This protocol follows the guidelines of institutional human research ethics committee.
1. Pre-insertion preparation
NOTE: The IABP is preferably inserted in the cardiac catheterization lab under fluoroscopic guidance. Bedside placement can be considered in very critical clinical situations.
<ol>
	<li>Begin by preparing the catheterization laboratory for the procedure. Prepare sterile drapes and chlorhexidine or povidone iodine, IABP control unit, IABP catheter, ultrasound for arterial access, 1% lidocaine for local anesthesia, micropuncture needle and wire, micropuncture sheath, 7-8.5 F arterial access sheath for the IABP depending on the balloon size or IABP manufacturer, sutures and sterile dressing.</li>
	<li>Prepare and drape the patient in the usual sterile fashion with a plan to access the femoral artery. 
	&#8203;NOTE: IABP can also be inserted through the axillary artery but this often requires a surgical cut down.</li>
	<li>Have the patient lay down flat on his or her back. Administer moderate conscious sedation if the clinical scenario permits, by infiltrating the groin access site liberally with 1% Lidocaine.</li>
	<li>Prepare the IABP catheter. Use a 50 mL syringe to apply a vacuum and completely deflate the balloon, using the one-way valve at the catheter hub.</li>
	<li>Remove the stylet in the catheter and manually flush the inner lumen with 3-5 mL of saline.</li>
</ol>
2. Insertion of the IABP
<ol>
	<li>Obtain arterial access using the Seldinger technique18. Use ultrasound guided vascular access to improve first pass success and minimize vascular complications.</li>
	<li>Insert a micropuncture needle at a 45&#730; angle and insert the introducer wire once blood return is obtained.</li>
	<li>Insert the micropuncture sheath.</li>
	<li>Exchange the micropuncture sheath for a larger IABP sheath. The sheath size varies by manufacturers and balloon size but is usually 7-8.5 F. 
	NOTE: There are two methods to introduce and advance the IABP catheter. The catheter can either be backloaded with a wire or can be advanced over a wire.</li>
	<li>Advance the IABP catheter through the sheath using short strokes until correct placement is achieved. The optimal balloon position is where the tip is situated distal to the left subclavian artery take off. This is often not easy to identify, and hence, use the carina of the trachea as a landmark, ensuring that the proximal end is above the renal arteries.</li>
	<li>Confirm position by fluoroscopy. Secure the catheter in place either by using sutures or manufacturer provided locking plates and apply sterile dressing. 
	&#8203;CAUTION: Incorrect balloon position results in reduced diastolic augmentation or vascular complications due to direct endovascular injury.</li>
</ol>
3. Switching on and setting up the IABP
<ol>
	<li>Remove the guidewire and aspirate 3 mL of blood from the inner lumen. Flush the inner lumen with 3-5 mL of saline.</li>
	<li>Attach a standard arterial pressure monitoring tubing to the catheter hub. Remove the one-way valve from the catheter and attach the catheter hub to the console using the provided extension catheter.</li>
	<li>Turn IABP On, then open the gas tank. Connect the ECG cable to the console. Connect the fiber optic or pressure cable to the console (depending on the manufacturer).</li>
	<li>Press the Start key on the console. This automatically purges and fills the balloon, calibrates, selects an appropriate ECG lead and trigger, and automatically sets the inflation and deflation timing.
	<ol>
		<li>Select an appropriate operation mode - Automatic, Semi-automatic or Manual depending on the clinical scenario.</li>
		<li>Select a trigger source. The IABP uses a trigger to identify the beginning of the next cardiac cycle. It deflates the balloon when it recognizes a trigger event. Trigger can be either ECG (R wave) or pressure (systolic upstroke).</li>
		<li>Observe the pressure changes on the IABP console by setting a 1:2 frequency. Confirm that the assisted systolic pressure is lower than unassisted one, there is decrease in assisted end-diastolic pressure and that diastolic augmentation is above the systolic pressure - all of which is associated with optimal IABP support (Figure 1).</li>
		<li>Set appropriate IABP frequency which can be 1:1, 1:2 or 1:3. This represents the frequency of balloon inflation with each trigger.</li>
		<li>Confirm that the IABP timing is appropriate. 
		NOTE: An ideal IABP timing consists of the following: a) Inflation occurring at the dicrotic notch which appears as a sharp &#34;V&#34;. Ideally, the diastolic augmentation rises above systole, and b) Deflation occurring just prior to the next systole (Figure 1).</li>
	</ol>
	</li>
	<li>Use a continuous flush through the inner lumen (usually 3 mL/h). 
	NOTE: The patient and the IABP console are now ready to be transported.</li>
	<li>Use systemic anticoagulation to reduce the risk of arterial thromboembolism. 
	&#8203;NOTE: This is institution dependent and some centers do not use systemic anticoagulation for an IABP frequency of 1:119.</li>
</ol>
4. Assessment of the patient after placement of IABP
<ol>
	<li>Check distal pulses. If the left radial pulse is weak, verify the position of the balloon to make sure that it is not occluding the left subclavian artery. If no distal pulses are detected in the lower limb, consider removing the IABP and possibly alternate access.</li>
	<li>Check the insertion site for any bleeding or hematoma.</li>
	<li>Monitor urine output. If there is a drop in urine output or if there is a concern for hematuria, recheck balloon position to confirm that the balloon lies above the level of the renal arteries.</li>
	<li>If there is blood in the IABP tubing, suspect balloon rupture. Immediately stop the IABP (this is usually done automatically) and remove the catheter.</li>
	<li>Obtain a chest X-ray daily to verify optimal device positioning. Also change the sterile dressing daily to reduce the chances of infection.</li>
</ol>
5. Removal of IABP
<ol>
	<li>Stop systemic anticoagulation and set IABP to 1:1.</li>
	<li>Palpate the femoral pulse and check the baseline distal perfusion by obtaining a Doppler of the pedal pulse.</li>
	<li>Check the activated clotting time. It should ideally be less than 150-160 seconds.</li>
	<li>Remove sutures.</li>
	<li>Once ready to pull, press the Stop button on the IABP console screen.</li>
	<li>Pull the IABP until resistance is met against the sheath.</li>
	<li>Pull the sheath and IABP as a unit.</li>
	<li>Hold manual pressure over the femoral artery for 20-30 minutes or until bleeding stops.</li>
	<li>Reassess distal pulses with Doppler. 
	NOTE: Manual pressure has been mentioned here in the protocol because it is universal. However, there are numerous other methods apart from manual pressure to help achieve femoral arterial hemostasis. These are institution dependent and include but are not limited to: external compression devices like FemoStop, vascular closure devices like Angioseal and Perclose ProGlide Suture-Mediated Closure System. The above-mentioned protocol was partly developed by using official device information guides and manuals across various manufactures of IABP.</li>
</ol>

