Percutaneous Right Axillary Intra-aortic Balloon Pump in Patients with Advanced Heart Failure : ASAIO Journal

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Percutaneous Right Axillary Intra-aortic Balloon Pump in Patients with Advanced Heart Failure

Alvarez Villela, Miguel*,†; Nagraj, Sanjana*; Milwidsky, Assi; Sanina, Cristina; Goldstein, Daniel J.; Forest, Stephen J.; Chavarria, Nelson*; Patel, Snehal R.; Sims, Daniel B.; Jorde, Ulrich P.; Latib, Azeem; Wiley, Jose M.

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doi: 10.1097/MAT.0000000000001753
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The intra-aortic balloon pump (IABP) is the most widely used temporary circulatory support (TCS) device in the United States.1 Its use in advanced heart failure patients has grown exponentially in recent years. Since the 2018 revision of United Network for Organ Sharing transplant listing criteria, use of IABP as a bridge to heart transplant has increased by three-fold with adequate waitlist and posttransplant outcomes.2 Concomitantly, the axillary (ax) artery has gained popularity as the IABP insertion site as it allows ambulation and prevents further deconditioning of these chronically ill patients.3

Reports of percutaneous placement of axIABP are limited in the literature.3–5 Although, serious complications associated with this technique thus far appear to be rare, catheter migration is a common event (as high as 40–60%) that leads to frequent repositioning and can potentially lead to serious events including retrograde transit of the IABP into the left ventricle or superior mesenteric artery.5,6 Traditionally, the left (L-) ax artery has been considered as the more favorable IABP insertion site compared with the right, as it has a larger diameter, avoids the right common carotid artery, and is thought to provide a more stable catheter position. However, the puncture site for L-ax artery is often limited in patients with advanced heart failure due to pacemaker (PPM) or defibrillator (ICD) generators in the left anterior chest. Outcomes related to the systematic use of the right (R-) ax artery as access site for indwelling IABPs in heart failure patients have not been reported.

Materials and Methods

We performed a retrospective chart review of all patients at our institution who underwent axIABP placement between February 2016 and April 2021. Demographics and patient outcomes are presented for each hospitalization, whereas clinical, laboratory data, and complication rates are attributed to each unique IABP placed. We compared the type and number of complications for R-axIABP versus L-axIABP. Clinical outcomes leading to IABP removal were collected.

Last-recorded invasive hemodynamics and laboratory values before IABP placement are reported. The Maquet CS300 IABP is used uniformly at our institution. Axillary intra-aortic balloon pump insertions were performed in the cardiac catheterization laboratory (CCL) under fluoroscopic and ultrasound guidance using micropuncture technique. (Figure 1) Right axillary intra-aortic balloon pump was adopted later in the study period, when we modified our practice to use almost exclusively conventional, fluid-filled catheters for ax placements (MEGA IABP catheter, Maquet Getinge Group), given an apparent higher incidence of device malfunction and migration with fiber-optic catheters. IABP sizing was according to manufacturer guidelines, 40cc balloons were used for patients with a height of less than 162 cm, and 50cc balloons for those greater than or equal to 162 cm. Anticoagulation with unfractionated heparin or bivalirudin to a goal partial thromboplastin time of 50–70 s is maintained routinely at our institution during all IABP support unless otherwise contraindicated. Removal was performed in the CCL with a secondary access site, either femoral artery or ipsilateral radial artery, maintained for potential bail-out. A vascular closure device (VCD) was attempted routinely except in those devices planned to be removed at the time of cardiac surgery. The Proglide Perclose (Abbott Vascular, Lake Bluff, IL) device was used preferentially. Angio-seal (St Jude Medical, St Paul, MN) was used in cases where access angle or vessel anatomy was not favorable for Perclose deployment. When a VCD could not be delivered or there was incomplete hemostasis after device deployment, balloon tamponade was performed using the secondary access site. For this, a Mustang balloon (Boston Scientific, Marlborough, MA) 7.0 × 40 mm or 8.0 × 40 mm was inflated to nominal pressure for 2–3 min followed by 2 min intervals of manual compression as needed. In cases where repeated balloon inflations were needed, a low-dose heparin bolus (300 U/kg) was administered during the procedure to prevent vessel thrombosis. A postclosure angiogram was obtained via the secondary access site after hemostasis was achieved to confirm vessel patency.

