Management of intra-aortic balloon pump rupture and entrapment: a case report and review of the literature

Abstract

Introduction:

Intra-aortic balloon pump (IABP) rupture with subsequent entrapment is a rare but serious complication. This report aims to present a case of IABP balloon rupture and entrapment, along with a systematic review of management strategies to guide clinical practice.

Presentation of case:

An 84-year-old female with acute ST-segment elevation myocardial infarction and cardiogenic shock underwent IABP implantation. Balloon rupture occurred 24 days later, accompanied by entrapment. Successful removal was achieved via laparotomy and right common iliac artery endarterectomy. The patient recovered without symptoms at 1-year follow-up.

Discussion:

IABP balloon rupture is uncommon (≈0.5%), often resulting from mechanical abrasion against atherosclerotic plaques. Early recognition and intervention are critical to prevent thrombosis and entrapment. Management options include thrombolysis, percutaneous extraction, or surgical removal depending on timing and clinical context.

Conclusion:

Prompt identification of balloon rupture and appropriate intervention are essential to avoid severe complications. A structured management algorithm is recommended to optimize outcomes.

Introduction

The intra-aortic balloon pump (IABP) is a circulatory assist device widely used in the rescue and treatment of critically ill patients. Although effective, its use is associated with potential complications that can significantly impact patient outcomes^[1,2^]. Among these, balloon rupture is a rare but serious complication. Upon occurrence, the IABP ceases to function correctly, and prolonged rupture may lead to difficulty in balloon removal, potentially necessitating surgical intervention and posing life-threatening risks^[3,4^]. This complication is infrequent, with management strategies primarily documented in isolated case reports worldwide.

IABP was first successfully applied in a patient with cardiogenic shock following myocardial infarction by Kantrowitz et al in 1967^[5^]. Since then, its clinical use has expanded considerably. It is estimated that approximately 70 000 IABP implants are performed annually in the United States, though comparable data are not available for China^[1,2^]. The device functions by positioning a balloon in the descending aorta. During systole, balloon deflation reduces cardiac afterload and increases cardiac output, thereby improving perfusion to vital organs. During diastole, balloon inflation augments diastolic pressure, enhancing coronary artery perfusion and myocardial oxygen supply^[2,6–9,10^]. Common indications include cardiogenic shock refractory to medication, mechanical complications of myocardial infarction, refractory ventricular arrhythmias, and support during high-risk percutaneous or surgical interventions.

HIGHLIGHTS

• An octogenarian with a complex MI developed a rare IABP balloon rupture and entrapment.

• Successful surgical extraction was achieved via abdominal aortotomy and endarterectomy.

• Early recognition relying on device alarm and visible blood prevented fatal outcomes.

• Multidisciplinary management led to full recovery despite high surgical risk.

Despite its benefits, IABP carries risks such as balloon rupture, aortic dissection, thromboembolism, limb ischemia, and thrombocytopenia^[3,4^]. The incidence of balloon rupture and entrapment is approximately 0.5%^[3,4^]. Xing et al^[11^] reported a mortality rate of 50% in a small series of balloon rupture cases, underscoring the need for early recognition and intervention. Most reports to date are limited to case studies, indicating a lack of consolidated clinical guidance.

We encountered a case of IABP balloon rupture with subsequent entrapment that required surgical removal via abdominal aortotomy and endarterectomy. The patient was successfully treated and discharged without sequelae. This case highlights the severity of this complication and the need for systematic management approaches.

Objective: This report presents a case of IABP balloon rupture and entrapment, reviews the relevant literature, and summarizes diagnostic and therapeutic strategies to improve clinical management of this rare but serious condition.

This case report has been reported in line with the SCARE checklist^[12^].

Case presentation

Patient information

An 84-year-old female presented to the emergency department on 1 December 2023, with a chief complaint of “abdominal pain and vomiting for 1 hour”. During evaluation, she experienced a brief, self-resolved episode of loss of consciousness and unresponsiveness.

