Ischemic Leg Following IABP Insertion: Timing of Diagnosis and Treatment

  • Theodore Hart
  • Ross MilnerEmail author
Part of the Difficult Decisions in Surgery: An Evidence-Based Approach book series (DDSURGERY)


Lower extremity ischemia is a significant and frequent complication following intra-aortic balloon pump insertion that is well documented since the introduction of this therapy. Surgeons now encounter limb ischemia in the context of multiple mechanical circulatory support devices used for hemodynamic support in a variety of critically ill patients. The current literature is limited to reviews and case series that highlight the associated morbidity and existing experience with several management approaches. Comparisons of existing management approaches as well as high-quality prospective data are largely lacking. The objective of this chapter is to provide an up-to-date review of the evidence available to guide management of acute limb ischemia when a patient requires an intra-aortic balloon pump for circulatory support.


Intra-aortic balloon pump Balloon counterpulsation IABP Limb ischemia 


  1. 1.
    Alpert J, Bhaktan EK, Gielchinsky I, Gilbert L, Brener BJ, Brief DK, Parsonnet V. Vascular complications of intra-aortic balloon pumping. Arch Surg. 1976;111(11):1190–5.CrossRefGoogle Scholar
  2. 2.
    Kvilekval KH, Mason RA, Newton GB, Anagnostopoulos CE, Vlay SC, Giron F. Complications of percutaneous intra-aortic balloon pump use in patients with peripheral vascular disease. Arch Surg. 1991;126(5):621–3.CrossRefGoogle Scholar
  3. 3.
    Mackenzie DJ, Wagner WH, Kulber DA, Treiman RL, Cossman DV, Foran RF, Cohen JL, Levin PM. Vascular complications of the intra-aortic balloon pump. Am J Surg. 1992;164(5):517–21.CrossRefGoogle Scholar
  4. 4.
    Ferguson JJ 3rd, Cohen M, Freedman RJ Jr, Stone GW, Miller MF, Joseph DL, Ohman EM. The current practice of intra-aortic balloon counterpulsation: results from the Benchmark Registry. J Am Coll Cardiol. 2001;38(5):1456–62.CrossRefGoogle Scholar
  5. 5.
    Lamb KM, DiMuzio PJ, Johnson A, Batista P, Moudgill N, McCullough M, Eisenberg JA, Hirose H, Cavarocchi NC. Arterial protocol including prophylactic distal perfusion catheter decreases limb ischemia complications in patients undergoing extracorporeal membrane oxygenation. J Vasc Surg. 2017;65(4):1074–9.CrossRefGoogle Scholar
  6. 6.
    Cohen M, Dawson MS, Kopistansky C, McBride R. Sex and other predictors of intra-aortic balloon counterpulsation-related complications: prospective study of 1119 consecutive patients. Am Heart J. 2000;139:282–7.PubMedGoogle Scholar
  7. 7.
    Barnett MG, Swartz MT, Peterson GJ, Naunheim KS, Pennington DG, Vaca KJ, Fiore AC, McBride LR, Peigh P, Willman VL, et al. Vascular complications from intraaortic balloons: risk analysis. J Vasc Surg. 1994;19(1):81–9.CrossRefGoogle Scholar
  8. 8.
    Göl MK, Bayazit M, Emir M, Taşdemir O, Bayazit K. Vascular complications related to percutaneous insertion of intraaortic balloon pumps. Ann Thorac Surg. 1994;58(5):1476–80.CrossRefGoogle Scholar
  9. 9.
    Yuksel V, Huseyın S, Ozdemır AC, Ege T. Vascular complications of the intra-aortic balloon pump in patients undergoing open heart surgery: 10 years’ experience. Thorac Cardiovasc Surg. 2013;61(5):453–5.PubMedGoogle Scholar
  10. 10.
    Cohen M, Ferguson JJ 3rd, Freedman RJ Jr, Miller MF, Reddy RC, Ohman EM, Stone GW, Christenson J, Joseph DL. Comparison of outcomes after 8 vs. 9.5 French size intra-aortic balloon counterpulsationcatheters based on 9,332 patients in the prospective Benchmark registry. Catheter Cardiovasc Interv. 2002;56(2):200–6.CrossRefGoogle Scholar