F1
Figure 1.:
(A–E): Technique for R-axIABP insertion at our institution. The ax artery is identified via limited angiogram performed via the ipsilateral radial artery. A pigtail catheter is used for the angiogram (A). The tip of the pigtail is then positioned immediately distal to the origin of the lateral thoracic artery. The pigtail is “opened” in the AP projection to ensure that the center of the pigtail marks the middle of the artery and a micropuncture needle is inserted coaxial to the body of the catheter, into the middle of the pigtail. Once blood return is seen, the micropuncture wire is inserted (B). The access site is serially dilated (if sheathless, dilated to 5Fr for 40cc catheter and 6Fr to 50cc catheter) and the IABP is then inserted over a stiff 0.018” wire to the desired position (C). The wire is removed and the IABP is secured in place (D). ax, axillary; axIABP, axillary intra-aortic balloon pump; AP, anterior–posterior.

Results

Thirty-one patients with a total of 32 hospitalizations received 38 Ax IABPs during the study period: 17 L-ax (Figure 2) and 21 R-ax. Between June 2016 and August 2019, 13 out of 14 cases (92%) were performed via the L-ax access, whereas 20 out of 24 (83%) cases performed between September 2019 and April 2021 were done via the R-ax access. The decision to transition to R-ax access was based on the frequent interference of ipsilateral ICD and PPM generators in the left deltopectoral triangle in cases done before September 2019.

There were no significant differences in baseline clinical, hemodynamic, or laboratory characteristics between patients with L- vs. R-axIABP, except for a lower systolic blood pressure (89 ± 11 vs. 100 ± 20 mmHg), higher baseline heart rate (101 ± 13 vs. 90 ± 18 bpm; P = 0.033), and shorter IABP dwell time (3.9 ± 2.5 vs. 6.7 ± 3.5 days; P = 0.022) in the L-axIABP group.

Sheathless insertion was used in eight patients with L-axIABP (47%) and in two patients with R-axIABP (10%). The fluid-filled MEGA catheter was used in three (13%) patients with L-axIABP and in 14 (70%) of R-ax cases.

There were no events of mesenteric ischemia, bacteremia, access-site hematoma pseudoaneurysm, or bleeding requiring transfusion. Despite higher dwell time, patients with R-axIABP suffered nominally lower rates of device migration or malfunction leading to exchange, or repositioning under fluoroscopy was higher for patients with L-axIABP (Table 1).

F2
Figure 2.:
Still fluoroscopic image showing the course of the IABP when inserted via the L-ax artery. Course of the IABP when inserted via the L-ax artery. The steps followed for placement are the same as described in Figure 1. IABP, intra-aortic balloon pump; L-ax, left axillary.
Table 1. - Comparison of Left and Right Aaxillary IABP
Demographic Characteristics (n = 32) L-axIABP (n = 13) R-axIABP (n = 19) p
Age, years 52 ± 21 59 ± 11 0.200
Gender, males 9 (69%) 15 (79%) 0.533
IABP dwell time, days 4 (2–5) 7 (4–9) 0.059
ICMP 6 (46%) 7 (37%) 0.598
AICD 5 (39%) 15 (79%) 0.020
Clinical and Laboratory Data (n = 38) L-axIABP n = 18 R-axIABP n = 20 p
Inotropes before IABP insertion 18 (100%) 17 (85%) 0.087
Blood pressure, sys/dia, mmHg 89/59 ± 11/10 100/64 ± 20/15 0.044/0.186
Heart rate, bpm 101 ± 8 90 ± 19 0.033
LVEF, % 24 ± 9 22 ± 13 0.645
LVEDD, cm 6 ± 2 6.7 ± 0.9 0.188
Creatinine, mg/dl 2.4 ± 2.3 2.5 ± 2.7 0.863
Hemoglobin, g/dl 9.5 ± 1.5 10.4 ± 1.5 0.084
RAP, mmHg 14 ± 9 14 ± 12 0.835
PCWP, mmHg 29 ± 12 24 ± 8 0.126
Cardiac index, L/min/m2 2 ± 0.6 2.1 ± 1 0.681
PAPi 3.45 ± 5 2.11 ± 1 0.248
Complication rate
 IABP migration/kink/malfunction leading to exchange or repositioning 9 (50%) 4 (20%) 0.052
 Stroke 1 (6%) 0 0.285
 Arm ischemia 3 (17%) 0 0.057
 Axillary artery thrombosis 2 (11%) 2 (10%) 0.911
Closure mechanism
Balloon tamponade 7 (41%) 4 (20%) 0.484
Proglyde Perclose 9 (53%) 12 (60%)
Angio-seal 1 (6%) 2 (10%)
Planned open surgical repair 1 (6%) 2 (10%)
Escalation of temporary circulatory support
Femoral IABP 1 (6%) 0 0.662
Impella 3 (17%) 2 (10%)
ECMO 1 (6%) 3 (15%)
None 13 (77%) 15 (71%)
Patient Outcomes (n = 32) L-axIABP (n = 13) R-axIABP (n = 19) p
Death 2 (15%) 2 (11%) 0.686
Recovered 2 (16%) 2 (11%)
OHT 7 (54%) 12 (63%)
BiVAD 1 (8%) 3 (16%)
CABG 1 (8%) 0
AICD, automatic implantable cardioverter-defibrillator; BiVAD, biventricular ventricular assist device; CABG, coronary artery bypass graft surgery; ECMO, extra-corporeal membrane oxygenation; IABP, intra-aortic balloon pump; ICMP, ischemic cardiomyopathy; LVEDD, left ventricular end-diastolic diameter; LVEF, left ventricular ejection fraction; OHT, orthotopic heart transplantation; PAPi, pulmonary artery pulsatility index; PCWP, pulmonary capillary wedge pressure; RAP, right atrial pressure.