<ol><li>Hochman, J. S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Early+revascularization+in+acute+myocardial+infarction+complicated+by+cardiogenic+shock.+SHOCK+Investigators.+Should+We+Emergently+Revascularize+Occluded+Coronaries+for+Cardiogenic+Shock%5BTitle%5D)+AND+%22New+England+Journal+of+Medicine%22%5BJournal%5D)">Early revascularization in acute myocardial infarction complicated by cardiogenic shock. SHOCK Investigators. Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock.</a> New England Journal of Medicine. 341 (9), 625-634 (1999).</li>
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<li>Parissis, H., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((IABP%3A+history-evolution-pathophysiology-indications%3A+what+we+need+to+know%5BTitle%5D)+AND+%22Journal+of+Cardiothoracic+Surgery%22%5BJournal%5D)">IABP: history-evolution-pathophysiology-indications: what we need to know.</a> Journal of Cardiothoracic Surgery. 11 (1), 122(2016).</li>
<li>O'Gara, P. T., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((ACCF%2FAHA+guideline+for+the+management+of+ST-elevation+myocardial+infarction%3A+executive+summary%3A+a+report+of+the+American+College+of+Cardiology+Foundation%2FAmerican+Heart+Association+Task+Force+on+Practice+Guidelines%5BTitle%5D)+AND+%22Circulation%22%5BJournal%5D)">ACCF/AHA guideline for the management of ST-elevation myocardial infarction: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.</a> Circulation. 127 (4), 529-555 (2013).</li>
<li>Ibanez, B., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((2017+ESC+Guidelines+for+the+management+of+acute+myocardial+infarction+in+patients+presenting+with+ST-segment+elevation%3A+The+Task+Force+for+the+management+of+acute+myocardial+infarction+in+patients+presenting+with+ST-segment+elevation+of+the+European+Society+of+Cardiology+%28ESC%29%5BTitle%5D)+AND+%22European+Heart+Journal%22%5BJournal%5D)">2017 ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC).</a> European Heart Journal. 39 (2), 119-177 (2018).</li>
<li>Santa-Cruz, R. A., Cohen, M. G., Ohman, E. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Aortic+counterpulsation%3A+a+review+of+the+hemodynamic+effects+and+indications+for+use%5BTitle%5D)+AND+%22Catheterization+and+Cardiovascular+Interventions%22%5BJournal%5D)">Aortic counterpulsation: a review of the hemodynamic effects and indications for use.</a> Catheterization and Cardiovascular Interventions. 67 (1), 68-77 (2006).</li>
<li>Hendrickx, H. H., Berkowitz, D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Differences+between+intra-aortic+balloon+pumps+and+their+use%5BTitle%5D)+AND+%22Critical+Care+Medicine%22%5BJournal%5D)">Differences between intra-aortic balloon pumps and their use.</a> Critical Care Medicine. 10 (11), 796-797 (1982).</li>
<li>Parissis, H., Soo, A., Leotsinidis, M., Dougenis, D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((A+statistical+model+that+predicts+the+length+from+the+left+subclavian+artery+to+the+celiac+axis%3B+towards+accurate+intra+aortic+balloon+sizing%5BTitle%5D)+AND+%22Journal+of+Cardiothoracic+Surgery%22%5BJournal%5D)">A statistical model that predicts the length from the left subclavian artery to the celiac axis; towards accurate intra aortic balloon sizing.</a> Journal of Cardiothoracic Surgery. 6, 95(2011).</li>
<li>Seldinger, S. I. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Catheter+Replacement+of+the+Needle+in+Percutaneous+Arteriography%3A+A+New+Technique%5BTitle%5D)+AND+%22Circulation%22%5BJournal%5D)">Catheter Replacement of the Needle in Percutaneous Arteriography: A New Technique.</a> Circulation. 39 (5), 368-376 (1953).</li>
<li>Pucher, P. H., Cummings, I. G., Shipolini, A. R., McCormack, D. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Is+heparin+needed+for+patients+with+an+intra-aortic+balloon+pump%5BTitle%5D)+AND+%22Interactive+Cardiovascular+and+Thoracic+Surgery%22%5BJournal%5D)">Is heparin needed for patients with an intra-aortic balloon pump.</a> Interactive Cardiovascular and Thoracic Surgery. 15 (1), 136-139 (2012).</li>
<li>Collet, J. P., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((2020+ESC+Guidelines+for+the+management+of+acute+coronary+syndromes+in+patients+presenting+without+persistent+ST-segment+elevation%3A+The+Task+Force+for+the+management+of+acute+coronary+syndromes+in+patients+presenting+without+persistent+ST-segment+elevation+of+the+European+Society+of+Cardiology+%28ESC%29%5BTitle%5D)+AND+%22European+Heart+Journal%22%5BJournal%5D)">2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: The Task Force for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation of the European Society of Cardiology (ESC).</a> European Heart Journal. , (2020).</li>
