; 61: 554-557