No differences were noted in the need for escalation of TCS or clinical outcomes leading to axIABP removal in each group. When escalation to Impella was required, this was inserted via the femoral artery with removal of the axIABP.

Most patients in this series eventually received heart transplantation, leading to IABP removal. A single patient with L-axIABP was bridged to coronary artery bypass graft surgery (CABG) surgery, during which the left internal mammary artery (LIMA) was used as a conduit for the left anterior descending artery. The IABP in this case was removed in the CCL after surgery. Whether the R-ax access should be preferred in patients bridged to CABG is an interesting consideration. Perhaps sparing of the L subclavian could facilitate LIMA grafting. Since most patients in our series were bridged to orthotopic heart transplantation (OHT) or recovery, we did not hold routine discussions regarding revascularization strategies in these patients.

Notably, one patient with R-axIABP suffered retrograde migration of the IABP into the left ventricle after concomitant peripheral venoarterial-extra-corporeal membrane oxygenation (VA-ECMO) support was instituted. We published details on this event previously6, as it triggered our uniform adoption of the MEGA IABP catheter (Maquet Getinge Group).

Conclusions

Our findings suggest that use of the R-ax artery as access site for indwelling IABP catheters is safe and feasible in patients with advanced heart failure being bridged to recovery or definitive therapies. Compared to those with L-axIABP, patients with R-axIABP experienced nominally lower rates of complications at our institution. However, an era effect in favor of R-axIABP is likely present since important adaptations in our practice occurred concomitant to R-ax access adoption, namely the use of fluid-filled IABP catheters. Of note, sheathless insertion is being used routinely in all axIABP cases at our institution since this series was collected. Valid concerns exist regarding the risk of interference of the R-axIABP with carotid blood flow. Although we did not observe a higher rate of strokes with this access, we did not monitor cerebral perfusion via noninvasive methods. This may be an important area for future studies.

This report provides initial evidence for the wider adoption of R-axIABP placement in patients with limited access options in the left deltopectoral triangle due to the presence of pacemaker or defibrillator generators.

References

1. Stretch R, Sauer CM, Yuh DD, Bonde P: National trends in the utilization of short-term mechanical circulatory support: Incidence, outcomes, and cost analysis. J Am Coll Cardiol. 64: 1407–1415, 2014.
2. Huckaby LV, Seese LM, Mathier MA, Hickey GW, Kilic A: Intra-aortic balloon pump bridging to heart transplantation: Impact of the 2018 allocation change. Circ Heart Fail. 13: e006971, 2020.
3. Bhimaraj A, Agrawal T, Duran A, et al.: Percutaneous left axillary artery placement of intra-aortic balloon pump in advanced heart failure patients. Heart Fail. 8: 313–323, 2020.
4. Estep JD, Cordero-Reyes AM, 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. 1: 382–388, 2013.
5. Rosenbaum AN, Jain CC, Shadrin IY, El Hajj SC, El Sabbagh A, Behfar A: Percutaneous axillary intra-aortic balloon pump insertion technique as bridge to advanced heart failure therapy. ASAIO J. 67: e81–e85, 2021.
6. Alvarez CK, Alvarez Villela M, Wiley JM, et al.: Axillary intra-aortic balloon pump migration into the left ventricle during peripheral venoarterial extracorporeal membrane oxygenation support. Circ Heart Fail. 13: e007017, 2020.
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