<li>Thiele, H., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Intraaortic+Balloon+Pump+in+Cardiogenic+Shock+Complicating+Acute+Myocardial+Infarction%5BTitle%5D)+AND+%22Circulation%22%5BJournal%5D)">Intraaortic Balloon Pump in Cardiogenic Shock Complicating Acute Myocardial Infarction.</a> Circulation. 139 (3), 395-403 (2019).</li>
<li>Unverzagt, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Intra-aortic+balloon+pump+counterpulsation+%28IABP%29+for+myocardial+infarction+complicated+by+cardiogenic+shock%5BTitle%5D)+AND+%22Cochrane+Database+Systematic+Review%22%5BJournal%5D)">Intra-aortic balloon pump counterpulsation (IABP) for myocardial infarction complicated by cardiogenic shock.</a> Cochrane Database Systematic Review. (3), 007398(2015).</li>
<li>Deppe, A. C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Preoperative+intra-aortic+balloon+pump+use+in+high-risk+patients+prior+to+coronary+artery+bypass+graft+surgery+decreases+the+risk+for+morbidity+and+mortality-A+meta-analysis+of+9%2C212+patients%5BTitle%5D)+AND+%22Journal+of+Cardiac+Surgery%22%5BJournal%5D)">Preoperative intra-aortic balloon pump use in high-risk patients prior to coronary artery bypass graft surgery decreases the risk for morbidity and mortality-A meta-analysis of 9,212 patients.</a> Journal of Cardiac Surgery. 32 (3), 177-185 (2017).</li>
<li>Li, Y., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Effect+of+an+intra-aortic+balloon+pump+with+venoarterial+extracorporeal+membrane+oxygenation+on+mortality+of+patients+with+cardiogenic+shock%3A+a+systematic+review+and+meta-analysis%5BTitle%5D)+AND+%22European+Journal+of+Cardiothoracic+Surgery%22%5BJournal%5D)">Effect of an intra-aortic balloon pump with venoarterial extracorporeal membrane oxygenation on mortality of patients with cardiogenic shock: a systematic review and meta-analysis.</a> European Journal of Cardiothoracic Surgery. 55 (3), 395-404 (2019).</li>
<li>Wernly, B., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Mechanical+circulatory+support+with+Impella+versus+intra-aortic+balloon+pump+or+medical+treatment+in+cardiogenic+shock-a+critical+appraisal+of+current+data%5BTitle%5D)+AND+%22Clinical+Research+Cardiology%22%5BJournal%5D)">Mechanical circulatory support with Impella versus intra-aortic balloon pump or medical treatment in cardiogenic shock-a critical appraisal of current data.</a> Clinical Research Cardiology. 108 (11), 1249-1257 (2019).</li>
<li>Seto, A. H., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Real-time+ultrasound+guidance+facilitates+femoral+arterial+access+and+reduces+vascular+complications%3A+FAUST+%28Femoral+Arterial+Access+With+Ultrasound+Trial%29%5BTitle%5D)+AND+%22JACC+Cardiovascular+Interventions%22%5BJournal%5D)">Real-time ultrasound guidance facilitates femoral arterial access and reduces vascular complications: FAUST (Femoral Arterial Access With Ultrasound Trial).</a> JACC Cardiovascular Interventions. 3 (7), 751-758 (2010).</li>
<li>Erdogan, H. B., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((In+which+patients+should+sheathless+IABP+be+used%3F+An+analysis+of+vascular+complications+in+1211+cases%5BTitle%5D)+AND+%22Journal+of+Cardiac+Surgery%22%5BJournal%5D)">In which patients should sheathless IABP be used? An analysis of vascular complications in 1211 cases.</a> Journal of Cardiac Surgery. 21 (4), 342-346 (2006).</li>
<li>Huckaby, L. V., Seese, L. M., Mathier, M. A., Hickey, G. W., Kilic, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Intra-Aortic+Balloon+Pump+Bridging+to+Heart+Transplantation%3A+Impact+of+the+2018+Allocation+Change%5BTitle%5D)+AND+%22Circulation+%3A+Heart+Failure%22%5BJournal%5D)">Intra-Aortic Balloon Pump Bridging to Heart Transplantation: Impact of the 2018 Allocation Change.</a> Circulation : Heart Failure. 13 (8), 006971(2020).</li>
<li>Estep, J. D., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Percutaneous+placement+of+an+intra-aortic+balloon+pump+in+the+left+axillary%2Fsubclavian+position+provides+safe%2C+ambulatory+long-term+support+as+bridge+to+heart+transplantation%5BTitle%5D)+AND+%22JACC+Heart+Failure%22%5BJournal%5D)">Percutaneous placement of an intra-aortic balloon pump in the left axillary/subclavian position provides safe, ambulatory long-term support as bridge to heart transplantation.</a> JACC Heart Failure. 1 (5), 382-388 (2013).</li>
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<li>Siriwardena, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Complications+of+intra-aortic+balloon+pump+use%3A+does+the+final+position+of+the+IABP+tip+matter%5BTitle%5D)+AND+%22Anesthesia+Intensive+Care%22%5BJournal%5D)">Complications of intra-aortic balloon pump use: does the final position of the IABP tip matter.</a> Anesthesia Intensive Care. 43 (1), 66-73 (2015).</li>
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 <a target="_blank" href="https://citoday.com/device-guide/european/intra-aortic-balloon-pumps-1">https://citoday.com/device-guide/european/intra-aortic-balloon-pumps-1</a> (2020).</li>
</ol>