Clinical findings

Initial examination revealed: body temperature 36.3°C, pulse 110 beats/min, respiratory rate 20 breaths/min, and blood pressure 80/46 mmHg. The patient was lethargic; cardiorespiratory examination showed clear lung fields, regular heart rhythm without murmurs, and unremarkable abdominal and extremity findings. Electrocardiogram demonstrated an acute extensive anterior myocardial infarction. Cardiac ultrasound identified left ventricular wall myocardial infarction accompanied by a ventricular aneurysm (approximately 22 × 12 mm). The patient was diagnosed with acute extensive anterior myocardial infarction, cardiogenic shock, and left ventricular aneurysm formation.

Diagnostic assessment

Emergency coronary angiography via transradial access revealed subtotal occlusion of the proximal left anterior descending artery (LAD), 50-60% stenosis of the proximal to mid-left circumflex artery, and 30-40% stenosis of the proximal to mid-right coronary artery with localized 50-60% narrowing distally. A 2.5 mm × 33 mm drug-eluting stent was deployed in the proximal to mid-LAD. Despite high-dose vasopressor administration, hypotension persisted (60-70/40-50 mmHg), prompting initiation of IABP support for cardiogenic shock. Balloon position was confirmed by bedside X-ray.

Therapeutic intervention

Pharmacotherapy included dual antiplatelet therapy (aspirin and clopidogrel), anticoagulation with enoxaparin, atorvastatin for lipid management, inotropic and vasopressor support (dopamine and norepinephrine), diuretics combined with recombinant human brain natriuretic peptide for heart failure, antibiotic prophylaxis, and gastroprotection.

The clinical course was complicated by the development of a ventricular septal perforation (VSP). Cardiac ultrasound on postoperative day 2 revealed a 6-mm apical VSP with resolution of the previously noted ventricular aneurysm. However, serial echocardiograms documented progressive enlargement of the VSP to 8 mm (day 3), 10 mm (day 5), 15 mm (day 8), and 16 mm (day 13). By day 19, the VSP (16 mm) was accompanied by a newly formed apical ventricular aneurysm (26 × 14 mm), which further expanded to 28 × 18 mm alongside an 18-mm VSP by day 22.

Despite these mechanical complications, hemodynamic parameters gradually stabilized with IABP support, allowing for the titration and eventual reduction of vasopressor doses, and blood pressure was maintained at 90-112/60-78 mmHg. However, due to the severity of the VSP and ongoing cardiogenic shock, early weaning from IABP support was not feasible.

On day 23, the IABP console triggered intermittent blood detection alarms without visible blood in the tubing. Device function resumed normally after brief cessation, suggesting a false alarm. On day 24, recurrent alarms were accompanied by visible blood in the safety chamber (Fig. 1). Balloon rupture was suspected, and immediate removal was attempted. Resistance during withdrawal indicated balloon entrapment near the abdominal aorta.

Figure 1.

Red blood visible within the IABP device tubing. IABP, intra-aortic balloon pump.

Abdominal aortography via left common femoral artery access confirmed balloon location approximately 10 cm above the right common iliac artery (Fig. 2). Under general anesthesia, the patient underwent abdominal aortotomy, thrombectomy, and right common iliac artery endarterectomy. Due to extraction difficulty, the balloon was incised distally, thrombus was evacuated, and the balloon was decompressed and successfully removed (Fig. 3).

Figure 2.

Abdominal aortography reveals the pigtail catheter at the level of the first lumbar vertebra (the filling defect indicated by the red arrow shows the shadow of the balloon within the abdominal aorta, retained at the right common iliac artery, with no significant contrast opacification of the right iliac artery).

Figure 3.

The distal end of the balloon catheter was incised intraoperatively, and thrombus was expressed followed by decompression and removal.

Outcome and follow-up

Postoperatively, the patient received 400 mL of plasma and 2 units of leukocyte-depleted red blood cells for volume and blood product support. Hemodynamic stability was maintained with dopamine and low-dose norepinephrine.

The endotracheal tube was successfully extubated on postoperative day 25 without significant discomfort. Vital signs at that time were stable: temperature 36.5°C, pulse 65 beats/min, respiratory rate 12 breaths/min, and blood pressure 102/46 mmHg. By day 30, vasopressors were completely discontinued, and vital signs remained stable.

