Intra-aortic balloon pumps (IABPs) are a ubiquitous form of mechanical support in patients with heart failure (1). Over the past several years, a left axillary approach has increasingly replaced the standard femoral approach for IABP placement. During this time, there have been reports of IABP kinking in a small percentage of patients, as illustrated in this case (2,3).
A 73-year-old man presented with shortness of breath secondary to acute-on-chronic systolic heart failure. A left axillary approach IABP was placed as a bridge to left ventricular assist device. A chest radiograph obtained immediately following placement (Fig 1, A) demonstrated appropriate position of the proximal IABP metallic marker over the aortic arch, with the proximal marker slightly below the top of the aortic knob. The next day, a follow-up chest radiograph (Fig 1, B) demonstrated a new, second metallic marker overlying the aortic arch, as well as an abnormal tubular lucency overlying the ascending aorta and aortic arch. A non–contrast material–enhanced chest CT confirmed a malpositioned IABP that was folded upon itself in the ascending aorta (Fig 2). The patient was brought back to the cardiac catheterization laboratory, and the IABP was repositioned under fluoroscopic guidance (Fig 1, C).
Figure 1:
A, Anteroposterior chest radiograph immediately after left axillary approach intra-aortic balloon pump (IABP) placement demonstrates proximal metallic IABP marker (circle) projecting over the aortic arch. B, Follow-up chest radiograph 1 day later now demonstrates two metallic IABP markers overlying the aortic arch (circles) and a tubular lucency overlying the ascending aorta and aortic arch (arrows). C, Fluoroscopic image obtained from the cardiac catheterization laboratory during repositioning demonstrates malpositioned IABP folded upon itself in the ascending aorta; the more cephalad marker (white circle) is proven to be the proximal marker in the mid-aortic arch, while the more caudad marker (black circle) is the distal marker in the distal arch.
Figure 2:
A, Axial and, B, sagittal chest CT scans demonstrate intra-aortic balloon pump folded upon itself in the ascending aorta (arrows), with both proximal and distal metallic markers (circles in B) in the aortic arch.
In brief, IABPs have two metallic markers, one at each end, to aid the proceduralist in placing the IABP and also to allow for subsequent monitoring of the IABP position radiographically. The IABP should be placed such that it is distal to the left subclavian artery origin and proximal to the renal arteries (4). The proximal marker should be radiographically positioned 2–3 cm distal to the origin of the left subclavian artery or 2 cm above the carina; depending on the degree of collimation, the distal metallic marker may not be visualized on a chest radiograph (5).
Footnotes
Disclosures of Conflicts of Interest: I.R.D. disclosed no relevant relationships. F.M. Activities related to the present article: disclosed no relevant relationships. Activities not related to the present article: disclosed consultancy fees received from Boeringher Ingelheim; disclosed payment from Genetech for lectures including service on speakers bureaus. Other relationships: disclosed no relevant relationships. J.K. Activities related to the present article: disclosed no relevant relationships. Activities not related to the present article: disclosed consultancy fees from Zebra Medical; disclosed stock options, not executed.
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