  11. 11.
    Tatar H, Ciçek S, Demirkilic U, Ozal E, Süer H, Aslan M, Oztürk OY. Vascular complications of intraaortic balloon pumping: unsheathed versus sheathed insertion. Ann Thorac Surg. 1993;55(6):1518–21.CrossRefGoogle Scholar
  12. 12.
    Meisel S, Shochat M, Sheikha SA, Osipov A, Kogan A, Anabussi N, Suari B, Frimerman A, Shotan A, Sahar G, Peled B. Utilization of low-profile intra-aortic balloon catheters inserted by the sheathless technique in acute cardiac patients: clinical efficacy with a very low complication rate. Clin Cardiol. 2004;27(11):600–4.CrossRefGoogle Scholar
  13. 13.
    de Jong MM, Lorusso R, Al Awami F, Matteuci F, Parise O, Lozekoot P, Bonacchi M, Maessen JG, Johnson DM, Gelsomino S. Vascular complications following intra-aortic balloon pump implantation: an updated review. Perfusion. 2018;33:96–104. Scholar
  14. 14.
    Kogan A, Preisman S, Sternik L, Orlov B, Spiegelstein D, Hod H, Malachy A, Levin S, Raanani E. Heparin-free management of intra-aortic balloon pump after cardiac surgery. J Card Surg. 2012;27(4):434–7.CrossRefGoogle Scholar
  15. 15.
    Laish-Farkash A, Hod H, Matetzky S, Guetta V. Safety of intra-aortic balloon pump using glycoprotein IIb/IIIa antagonists. Clin Cardiol. 2009;32(2):99–103.CrossRefGoogle Scholar
  16. 16.
    Meharwal ZS, Trehan N. Vascular complications of intra-aortic balloon insertion in patients undergoing coronaryreavscularization: analysis of 911 cases. Eur J Cardiothorac Surg. 2002;21(4):741–7.CrossRefGoogle Scholar
  17. 17.
    Severi L, Vaccaro P, Covotta M, Landoni G, Lembo R, Menichetti A. Severe intra-aortic balloon pump complications: a single-center 12-year experience. J Cardiothorac Vasc Anesth. 2012;26(4):604–7.CrossRefGoogle Scholar
  18. 18.
    Dick P, Mlekusch W, Delle-Karth G, Nikfardjam M, Schillinger M, Heinz G. Decreasing incidence of critical limb ischemia after intra-aortic balloon pump counterpulsation. Angiology. 2009;60(2):235–41.CrossRefGoogle Scholar
  19. 19.
    Christenson JT, Sierra J, Romand JA, Licker M, Kalangos A. Long intraaortic balloon treatment time leads to more vascular complications. Asian Cardiovasc Thorac Ann. 2007;15(5):408–12.CrossRefGoogle Scholar
  20. 20.
    Erdogan HB, Goksedef D, Erentug V, Polat A, Bozbuga N, Mansuroglu D, Guler M, Akinci E, Yakut C. In which patients should sheathless IABP be used? An analysis of vascular complications in 1211 cases. J Card Surg. 2006;21(4):342–6.CrossRefGoogle Scholar
  21. 21.
    Arceo A, Urban P, Dorsaz PA, Chatelain P, Verin V, Suilen C, Rombaut E, Chevrolet JC. In-hospital complications of percutaneous intraaortic balloon counterpulsation. Angiology. 2003;54(5):577–85.CrossRefGoogle Scholar
  22. 22.
    Colyer WR Jr, Burket MW, Ansel GM, Ramee SR, Minor RL, Gibson CM, Cooper CJ. Intra-aortic balloon pump placement following aorto-iliac angioplasty and stent placement. Catheter Cardiovasc Interv. 2002;55(2):163–8.CrossRefGoogle Scholar
  23. 23.
    Sirbu H, Busch T, Aleksic I, Friedrich M, Dalichau H. Ischaemic complications with intra-aortic balloon counter-pulsation: incidence and management. Cardiovasc Surg. 2000;8(1):66–71.CrossRefGoogle Scholar
  24. 24.
    Arafa OE, Pedersen TH, Svennevig JL, Fosse E, Geiran OR. Vascular complications of the intraaortic balloon pump in patients undergoing open heart operations: 15-year experience. Ann Thorac Surg. 1999;67(3):645–51.CrossRefGoogle Scholar