On day 35, a comprehensive cardiac surgery assessment was performed. Given the patient’s advanced age and complex cardiac condition, surgical repair of the VSP was deemed prohibitively high-risk. Conservative medical management was recommended and continued.

The patient denied any chest tightness or dyspnea. Subsequent vital signs included temperature 36.6°C, pulse 74 beats/min, respiratory rate 18 breaths/min, blood pressure 112/68 mmHg, and oxygen saturation of 99% on room air.

After a total hospitalization of 46 days, the patient was discharged in stable condition. Detailed objective assessments were obtained during post-discharge follow-up. At the 1-month and 5-month visits, her left ventricular ejection fraction was 57% and 58%, respectively. The VSP remained persistent, measuring 8-12 mm in diameter, and the apical left ventricular aneurysm had stabilized at 20 × 14 mm but contained a thrombus. Her functional status was consistent with New York Heart Association Class III. The anticoagulation regimen was switched to rivaroxaban to mitigate thromboembolic risk. She reported no symptoms of angina, syncope, or arrhythmias, though she had not participated in a structured cardiac rehabilitation program. Follow-up visits at 1 and 5 months post-discharge showed sustained clinical stability, and the patient maintained independence in daily activities.

Discussion

Common complications associated with IABP use include thrombocytopenia and fever, accounting for approximately 50 and 36% of cases, respectively. Less frequent complications such as vascular injury and limb ischemia occur in about 1-2% of cases^[3,13,14^]. In contrast, intra-aortic balloon rupture is a rare complication that can lead to gas embolism and balloon entrapment within the aorta upon occurrence. Balloon rupture was first reported by Rajani et al^[15^], followed by descriptions from Aru and colleagues^[16^]. Its incidence is likely below 0.5%. The primary mechanism of balloon rupture^[17^] involves mechanical abrasion of the balloon against atherosclerotic plaques or severely calcified aortic walls. After perforation, the negative pressure generated during balloon deflation draws blood into the balloon, where it rapidly reacts with helium to form firm blood clots. These clots, combined with the tortuous, atherosclerotic aorta, encapsulate the partially deflated balloon, resulting in failure of IABP counterpulsation and subsequent entrapment of the balloon during attempted removal.

Early recognition and prompt removal of a ruptured balloon are crucial to prevent further vascular injury and limb ischemia. Balloon rupture can be identified by the presence of blood within the catheter shaft between the balloon and the console^[3^]. If the IABP fails to maintain consistent counterpulsation, the console will trigger an alarm, necessitating emergency intervention upon confirmation of balloon rupture. In clinical practice, the detection of balloon rupture primarily relies on alarms from the IABP console; however, these alarms are not entirely reliable. According to a study by Nishida et al^[18^] involving a cohort of 2803 patients, the gas leak alarm demonstrated low sensitivity for balloon rupture, effectively alerting only 29% of affected patients. The primary indicator of rupture remains the presence of blood within the catheter shaft, underscoring the necessity of regularly inspecting the catheter during IABP use. Nonetheless, approximately 6% of balloon rupture cases are only identified during attempted removal.

Forcible removal of a retained ruptured balloon may cause severe vascular injury. When early detection of balloon rupture is accompanied by difficulty in extraction, a conservative approach is the Lambert technique (intracavitary thrombolysis). Lambert et al^[19^] reported clinical cases where intracavitary thrombolysis with streptokinase and heparinized saline irrigation successfully dissolved intraluminal clots, enabling three patients to avoid surgical intervention. Aggregated data from the literature review (Table 1) indicate a survival rate of 71.4% (5/7) for this strategy. This suggests that injecting thrombolytic agents into the gas chamber of the balloon catheter can facilitate clot dissolution, allowing balloon retraction and subsequent uneventful removal. However, if the “trapped thrombosed balloon” is identified late (>60 minutes), thrombolysis is unlikely to resolve the solidified clot. Therefore, we recommend proceeding with surgical exploration via femoral artery, iliofemoral artery, or abdominal aortotomy following aortic computed tomography angiography or aortography (Table 1). This recommendation is strongly supported by the summary data in Table 1, which shows substantially higher survival rates for definitive surgical approaches (e.g., 90.9% for femoral arteriotomy and 85.7% for laparotomy). It is critical to note that, to prevent massive hemorrhage during catheter extraction, the entrapped balloon catheter should be removed via proximal arteriotomy first. In summary, we have outlined a specific management algorithm (Fig. 4).

