Leg amputation: A rare complication of intra-aortic balloon pump.

Intra-aortic balloon pump (IABP) is a bridge to definitive management in a patient with compromised systolic function. It is a life-saving mechanical support to the failing myocardium. It is a procedure that should be employed judiciously with utmost caution. In this correspondence, we aim to highlight a rather serious complication associated with IABP use. A patient with triple vessel disease was posted for coronary artery bypass grafting with poor left ventricular function (ejection fraction 30%) and previous myocardial infarction 4 months back. An IABP was inserted in the left femoral artery following which he developed irreversible ischemia of the left lower limb leading to amputation of the limb. This catastrophic complication is one of the most dreaded impediments in the use of IABP. The clinician needs to weigh the pros and cons carefully and employ this vital procedure only when its use is explicitly justified.

INTRODUCTION

Intra-aortic balloon pump (IABP) is the most commonly used mechanical circulatory support for patients with acute coronary syndromes and cardiogenic shock.

It can be inserted prophylactically or intraoperatively. The IABP is a polyethylene balloon mounted on a catheter, which is generally inserted into the aorta through the femoral artery in the leg. At the start of diastole, the balloon (filled with helium) inflates, augmenting coronary perfusion. At the beginning of systole, the balloon deflates; blood is ejected from the left ventricle, increasing the cardiac output by as much as 40% and decreasing the left ventricular stroke work and myocardial oxygen requirements.

Intraoperative indications are a failure to wean from the cardiopulmonary bypass or elevated left sided filling pressures. Prophylactic indications for preoperative placement of IABP includes poor ventricular function (ejection fraction [EF] <20%), compelling anatomy including severe left main coronary disease, or continuous chest pain refractory to medical management.

Advances in IABP technology has led to a reduction in complication rates. However, adverse events are still encountered, and few have a poor prognosis.[123]

CASE REPORT

A 69-year-old male was admitted with chest pain off and on. There was no history of hypertension or diabetes, but he had suffered myocardial infarction 4 months back. Coronary angiography demonstrated triple vessel disease with 90% block in the middle of three major coronary arteries, i.e., left anterior descending artery, left circumflex and right coronary artery. All routine investigations were normal and cardiac echography showed basal and mid inferoseptal severe hypokinesia with left ventricular EF of 30%. Valvular functions were normal with Grade I diastolic dysfunction.

In the operation theater, 14-gauge intravenous cannula and 20-gauge arterial cannula was secured under local anesthesia. The patient was induced with fentanyl 500 µg, propofol 30 mg and vecuronium 8 mg intravenously. The trachea was intubated with 8.5 mm endotracheal tube. After intubation, sheathless intra-aortic balloon (8 Fr G) was put with Seldinger technique into the left femoral artery. There was significant bleeding while introducing the IABP. Monitoring included 12 lead electrocardiogram, saturation, capnography, invasive blood pressure, central venous pressure, pulmonary artery pressure, temperature, and urine output. The coronary artery bypass grafting lasted for 5 h and was uneventful. Patient was shifted to intensive care unit with stable hemodynamics parameters and extubated on postoperative day 1. On the 3rd postoperative day, following removal of IABP, patient's left leg was cold with the progressive development of black discoloration of the foot. Peripheral pulses femoral and popliteal were present, but anterior tibial artery could not be palpated. In view of a thrombus occluding the artery, medical management was initiated in the form of heparin, cilastazole, and pentoxifylline. Thromboembolectomy followed by fasciotomy was performed, but ischemia was not relieved. The limb had started becoming discolored and gangrenous. On the 12th postoperative day, left limb was amputated 15 cm below knee under general anesthesia.

DISCUSSION

IABP is an important physiologic adjunct in the temporary support for the failing myocardium. The counter pulsation action of IABP improves cardiac output by decreasing the afterload stress of the left ventricle and increasing coronary artery perfusion during diastole.[4] IABP complications can include limb ischemia, false aneurysm formation, thromboemboli, and femoral artery stenosis.[5] Spinal cord ischemia, visceral ischemia, groin infection, balloon rupture, or entrapment peripheral neuropathy are also among the reported complication associated with IABP.[4] Although technical advances such as percutanecous insertion, smaller diameter catheter, and sheathless insertion have simplified the use of IABP, but the IABP complication rate (7.2–47%)[6] still remains significantly high. IABP should be used judiciously in cases of a compelling indication only. Its unwarranted use should be restricted. The incidence of limb amputation is however very rare (0.1%).[7] Prompt recognition of this complication as well as aggressive treatment including emergency revascularization results in salvage of most of these limbs.[8]

Peripheral vascular disease, female gender, and diabetes mellitus are significant predictors,[7] and demonstrated a high rate of vascular complications in post-surgical patients (26%).[91011] In our case, the patient was male, neither hypertensive nor diabetic. The probable cause in this patient was bleeding during insertion resulting in thrombus formation leading to limb ischemia. Davidavicius et al.[12] reported that the incidence of all over bleeding in patients requiring IABP support was 19% of which 1.9% developed ischemia of limb. Several important aspects can be considered to reduce the rate of bleeding complications in patients requiring IABP support procedures. Modification of intraprocedural pharmacotherapy such as replacing unfractionated heparin with newer direct thrombin inhibitors, like bivalirudin would be an important first step and aggressive revascularization should be done. In our case, thromboembolectomy and fasciotomy were done and medical treatment with heparin, cilostazol, and pentoxifylline was started. Despite the limb could not be salvaged and below knee amputation was done. To conclude, IABP s are effective both prophylactically and intraoperatively to manage patients who would not otherwise survive the cardiac surgery. Although the outcome for cardiac surgical patients can be markedly improved with IABP, it is not without complications. Vigilance to preoperative vascular status and continued careful physical examination to identify early vascular changes after IABP placement is imperative, especially in women. Despite the high morbidity and mortality of vascular related IABP complications, a policy of aggressive treatment for vascular insufficiency is warranted.

CONCLUSION

IABP provides circulatory assistance to the ischemic myocardium. Though IABP is being widely used in cardiac catheterization laboratories, its insertion is invariably associated with complications. Thus, we aim to highlight with this case report the complication of lower extremity ischemia culminating in amputation.

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Conflicts of interest

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