Ganesh Gajanan MD has no conflicts of interests to declare
Emmanouil S. Brilakis, MD, PhD has the following disclosures : Consulting/speaker honoraria from Abbott Vascular, American Heart Association (associate editor Circulation), Amgen, Biotronik, Boston Scientific, Cardiovascular Innovations Foundation (Board of Directors), ControlRad, CSI, Ebix, Elsevier, GE Healthcare, InfraRedx, Medtronic, Siemens, and Teleflex; research support from Regeneron and Siemens. Shareholder: MHI Ventures.
Jolanta M. Siller-Matula, MD, PhD has the following disclosures: Lecture or consultant fees from AstraZeneca, Daiichi-Sankyo, Eli Lilly, Bayer and research grant from Roche Diagnostics;
Ronald L. Zolty, MD, PhD has the following disclosures: Consultant for Actelion, Bayer, United Therapeutics and Alnhylam
Poonam Velagapudi MD has no conflicts of interests to declare.

Mechanical circulatory support is a rapidly evolving field. Even with the arrival of newer support devices, IABP remains the most widely used and simplest to deploy mechanical circulatory support device available currently25. In this article we describe in detail, the procedure for percutaneous insertion of IABP, the indications, evidence, troubleshooting and complications. Despite conflicting evidence regarding the use of IABP in AMI-related cardiogenic shock, it remains the most widely used form of mechanical support. In addition to use in AMI related cardiogenic shock IABP is also used in coronary artery bypass surgery and as a bridge to advanced heart failure therapies like LVAD or cardiac transplant.
Insertion of the IABP is straightforward and the technique can be rapidly deployed either at bedside or preferably in the cardiac catheterization laboratory where fluoroscopic guidance can be used to confirm positioning. We recommend using ultrasound guidance to obtain arterial access to improve first pass success and better safety profile26. The IABP wire can either be backloaded (advancing the balloon and wire together as a unit) or over the wire as mentioned above. However, in patients with known peripheral vascular disease, we recommend the &#34;over the wire&#34; method. This helps confirm whether it is possible to navigate the IABP catheter through a narrow or tortuous vasculature. In patients with risk factors for limb ischemia, sheathless insertion technique can be considered which reduces the risk of ischemic complications secondary to the vascular sheath27.
IABP is now being increasingly used in patients with end stage heart failure as a bridge to decision or advanced heart failure therapies like LVAD or cardiac transplant. A large study looking at the use of IABP in 1342 patients showed that IABP utilization increased over three fold since the 2018 cardiac transplant allocation change28. Since these patients often require mechanical support for a prolonged period of time, IABP insertion through the axillary artery can be considered. The axillary approach is well tolerated and permits ambulation and reduces the risk of infection in those requiring prolonged mechanical support. This overcomes the major limitation of the femoral approach which restricts ambulation and thereby promoting deconditioning in this tenuous patient population29. Newer devices which operate on the same principles as an IABP like the intravascular ventricular assist system (iVAS) are currently being studied which allow the patient to be discharged home with a temporary mechanical support device30.
Complications from IABP most commonly result from difficult arterial access, malposition and patient risk factors like peripheral vascular disease. Due to the endovascular nature of the device, the most common complications are primarily related to vascular injury. Other complications include cerebrovascular accident, thrombocytopenia, insertion site bleeding, aortic dissection, spinal cord ischemia, blood stream infections, balloon rupture and gas embolism11,27,31,32. Troubleshooting of the device and the common complications are summarized in Table 3.

Cardiogenic shock is a clinical condition characterized by decreased end organ perfusion due to severe cardiac dysfunction. The most widely accepted definition of cardiogenic shock is based on the Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock trial (SHOCK)1 and Intra-aortic Balloon Support for Myocardial Infarction with Cardiogenic Shock (IABP-SHOCK-II) trial2 and includes the following parameters:
1. Systolic blood pressure &#60;90 mm Hg for &#8805;30 min or vasopressor and/or mechanical support to maintain SBP &#8805;90 mm Hg
2. Evidence of end-organ hypoperfusion (urine output &#60;30 mL/h or cool extremities)
3. Hemodynamic criteria: cardiac index &#8804;2.2 L/min/m2 and pulmonary capillary wedge pressure &#8805;15 mm Hg
Acute myocardial infarction (AMI) is the most common cause of cardiogenic shock accounting for approximately 30% of cases3. Despite advances in the treatment of patients with AMI with early invasive revascularization, the mortality of cardiogenic shock remains high4. The mechanism of diastolic augmentation showing improvement in coronary perfusion and decreased left ventricular work was first demonstrated in 19585. Subsequently, in 1962 the first experimental prototype of IABP was developed6. Six years later, Kantrowitz et al.7 presented the first clinical experience of IABP use in four patients with AMI and cardiogenic shock unresponsive to medical therapy.
The IABP&#39;s mechanism of action involves inflation of the balloon during diastole and deflation during systole. This results in two important hemodynamic consequences: When the balloon inflates in diastole, the blood in the aorta is displaced proximally towards the aortic root thereby increasing coronary blood flow. When the balloon deflates in systole, it causes a vacuum or suction effect decreasing afterload and augmenting cardiac output8. The hemodynamic changes caused by IABP are listed below9 (Table 1):
1.Increase in aortic diastolic pressure
2.Decrease in systolic blood pressure
3.Increase in mean arterial pressure
4.Decrease in pulmonary capillary wedge pressure
5.Increase in cardiac output by ~20%
6.Increase in coronary blood flow10
The major indications of IABP are cardiogenic shock (due to AMI and other causes like ischemic and non-ischemic cardiomyopathy, myocarditis), mechanical complications of AMI like ventricular septal defect or severe mitral regurgitation, mechanical support during high risk percutaneous coronary interventions11, as a bridge to coronary artery bypass surgery in patients with critical CAD, inability to wean off cardiopulmonary bypass and as a bridge to decision or advanced therapies like left ventricular assist devices (LVAD) or cardiac transplantation in end stage heart failure12,13,14,15. Contraindications to use of IABP include moderate or severe aortic regurgitation which can worsen with counterpulsation, severe peripheral vascular disease which would preclude optimal arterial access and placement of the device and aortic pathologies like dissection12,15.
The IABP device consists of a console to control the unit and a vascular catheter with the balloon.
The console includes the following four components:
a) Monitor unit which helps to process and determine a trigger signal for the balloon. The signal can be either electrocardiographic (ECG) triggering or pressure signal triggering;
b) Control unit: Processes the trigger signal and activates the gas valve to help with inflation or deflation;
c) A gas cylinder that contains helium. Carbon dioxide is an alternative but is less preferred than helium. Helium has a lower density and provides better balloon inflation characteristics with more rapid inflation and deflation16;
d) A valve unit which helps with gas delivery.
The IABP (balloon) catheter is a 7-8.5 F vascular catheter with distance markings. The catheter has a polyethylene balloon mounted at the tip. The balloon size can vary from 20-50 mL. The ideal balloon has a length to cover from the left subclavian artery to the celiac artery take off, the inflated diameter measuring 90 to 95% of that of the descending aorta. The most commonly used balloon size in adult patients (height 5&#39;4&#8243;/162 cm to 6&#39;/182 cm) is 40 mL. A 50 mL balloon is used for patients &#62;6&#39;/182 cm and 34 cm balloon for 5&#39;/152 cm to 5&#39;4&#8243;/162 cm tall patients12,17 (Table 2).