Table 1.

Summary of literature review on management strategies for entrapped ruptured intra-aortic balloon pump in Chinese and English studies.

Surgical Approach	Number of Patients	Implantation-to-Rupture Interval	Outcomes (Recovery, Mortality)	Literature Sources	Years	Survival Rate
【A. Original Case Data】
Femoral arteriotomy	11	11 hours to 28 days; unspecified	10, 1	Aru GM, et al[16]	1986	90.9%
				Milgalter E, et al[20]	1986
				Alvarez JM, et al[21]	1993
				Silberman S, et al[22]	1994
				Shafei H, et al[23]	1991
				Olearchyk AS[24]	1992
				Kolvekar S, et al[25]	1993
				Babatasi G, et al[26]	1999
				Hikosaka T, et al[27]	2002
				Fitzmaurice GJ[4]	2012
				Jahollari A[28]	2014
Femoral Arteriotomy with Traction and Emergency Laparotomy	4	2 to 11 days; unspecified	2, 2	Horowitz MD,et al[29]	1993	50.0%
				Millham FH, et al[30]	1991
				Luengtaviboon K, et al[31]	2002
				Bhamidipaty M et al[32]	2016
Intracavitary Thrombolysis	7	3 to 10 days; unspecified	5, 2	Lambert CJ[19]	1987	71.4%
				Horowitz MD, et al[29]	1993
				Fukushima Y, et al[33]	1995
				Cipriani L, et al[34]	1998
				Raslan A, et al[35]	2020
Laparotomy	7	1 to 6 days; unspecified	6, 1	Kirksey L, et al[36]	2002	85.7%
				Millham FH, et al[30]	1991
				Nishizawa J, et al[37]	1991
				Grande AM, et al[38]	1995
				Uwabe K, et al[39]	2007
				Warrillow SJ, et al[40]	2008
				Raslan A, et al[35]	2019
Percutaneous Extraction	7	4 hours to 4 days; unspecified	2, 5	Alvarez JM, et al[21]	1993	28.6%
				Brodell GK, et al[41]	1989
				Sogomonian R, et al[3]	2020
				Mizrahi I, et al[13]	2019
Transaxillary Removal	1	9 days	1, 0	Fukushima Y, et al[33]	1995	100%
Surgical Removal/Forced Extraction	11	Unspecified	11, 0	Nishida H, et al[18]	1994	100%
Mechanism Unspecified	5	34 hours to 2 days; unspecified	5, 0	Rajani R, et al[15]	1980	100%
				Alvarez JM, et al[21]	1993
				Mihatov N, et al[42]	2015
				Liu Mingchen[43]	2014
【B. Summary Analysis】
Overall (All Cases)	53	Various/Unspecified	42, 11	Aggregated from sources[3,4,13,15,43] above	1980-2020	79.2%
Comparative Outcomes by Primary Approach
Femoral Arteriotomy	11	11 hours to 28 days	10, 1	Sources:[16,20,28]	1986-2014	90.9%
Laparotomy	7	1 to 6 days	6, 1	Sources:[30,35,40]	1991-2020	85.7%
Intracavitary Thrombolysis	7	3 to 10 days	5, 2	Sources:[19,29,33,35]	1987-2020	71.4%
Percutaneous Extraction	7	4 hours to 4 days	2, 5	Sources:[3,13,21,41]	1989-2020	28.6%
Temporal Trend (n = 42)
Pre-2000 Era	17	Not consistently specified	17, 0	Sources:[15,18,20,21,29,30,33,37,38,42]	1980-1995	100%
2000-2020 Era	25	Not consistently specified	18, 7	Sources:[3,4,13,27,28,31,32,35,36,39,41,43]	2002-2020	72.0%

Era analysis excludes the “Femoral arteriotomy” group (n = 11, sources^[16,20,28^], years 1986-2014) as its publication years span both eras. The interval from rupture to intervention was frequently “unspecified”, precluding formal time-to-outcome analysis.

