AJR 2005; 184:1245-1246
© American Roentgen Ray Society
Intraaortic Balloon Pump Location and Aortic Dissection
Lynne M. Hurwitz and
Philip C. Goodman
Department of Radiology, Duke University Medical Center, Box 3808,
Durham, NC 27710.
Received June 17, 2004;
accepted after revision July 22, 2004.
Address correspondence to L. M. Hurwitz
(hurwi001{at}mc.duke.edu).
Introduction
A 72-year-old woman with hyperlipidemia and hypertension presented
with epigastric discomfort that radiated substernally and increased with
exercise. Initial evaluation revealed a new left bundle branch block.
Subsequent cardiac catheterization showed a 95% stenosis in the left anterior
descending artery and an ejection fraction of 30-40%. The patient was admitted
to the cardiac ICU where symptoms and laboratory data of on-going myocardial
ischemia were observed.
The admission chest radiograph (Fig.
1A) showed the heart to be at the upper limits of normal in size.
The remainder of the chest was normal. While in the cardiac ICU, the patient
became hypotensive. An intraaortic balloon pump (9.5F, 40-mL balloon [DL,
Datascope]) was placed without difficulty and its location was confirmed using
fluoroscopy. Normal function was noted with 1:1 augmentation in systole, and
the patient's hypotension improved.
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Fig. 1A. —72-year-old woman with hyperlipidemia and hypertension
presented with epigastric discomfort that radiated substernally and increased
with exercise. Admission posteroanterior chest radiograph shows heart size and
shape are within normal limits. Lungs, mediastinum, pleural spaces, and bones
are also normal.
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A follow-up chest radiograph (Fig.
1B) showed the intraaortic balloon pump with its tip approximately
3 cm below the top of the aortic arch, overlying the lateral aortic wall.
Because the patient complained of abdominal pain, a CT scan of the chest,
abdomen, and pelvis was obtained to look for a retroperitoneal hematoma or
ischemic bowel. The CT images showed extensive atherosclerotic disease and a
Stanford B type dissection of the aorta. The intraaortic balloon pump was seen
within the false lumen (Figs.
1C and
1D). The catheter was
subsequently removed without immediate complications. A three-vessel coronary
artery bypass grafting procedure was performed without complication the next
day, and the patient was discharged from the hospital without further
intervention.
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Fig. 1B. —72-year-old woman with hyperlipidemia and hypertension
presented with epigastric discomfort that radiated substernally and increased
with exercise. Anteroposterior supine chest radiograph obtained 6 hr after
admission shows intraaortic balloon pump with tip of balloon pump located
laterally along wall of descending thoracic aorta.
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Fig. 1C. —72-year-old woman with hyperlipidemia and hypertension
presented with epigastric discomfort that radiated substernally and increased
with exercise. Contrast-enhanced CT scan of mid thorax 1 day after admission
shows type B Stanford dissection and radiopaque intraaortic balloon pump tip
within false lumen.
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Fig. 1D. —72-year-old woman with hyperlipidemia and hypertension
presented with epigastric discomfort that radiated substernally and increased
with exercise. Contrast-enhanced CT scan of upper abdomen 1 day after
admission shows gas in catheter balloon (arrow) lateral to intimal
calcification.
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Discussion
Intraaortic balloon pumps are used to improve coronary artery perfusion in
patients with acute cardiac decompensation resulting from myocardial
infarction [1]. When distended
in diastole, the balloon causes increased pressure in the proximal aorta, thus
improving coronary artery perfusion; increased oxygenation of the myocardium;
and improved cardiac output. Forced deflation during systole decreases cardiac
afterload, resulting in decreased left ventricular work and oxygen
requirements. The device used in this case has a 26-cm-long balloon that
inflates with 30-50 cm3 of gas. At the tip of this catheter is an
approximately 1-cm metallic marker that is visible on radiographs or
fluoroscopy and is used to ensure proper placement—ideally, just distal
to the left subclavian artery. If the balloon pump is too proximal in the
aorta, occlusion of the brachiocephalic, left carotid, or left subclavian
arteries may occur. If the catheter is too distal, the celiac, superior
mesenteric, or renal arteries may be obstructed.
Complications of intraaortic balloon pump placement are seen in 8-29% of
procedures and include limb ischemia, aortic dissection, mesenteric ischemia,
renal insufficiency, neurologic complications, thrombocytopenia, bleeding, and
infection [2,
3]. Most problems are vascular.
Independent risk factors for vascular complications include female sex,
diabetes, cigarette smoking, peripheral vascular disease, and the prior use of
antiplatelet drugs [3,
4]. Aortic dissection occurs in
1-4% of intraaortic balloon pump insertions
[3,
5]. In general, catheter
insertion into a false lumen will lead to poor intraaortic balloon pump
function. However, there is a report of a balloon pump functioning normally
from within the false channel presumably by transmitting pressure across the
intimal flap [5].
Chest radiographs are commonly obtained to evaluate the position of an
intraaortic balloon pump. Ideally, the tip is positioned approximately 2-4 cm
below the level of the aortic arch. Usually, this assessment is adequate;
however, as shown in this case, attention to the relationship of the tip to
the aortic wall may provide a clue to a misplaced intraaortic balloon pump.
Lateral positioning of an intraaortic balloon pump was previously reported in
a patient with the catheter in the aortic wall
[6]. Our report is the first to
document the malpositioned catheter on CT.
The chest radiographic findings of aortic dissection have been well
described in the literature
[7-10]
and include interval enlargement of the aorta, greater than 6-mm displacement
of intimal calcification from the adventitial border on the lateral
radiograph, rightward displacement of the trachea, and double contour of the
aortic arch. These findings are either rare or nonspecific and thus
prospective detection of aortic dissection on chest radiography is limited to
approximately 25% of cases
[11]. The diagnosis may be
made successfully with CT, transesophageal echocardiography, and MRI.
This case illustrates the benefit of clinical and radiographic correlation.
The location of the intraaortic balloon pump within the false lumen usually
manifests clinically with poor augmentation; however, this does not always
happen, as in this case. One should be alert to the possibility of a misplaced
intraaortic balloon pump if the tip consistently overlies the lateral aspect
of the aorta on chest radiographs. Be aware however that a balloon catheter
malpositioned in the ventral or dorsal aortic wall would not necessarily
appear abnormally placed on posteroanterior or anteroposterior chest
radiographs.
References
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Introduction
Discussion