<table><tbody><tr><td>IABP catheter and console</td><td>Getinge</td><td>Sensation Plus</td><td></td></tr><tr><td>Micropuncture Introducer Set</td><td>Cook Medical</td><td>G48006</td><td></td></tr><tr><td>Sterile drapes</td><td>Haylard</td><td></td><td></td></tr><tr><td>Ultrasound</td><td>GE</td><td></td><td></td></tr><tr><td>Lidocaine</td><td>Pfizer</td><td></td><td></td></tr></tbody></table>

the intra-aortic balloon pump

Cardiogenic shock remains one of the most challenging clinical syndromes in modern medicine. Mechanical support is being increasingly used in the management of cardiogenic shock. Intra-aortic balloon pump (IABP) is one of the earliest and most widely used types of mechanical circulatory support. The device acts by external counterpulsation and uses systolic unloading and diastolic augmentation of aortic pressure to improve hemodynamics. Although IABP provides less hemodynamic support when compared with newer mechanical circulatory support devices, it can still be the mechanical support device of choice in appropriate situations because of its relative simplicity of insertion and removal, need for smaller size vascular access and better safety profile. In this review, we discuss the equipment, procedural and technical aspects, hemodynamic effects, indications, evidence, current status and recent advances in the use of IABP in cardiogenic shock.