Figure 4.

Algorithm for management of entrapped balloon after rupture in the artery.

Identifying risk factors for IABP balloon rupture and entrapment is crucial for risk stratification and preventive management. The key risk factors discussed in the literature are systematically summarized in Table 2, categorized by their potential for modification to guide clinical practice.

Table 2.

Risk factors for IABP-related complications (focus on rupture/entrapment).

Risk Factor	Category	Evidence Source
Female sex	Non-modifiable	Ferguson et al[14]
Age >75 years	Non-modifiable	Ferguson et al[14]
Body surface area <1.65 m2	Non-modifiable	Ferguson et al[14]
Peripheral arterial disease	Potentially Modifiable	Ferguson et al[14]
Diabetes mellitus	Potentially Modifiable	Kirksey et al[36]
Significant aortic atherosclerosis/calcification	Potentially Modifiable	Parissis et al[17]
Oversized balloon selection	Technique-Related	Rastan et al[44]
Use of an insertion sheath (vs. sheathless technique) in high-risk patients*	Technique-Related	Erdogan et al[45]
Excessive guidewire insertion angle (>45°)	Technique-Related	Alvarez et al[21]
Balloon over-inflation or under-inflation	Technique-Related	Silberman et al[22]
Prolonged IABP duration	Technique-Related	Rastan et al[44]
Absence of or inadequate guidewire support	Technique-Related	Clinical experience/procedural guideline

^*Particularly relevant for patients with peripheral arterial disease or diabetes. IABP, intra-aortic balloon pump

The primary cause of balloon rupture is atherosclerosis. However, several additional factors contribute to this complication: the absence of a guidewire or inadequate support, inherent fragility of the balloon material, an excessive insertion angle of the guidewire (>45°), which predisposes the balloon to kinking or knotting against the posterior arterial wall, and insufficient balloon wrapping or under-inflation, both of which can compromise balloon membrane integrity. Prolonged overinflation of the balloon also increases the risk of rupture^[21^].

Based on these findings, we propose the following targeted recommendations to reduce the risk of IABP rupture: For high-risk patients (e.g., those with peripheral arterial disease, diabetes, or small body surface area), routine aortic and iliac angiography may be performed during cardiac catheterization to accurately identify atherosclerotic disease and tortuous vasculature, facilitating preoperative planning. Rastan et al^[44,46^] recommend using the smallest feasible balloon size (e.g., 7.5Fr for high-risk patients versus standard 8Fr), employing a sheathless IABP insertion technique (particularly beneficial for patients with vascular disease^[45^]), and expediting IABP removal (aiming for removal within 24-72 hours once hemodynamically stable). Silberman et al^[22^] advocate setting the lowest effective balloon counterpulsation ratio (e.g., reducing from 1:1 to 1:2 or 1:3 as soon as possible) to achieve the desired cardiac support while minimizing friction.

In our case, the IABP device intermittently alarmed indicating blood detection, though no blood was visible in the tubing. Balloon inflation was immediately paused, and the circuit and equipment were thoroughly inspected without identifying abnormalities. After restarting, the IABP resumed normal operation, leading to the initial assumption of a false alarm. However, upon subsequent confirmation of blood within the tubing, balloon rupture was definitively diagnosed. By this time, approximately 24 hours had elapsed since the initial console alarm. Due to insufficient awareness of IABP balloon rupture, the opportunity for timely balloon removal was missed, ultimately necessitating surgical extraction. Upon retrospective analysis, thrombus formation likely occurred following balloon rupture, which itself resulted from prolonged contact between the balloon and the atherosclerotic aortic wall. Forcible removal of the clot and balloon would have risked aortic dissection and uncontrollable hemorrhage.

