Aortic Rupture From Intra-Aortic Balloon Pump After Type A Dissection and Aortic Valve Replacement

Introduction: Intra-aortic balloon pumps (IABP) are often used to reduce afterload and augment diastolic coronary perfusion to treat cardiogenic shock. Though generally safe, complications can be catastrophic.We describe a fatal case of a thoracic aortic rupture from IABP tip migration following combined type A dissection repair and aortic valve replacement.


Description: A 64-year-old man presented with acute dyspnea and troponinemia. CT angiography revealed a type A aortic dissection extending to the right subclavian and carotid arteries. Intraoperative echocardiography showed an ejection fraction (EF) of 20% with bicuspid aortic valve and moderate aortic insufficiency. The ascending aorta was replaced with a 32 mm Hemashield graft and the valve with a 21 mm bovine pericardial prosthesis. Due to low EF and hypotension, an IABP was placed via the left femoral artery. Chest film confirmed proper positioning of the tip distal to the left subclavian artery.
Six hours after arrival to the ICU the patient was repositioned which was followed by a sudden hemodynamic collapse. Heavy sanguinous chest tube output was noted. Repeat chest film showed the IABP tip outside the aorta and a large left hemothorax. The patient was emergently returned to the operating room. Upon re-opening the chest, the IABP tip was found to have perforated through the lateral aortic wall, distal to the left subclavian artery. The IABP was repositioned, and the perforation repaired with bovine pericardium. Despite successful cardiopulmonary bypass weaning, he developed refractory ventricular fibrillation and expired.


Discussion: We report the fifth known case of aortic perforation secondary to IABP via femoral access. Contributing factors likely included tenuous aortic integrity given aortic pathology coupled with tip migration after patient repositioning. This case brings awareness that subtle shifts of the IABP during repositioning may be sufficient to cause perforation. Alternative support devices such as Impella or TandemHeart may reduce this risk, as these devices avoid direct aortic wall contact.5
Clinicians should be aware of this potential catastrophic complication and remain vigilant when using IABPs in patients with aortic pathology. Alternative devices can be considered to reduce the risk of this complication.