Despite being used for many decades now, the evidence on IABP use has been controversial. Routine use of IABP in patients with AMI and cardiogenic shock is not recommended. The previous guidelines of the American Heart Association/American College of Cardiology (AHA/ACC) and the European Society of Cardiology (ESC) strongly recommended the use of the IABP in patients with AMI-associated cardiogenic shock (Class I B and Class I C) on the basis of pathophysiological considerations, non-randomized trials and registry data. However, the AHA/ACC in 2013 downgraded the use of IABP to class II A, primarily based on the results of the IABP Shock II trial13. The ESC STEMI Guidelines 2017 recommended no routine IABP counterpulsation but the guidelines state that IABP may be considered for haemodynamic support in selected patients as those with severe mitral insufficiency or ventricular septal defect14. The ESC NSTE-ACS 2020 guidelines discourage form routine use of IABP in patients with CS (class IIIB) but recommend IABP in ACS-related mechanical complications (class IIA)20.
The IABP Shock II trial2, randomized 600 patients with acute MI complicated by cardiogenic shock to either IABP or no IABP. At 30 days, there were no differences in outcomes, including length of stay in the intensive care unit, renal function, rates of major bleeding, peripheral ischemic complications, sepsis, or stroke. There was no difference in mortality at long-term follow-up of 12 months and 6.2 years21.The major limitations of the trial were - the timing of insertion of IABP was not controlled (86.6% were inserted post PCI). A lower mortality rate compared to other studies precludes application of this study to severe cardiogenic shock. Subsequent meta-analyses have showed that there is no convincing randomized data to support the routine use of IABP in AMI related cardiogenic shock22.
However, several recent studies have shown that there is still some utility for the use of IABP. A meta-analysis of 9212 patients investigated the utility of the IABP when implanted preoperatively in patients undergoing coronary bypass graft surgery. The results support the use of IABP in this clinical setting, with a 4% relative risk reduction of mortality. Also, the risk of MI, renal failure, intensive care, and hospital length of stay were reduced with IABP23. Interestingly, with the increasing use of advanced heart failure therapies, IABP is being increasingly used in combination with extracorporeal membrane oxygenation and was associated with better survival in a recent meta-analysis24.
<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Structure</td>
			<td>Hemodynamic effect</td>
		</tr>
		<tr>
			<td>Aorta</td>
			<td>↓systolic pressure, ↑diastolic pressure</td>
		</tr>
		<tr>
			<td>Left ventricle</td>
			<td>↓systolic pressure, ↓end-diastolic pressure, ↓volume, ↓wall tension</td>
		</tr>
		<tr>
			<td>Heart</td>
			<td>↓afterload, ↓preload, ↑cardiac output</td>
		</tr>
		<tr>
			<td>Coronaries</td>
			<td>↑/unchanged coronary blood flow</td>
		</tr>
	</tbody>
</table>
Table 1: Hemodynamic effects of IABP 
<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Company</td>
			<td>Product</td>
			<td>Catheter size (F)</td>
			<td>Sheath size (F)</td>
			<td>Balloon size (ml)</td>
		</tr>
		<tr>
			<td>Balton</td>
			<td>IABC Balloon</td>
			<td>7.5, 8</td>
			<td>7.5, 8</td>
			<td>20, 25, 30, 34, 40, 50</td>
		</tr>
		<tr>
			<td>Getinge</td>
			<td>Cardiosave IABP</td>
			<td>7, 7.5, 8</td>
			<td>7.5,8</td>
			<td>25, 30, 34, 40, 50</td>
		</tr>
		<tr>
			<td>Getinge</td>
			<td>CS300 IABP</td>
			<td>7, 7.5, 8</td>
			<td>7.5,8</td>
			<td>25, 30, 34, 40, 50</td>
		</tr>
		<tr>
			<td>Getinge</td>
			<td>Linear</td>
			<td>7.5</td>
			<td>7.5</td>
			<td>25, 34, 40</td>
		</tr>
		<tr>
			<td>Getinge</td>
			<td>Mega</td>
			<td>7.5, 8</td>
			<td>7.5, 8</td>
			<td>30, 40, 50</td>
		</tr>
		<tr>
			<td>Getinge</td>
			<td>Sensation</td>
			<td>7</td>
			<td>7</td>
			<td>34,40</td>
		</tr>
		<tr>
			<td>Getinge</td>
			<td>Sensation Plus</td>
			<td>7.5, 8</td>
			<td>7.5,8</td>
			<td>40,50</td>
		</tr>
		<tr>
			<td>Teleflex</td>
			<td>Arrow AC3 Optimus Intra-Aortic Balloon Pump</td>
			<td>7, 7.5, 8</td>
			<td>8,8.5</td>
			<td>30,40,50</td>
		</tr>
		<tr>
			<td>Teleflex</td>
			<td>Arrow RediGuard IAB Catheters</td>
			<td>7,8</td>
			<td>8,8.5</td>
			<td>30,40,50</td>
		</tr>
		<tr>
			<td>Teleflex</td>
			<td>Arrow Ultra 8 Fiber-Optic IAB Catheters</td>
			<td>8,8.5</td>
			<td>8,8.5</td>
			<td>30,40,50</td>
		</tr>
		<tr>
			<td>Teleflex</td>
			<td>Arrow Ultra 8 Fluid-Filled IAB Catheters</td>
			<td>8</td>
			<td>8</td>
			<td>30,40</td>
		</tr>
		<tr>
			<td>Teleflex</td>
			<td>Arrow UltraFlex 7.5 IAB Catheters</td>
			<td>7.5, 8</td>
			<td>8,8.5</td>
			<td>30,40,50</td>
		</tr>
	</tbody>
</table>
Table 2: Comparison of catheter and sheath sizes across different IABP manufacturers33
<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Problem</td>
			<td>Probable cause</td>
			<td>Solution</td>
		</tr>
		<tr>
			<td>Console alarm - “check IABP Catheter”</td>
			<td>Kink in tubing</td>
			<td>Relieve kink</td>
		</tr>
		<tr>
			<td></td>
			<td>Incomplete unfolding of balloon membrane</td>
			<td>Manually inflate and deflate balloon</td>
		</tr>
		<tr>
			<td></td>
			<td>A part of the balloon is in the sheath</td>
			<td>Check balloon position</td>
		</tr>
		<tr>
			<td>Rapid Gas Loss or Leak in IABP Circuit</td>
			<td>Possible rupture</td>
			<td>Check tubing for blood</td>
		</tr>
		<tr>
			<td></td>
			<td></td>
			<td>If there is no blood in the tubing, double check the connections</td>
		</tr>
		<tr>
			<td>Weak left radial pulse or left arm ischemia.</td>
			<td>Left subclavian artery occlusion</td>
			<td>Check position of IABP</td>
		</tr>
		<tr>
			<td>Low urine output or hematuria</td>
			<td>Renal artery occlusion</td>
			<td>Check position of IABP</td>
		</tr>
		<tr>
			<td>Excessive bleeding from insertion site</td>
			<td>Difficult arterial access, multiple sticks</td>
			<td>Apply firm pressure while ensuring distal flow</td>
		</tr>
		<tr>
			<td>Limb ischemia</td>
			<td>Arterial access site issues, peripheral vascular disease</td>
			<td>Consider removing the IABP. Consider alternate access</td>
		</tr>
		<tr>
			<td>Blood noted in catheter tubing</td>
			<td>Balloon rupture</td>
			<td>Stop the IABP and remove the catheter immediately</td>
		</tr>
		<tr>
			<td>Arterial dissection</td>
			<td>Improper advancement of the guidewire with subsequent insertion of the IABP into a false lumen</td>
			<td>Remove IABP</td>
		</tr>
	</tbody>
</table>
Table 3: Troubleshooting of potential device malfunction and major patient complications from IABP
<img alt="Cardiac cycle diagram showing pressure phases: systole, diastole, augmentation, assisted cycles." class="xfigimg" src="/files/ftp_upload/62132/62132fig01.jpg" data-altupdatedat="1747911167000" data-alt="Figure 1"> 
Figure 1: Hemodynamic waveform with IABP and appropriate timing of IABP augmentation <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/62132/62132fig01large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>

Watch this Scientific Journal Video about The Intra-Aortic Balloon Pump at JoVE.com

The Intra-Aortic Balloon Pump

We describe the steps for the percutaneous implantation of the intra-aortic balloon pump (IABP), a mechanical circulatory support device. It acts by counterpulsation, inflating at the onset of diastole, augmenting diastolic aortic pressure and improving coronary blood flow and systemic perfusion, and deflating before systole, reducing left ventricular afterload.

