Good News on Alternatives to the Femoral Approach for Hemodynamic Support

Intra-aortic balloon pumps (IABPs) are extremely useful for hemodynamic support in the setting of high-risk percutaneous coronary intervention (PCI), refractory ischemia despite intensive medical therapy, unstable hemodynamic states such as cardiogenic shock, and for mechanical complications of myocardial infarction.^1,2 Traditionally, IABPs have required femoral artery access due to the requirements for a “large” sheath (7 or 8 Fr) and a straight-line approach for the catheter shaft to prevent kinking of the gas line. Severely diseased iliac and femoral arteries preclude femoral IABP placement in some situations, either due to direct mechanical obstruction or due to flow compromise into the lower extremity with resultant limb ischemia. As peripheral artery disease is increasingly common in our interventional patient populations, this becomes an increasingly relevant topic.³ Therefore, the availability of a 6 Fr IABP placed via an alternate access site, the brachial artery in this case, is an important development and deserves immediate attention. 

In this series described by Fujii et al,⁴ the authors demonstrate the feasibility for 6 Fr brachial IABP access for prophylactic use in triple-vessel and left main interventions. They report a significant reduction in access-site complications when compared to the routine 8 Fr femoral approach. All access-site complications were bleeds with no reports of thrombosis. However, it is not entirely clear whether the reported benefit derives more from a difference in access sites, brachial versus femoral, or a difference in sheath sizes (6 Fr vs 8 Fr). Typically, the major vascular complication of brachial artery access is thrombosis, whereas the major vascular complication of femoral artery access is bleeding. As the sheath size becomes smaller, the bleeding complications would be reduced. Therefore, how much each factor contributes to the overall reduction in bleeding is still unclear. A comparison of complications using 6 Fr IABPs placed via the femoral route with 6 Fr IABPs placed via the brachial route would be needed to sort out these differences. 

With the renewed interest in non-femoral approaches to vascular access, such as radial access for diagnostic left heart catheterization and coronary intervention, along with an increase in complex coronary interventions that might require hemodynamic support, the brachial placement of a 6 Fr IABP is sure to be a useful tool for interventional cardiologists. More clinical reports on this are greatly needed.

References

1. Anderson JL, Adams CD, Antman EM, et al; 2011 Writing Group Members; ACCF/AHA Task Force Members. 2011 ACCF/AHA focused update incorporated into the ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2011;123(18):e426-e579.
2. Antman EM, Anbe DT, Armstrong PW, et al; American College of Cardiology; American Heart Association Task Force on Practice Guidelines; Canadian Cardiovascular Society. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association task force on practice guidelines (committee to revise the 1999 guidelines for the management of patients with acute myocardial infarction). Circulation. 2004;110(9):e82-e292.
3. Moussa ID, Jaff MR, Mehran R, et al. Prevalence and prediction of previously unrecognized peripheral arterial disease in patients with coronary artery disease: the peripheral arterial disease in interventional patients study. Catheter Cardiovasc Interv. 2009;73(6):719-724.
4. Fujii T, Masuda N, Ijichi T, et al. Feasibility of 6 Fr intra-aortic balloon pumping via the femoral or brachial approach. J Invasive Cardiol. 2012;24(12):641-644.