A retrospective analysis of this initial alarm is instructive. The differential diagnosis for such an isolated blood detection alarm includes: (1) a minor leak or early structural compromise of the balloon membrane; (2) a transient technical artifact in the console or cable; or (3) patient-related signal interference. In this instance, the alarm was specific to blood detection (not a low-pressure or trigger alarm), and the device functioned normally after a simple pause without recalibration, making a persistent technical fault less likely. No concurrent arrhythmias were documented. Therefore, the most plausible explanation is that the alarm represented a critical, missed early warning sign – likely a small, self-sealing leak or micro-perforation that allowed a minute amount of blood to enter the catheter lumen before being temporarily cleared by helium flow. This interpretation underscores that any such alarm, even if transient, must heighten suspicion for imminent balloon failure and should prompt immediate preparation for possible catheter removal.

The complications encountered in this case can be systematically categorized using the Clavien-Dindo classification system, which standardizes the reporting of surgical adverse events^[47^]. The development of a post-infarction VSP and ventricular aneurysm, which were managed successfully with pharmacological therapy and careful monitoring without the need for invasive intervention, corresponds to a Grade II complication (a deviation from the normal postoperative course requiring pharmacological treatment). In contrast, the IABP balloon rupture with entrapment constituted a major and life-threatening event. Its management necessitated an unplanned return to the operating room for emergency laparotomy, aortotomy, and endarterectomy under general anesthesia. This qualifies as a Grade IVa complication (a life-threatening complication requiring ICU management). Applying this classification underscores the significant incremental morbidity imposed by the device failure and facilitates comparative outcome analysis with other reported cases.

Conclusion

This case illustrates a rare but serious complication of IABP therapy: balloon rupture with subsequent entrapment in the abdominal aorta. An 84-year-old female with acute myocardial infarction and cardiogenic shock developed this complication 24 days after IABP insertion. Despite the progression of mechanical complications including VSP and ventricular aneurysm, the patient’s hemodynamic condition had stabilized with IABP support, making early device removal unfeasible. The rupture was identified through console alarms and visible blood in the safety chamber. Attempted percutaneous removal was unsuccessful due to entrapment, necessitating successful surgical extraction via abdominal aortotomy and endarterectomy.

The key lesson from this case is the critical importance of vigilant monitoring for signs of balloon rupture, such as console alarms or blood in the tubing, and the immediate cessation of pumping with attempted removal upon suspicion. Any delay can lead to thrombosis and entrapment, significantly increasing patient morbidity and necessitating complex surgical intervention. This case also underscores the value of a multidisciplinary approach involving cardiology, cardiac surgery, and vascular surgery in managing such high-risk complications.

Although this is a single case, it demonstrates that with prompt recognition, appropriate imaging (aortography), and definitive surgical management, even elderly patients with complex cardiac conditions can achieve good functional recovery and stable clinical condition following this serious device-related complication.

Ethical approval

This study was approved by the Science and Technology Ethics Committee of Linyi People’s Hospital [Approval No. Keji Lunli Shen (202 510-H-016)]. The research was conducted in accordance with the ethical standards of the institutional and national research committee and with the principles of the Declaration of Helsinki. Both the original Ethical Approval document and its certified English translation will be made available to the Editor-in-Chief upon request.

Consent

Verbal informed consent for publication was obtained from the patient and her immediate family. Due to geographical constraints following the patient’s discharge, a formal face-to-face consent process was not feasible. A detailed telephone conversation was conducted by the corresponding author (Dr. Xiong) on 15 September 2025, during which the full details of the case report, the use of anonymized information, and the implications of publication were explained. The patient and her family expressed clear understanding and provided voluntary consent. This conversation was documented in the patient’s research record. Informed consent was waived for this study by the Science and Technology Ethics Committee of Linyi People’s Hospital due to its retrospective design.

Sources of funding

This research was supported by the National Natural Science Foundation of China (grant nos. 82 000 242).

Conflicts of interest disclosure

The authors declare that they have no competing interests.

Research registration unique identifying number (UIN)

Not applicable.

Provenance and peer review

Not commissioned; externally peer-reviewed.

Data availability statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.

Acknowledgements

We thank all the participants in this study.