  25. 25.
    Davidson J, Baumgariner F, Omari B, Milliken J. Intra-aortic balloon pump: indications and complications. J Natl Med Assoc. 1998;90(3):137–40.PubMedPubMedCentralGoogle Scholar
  26. 26.
    Busch T, Sîrbu H, Zenker D, Dalichau H. Vascular complications related to intraaortic balloon counterpulsation: an analysis of ten years experience. Thorac Cardiovasc Surg. 1997;45(2):55–9.CrossRefGoogle Scholar
  27. 27.
    Jameson JS, Sayers RD, Macpherson DS, Spyt TJ. Management of lower limb ischaemia associated with the use of intra-aortic balloon pumps during cardiac surgery. Eur J Vasc Endovasc Surg. 1995;10(3):327–9.CrossRefGoogle Scholar
  28. 28.
    Eltchaninoff H, Dimas AP, Whitlow PL. Complications associated with percutaneous placement and use of intraaortic balloon counterpulsation. Am J Cardiol. 1993;71(4):328–32.CrossRefGoogle Scholar
  29. 29.
    Makhoul RG, Cole CW, McCann RL. Vascular complications of the intra-aortic balloon pump: an analysis of 436 patients. Am Surg. 1993;59(9):564–8.PubMedGoogle Scholar
  30. 30.
    Jiang CY, Zhao LL, Wang JA, Mohammod B. Anticoagulation therapy in intra-aortic balloon counterpulsation: does IABP really need anti-coagulation? J Zhejiang Univ (Sci). 2003;4(5):607–11.CrossRefGoogle Scholar
  31. 31.
    Boudoulas KD, Bowen T, Pederzolli A, Pfahl K, Pompili VJ, Mazzaferri EL Jr. Duration of intra-aortic balloon pump use and related complications. Acute Card Care. 2014;16(2):74–7.CrossRefGoogle Scholar
  32. 32.
    Allen RC, Schneider J, Longenecker L, Kosinski AS, Smith RB 3rd, Lumsden AB. Acute lower extremity ischemia after cardiac surgery. Am J Surg. 1993;166(2):124–9.CrossRefGoogle Scholar
  33. 33.
    Russo MJ, Jeevanandam V, Stepney J, Merlo A, Johnson EM, Malyala R, Raman J. Intra-aortic balloon pump inserted through the subclavian artery: a minimally invasive approach to mechanical support in the ambulatory end-stage heart failure patient. J Thorac Cardiovasc Surg. 2012;144(4):951–5.CrossRefGoogle Scholar
  34. 34.
    Tanaka A, Tuladhar SM, Onsager D, Asfaw Z, Ota T, Juricek C, Lahart M, Lonchyna VA, Kim G, Fedson S, Sayer G, Uriel N, Jeevanandam V. The subclavian intraaortic balloon pump: a compelling bride device for advanced heart failure. Ann Thorac Surg. 2005;100(6):2151–7.CrossRefGoogle Scholar
  35. 35.
    Russo MJ, Jeevanandam V, Hur MJ, Johnson EM, Siffring T, Shah AP, Raman J. Prophylactic subclavian artery intraaortic balloon counter-pulsation is safe in high-risk cardiac surgery patients. ASAIO J. 2015;61(5):36–9.CrossRefGoogle Scholar
  36. 36.
    Lin PH, Bush RL, Conklin BS, Chaikof EL, Lumsden AB. Percutaneous bedside femorofemoral bypass grafting for acute limb ischemia caused by intra-aortic balloon pump. J Vasc Surg. 2002;35(3):592–4.CrossRefGoogle Scholar
  37. 37.
    Dosluoglu HH, Dryjski ML. External femorofemoral bypass to relieve acute leg ischemia during circulatory assist. Vascular. 2004;12(3):198–201.CrossRefGoogle Scholar
  38. 38.
    Klein AJ, Messenger JC, Casserly IP. Endovascular treatment of intra-aortic balloon pump-induced acute limb ischemia. Catheter Cardiovasc Interv. 2007;70(1):138–42.PubMedGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Department of SurgeryUniversity of ChicagoChicagoUSA
  2. 2.Section of Vascular Surgery, Department of SurgeryUniversity of ChicagoChicagoUSA

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