Cardiogenic shock remains one of the most challenging clinical syndromes in modern medicine. Mechanical support is being increasingly used in the ...

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Research

JoVE Journal

Medicine

21.1K Views.  University of Nebraska Medical Center. De intra-aorta ballonpomp is een ondersteuningsapparaat dat werkt volgens het principe van tegenpulsatie. Het blaast op tijdens diastole waardoor de diastolische aortadruk wordt verhoogd, de coronaire bloedstroom en systemische perfusie worden verbeterd. En leegloopt tijdens systole, waardoor LV-nabelasting wordt verminderd.Het demonstreren van het inbrengen van een ballonpomp vandaag, zullen ikzelf en Dr.Ganesh Gajanan, Interventional Cardiology Fellow aan het University of Nebraska M...

Video: The Intra-Aortic Balloon Pump

Direct Pressure Monitoring Accurately Predicts Pulmonary Vein Occlusion During Cryoballoon Ablation

Cryoballoon ablation (CBA) is an established therapy for atrial fibrillation (AF). Pulmonary vein (PV) occlusion is essential for achieving antral contact and PV isolation and is typically assessed by contrast injection. We present a novel method of direct pressure monitoring for assessment of PV occlusion.
Transcatheter pressure is monitored during balloon advancement to the PV antrum. Pressure is recorded via a single pressure transducer connected to the inner lumen of the cryoballoon. Pressure curve characteristics are used to assess occlusion in conjunction with fluoroscopic or intracardiac echocardiography (ICE) guidance. PV occlusion is confirmed when loss of typical left atrial (LA) pressure waveform is observed with recordings of PA pressure characteristics (no A wave and rapid V wave upstroke). Complete pulmonary vein occlusion as assessed with this technique has been confirmed with concurrent contrast utilization during the initial testing of the technique and has been shown to be highly accurate and readily reproducible.
We evaluated the efficacy of this novel technique in 35 patients. A total of 128 veins were assessed for occlusion with the cryoballoon utilizing the pressure monitoring technique; occlusive pressure was demonstrated in 113 veins with resultant successful pulmonary vein isolation in 111 veins (98.2%). Occlusion was confirmed with subsequent contrast injection during the initial ten procedures, after which contrast utilization was rapidly reduced or eliminated given the highly accurate identification of occlusive pressure waveform with limited initial training.
Verification of PV occlusive pressure during CBA is a novel approach to assessing effective PV occlusion and it accurately predicts electrical isolation. Utilization of this method results in significant decrease in fluoroscopy time and volume of contrast.

Effective pulmonary vein isolation utilizing a cryoballoon depends on complete pulmonary vein occlusion. The point of occlusion can be effectively predicted by direct analysis of pulmonary vein pressure waveform analysis during balloon inflation using a simple and reproducible technique.

Cryoballoon  ablation (CBA) is an established therapy for atrial fibrillation (AF).  Pulmonary vein (PV) occlusion is essential for achieving antral ...

Use of Two Intracorporeal Ventricular Assist Devices As a Total Artificial Heart

Mechanical circulatory support (MCS) has been introduced as a viable alternative to heart transplantation primarily through the use of intracorporeal ventricular assist devices (VADs) for support of the left ventricle. However, certain clinical scenarios warrant biventricular mechanical support. One strategy for some patients is the excision of both ventricles and the implantation of two VAD pumps as a total artificial heart (TAH). This has recently been made possible by the improvements in device design and the small profile of centrifugal devices. This TAH approach remains experimental with many important challenges such as the device settings to balance the right and left circulation, the orientation of the devices and the outflow graft with their influence on hemolysis and stability, and the outcome of chronic support using such an orientation. This protocol aims to provide a reproducible approach for total artificial heart replacement with two intracorporeal centrifugal VADs in a cow model.

Here, we present a protocol using two centrifugal pumps as a total artificial heart replacement.

Mechanical circulatory support (MCS) has been introduced as a viable alternative to heart transplantation primarily through the use of intracorporeal ...

Invasive Hemodynamic Monitoring of Aortic and Pulmonary Artery Hemodynamics in a Large Animal Model of ARDS

One of the leading causes of morbidity and mortality in patients with heart failure is right ventricular (RV) dysfunction, especially if it is due to pulmonary hypertension. For a better understanding and treatment of this disease, precise hemodynamic monitoring of left and right ventricular parameters is important. For this reason, it is essential to establish experimental pig models of cardiac hemodynamics and measurements for research purpose. 
This article shows the induction of ARDS by using oleic acid (OA) and consequent right ventricular dysfunction, as well as the instrumentation of the pigs and the data acquisition process that is needed to assess hemodynamic parameters. To achieve right ventricular dysfunction, we used oleic acid (OA) to cause ARDS and accompanied this with pulmonary artery hypertension (PAH). With this model of PAH and consecutive right ventricular dysfunction, many hemodynamic parameters can be measured, and right ventricular volume load can be detected. 
All vital parameters, including respiratory rate (RR), heart rate (HR) and body temperature were recorded throughout the whole experiment. Hemodynamic parameters including femoral artery pressure (FAP), aortic pressure (AP), right ventricular pressure (peak systolic, end systolic and end diastolic right ventricular pressure), central venous pressure (CVP), pulmonary artery pressure (PAP) and left arterial pressure (LAP) were measured as well as perfusion parameters including ascending aortic flow (AAF) and pulmonary artery flow (PAF). Hemodynamic measurements were performed using transcardiopulmonary thermodilution to provide cardiac output (CO). Furthermore, the PiCCO2 system (Pulse Contour Cardiac Output System 2) was used to receive parameters such as stroke volume variance (SVV), pulse pressure variance (PPV), as well as extravascular lung water (EVLW) and global end-diastolic volume (GEDV). Our monitoring procedure is suitable for detecting right ventricular dysfunction and monitoring hemodynamic findings before and after volume administration.

We present a protocol of creating right ventricular dysfunction in a pig model by inducing ARDS. We demonstrate invasive monitoring of left and right ventricular cardiac output using flow probes around the aorta and the pulmonary artery, as well as blood pressure measurements in the aorta and pulmonary artery.

One of the leading causes of morbidity and mortality in patients with heart failure is right ventricular (RV) dysfunction, especially if it is due to ...

Development of a Selective Aortic Arch Perfusion System in a Porcine Model of Exsanguination Cardiac Arrest

Hemorrhage constitutes the majority of potentially preventable deaths from trauma. There is growing interest in endovascular resuscitation techniques such as selective aortic arch perfusion (SAAP) for patients in cardiac arrest. This involves active perfusion of the coronary circulation via a thoracic aortic balloon catheter and is approaching clinical application. However, the technique is complex and requires refinement in animal models before human use can be considered. This paper describes a large animal model of exsanguination cardiac arrest treated with a bespoke SAAP system.
Swine were anesthetized, instrumented and a splenectomy was performed before a controlled, logarithmic exsanguination was initiated. Animals were heparinized and the shed blood collected in a reservoir. Once cardiac arrest was observed, the blood was pumped through an extra-corporeal circuit into an oxygenator and then delivered through a 10 Fr balloon catheter placed in the thoracic aorta.
This resulted in the return of a spontaneous circulation (ROSC) as demonstrated by ECG and aortic root pressure waveform. This model and accompanying SAAP system allow for standardized and reproducible recovery from exsanguination cardiac arrest.

The goal of this protocol is to demonstrate a porcine exsanguination cardiac arrest model and a specifically built selective aortic arch perfusion circuit for translational research.

Hemorrhage constitutes the majority of potentially preventable deaths from trauma. There is growing interest in endovascular resuscitation techniques such ...

Post-Myocardial Infarction Heart Failure in Closed-chest Coronary Occlusion/Reperfusion Model in G&#246;ttingen Minipigs and Landrace Pigs

The development of heart failure is the most powerful predictor of long-term mortality in patients surviving acute myocardial infarction (MI). There is an unmet clinical need for prevention and therapy of post-myocardial infarction heart failure (post-MI HF). Clinically relevant pig models of post-MI HF are prerequisites for final proof-of-concept studies before entering into clinical trials in drug and medical device development.
Here we aimed to characterize a closed-chest porcine model of post-MI HF in adult G&#246;ttingen minipigs with long-term follow-up including serial cardiac magnetic resonance imaging (CMRI) and to compare it with the commonly used Landrace pig model.
MI was induced by intraluminal balloon occlusion of the left anterior descending coronary artery for 120 min in G&#246;ttingen minipigs and for 90 min in Landrace pigs, followed by reperfusion. CMRI was performed to assess cardiac morphology and function at baseline in both breeds and at 3 and 6 months in G&#246;ttingen minipigs and at 2 months in Landrace pigs, respectively.
Scar sizes were comparable in the two breeds, but MI resulted in a significant decrease of left ventricular ejection fraction (LVEF) only in G&#246;ttingen minipigs, while Landrace pigs did not show a reduction of LVEF. Right ventricular (RV) ejection fraction increased in both breeds despite the negligible RV scar sizes. In contrast to the significant increase of left ventricular end-diastolic (LVED) mass in Landrace pigs at 2 months, G&#246;ttingen minipigs showed a slight increase in LVED mass only at 6 months.
In summary, this is the first characterization of post-MI HF in G&#246;ttingen minipigs in comparison to Landrace pigs, showing that the G&#246;ttingen minipig model reflects post-MI HF parameters comparable to the human pathology. We conclude that the G&#246;ttingen minipig model is superior to the Landrace pig model to study the development of post-MI HF.

The overall goal of the current study is to present the techniques of induction of myocardial infarction (MI) and post-myocardial infarction heart failure (post-MI HF) in closed-chest, adult G&#246;ttingen minipigs and the characterization of post-MI HF model in G&#246;ttingen minipigs as compared to Landrace pigs.

The development of heart failure is the most powerful predictor of long-term mortality in patients surviving acute myocardial infarction (MI). There is an ...

Utilizing Percutaneous Ventricular Assist Devices in Acute Myocardial Infarction Complicated by Cardiogenic Shock

Cardiogenic shock is defined as persistent hypotension, accompanied by evidence of end organ hypo-perfusion. Percutaneous ventricular assist devices (PVADs) are used for the treatment of cardiogenic shock in an effort to improve hemodynamics. Impella is currently the most common PVAD and actively pumps blood from the left ventricle into the aorta. PVADs unload the left ventricle, increase cardiac output and improve coronary perfusion. PVADs are typically placed in the cardiac catheterization laboratory under fluoroscopic guidance via the femoral artery when feasible. In cases of severe peripheral arterial disease, PVADs can be implanted through an alternative access. In this article, we summarize the mechanism of action of PVAD and the data supporting their use in the treatment of cardiogenic shock.

Percutaneous ventricular assist devices are increasingly being utilized in patients with acute myocardial infarction and cardiogenic shock. Herein, we discuss the mechanism of action and hemodynamic effects of such devices. We also review algorithms and best practices for the implantation, management and weaning of these complex devices.

Cardiogenic shock is defined as persistent hypotension, accompanied by evidence of end organ hypo-perfusion. Percutaneous ventricular assist devices ...

Use of a Percutaneous Ventricular Assist Device/Left Atrium to Femoral Artery Bypass System for Cardiogenic Shock

The left atrial to femoral artery bypass (LAFAB) system is a mechanical circulatory support (MCS) device used in cardiogenic shock (CS) that bypasses the left ventricle by draining blood from the left atrium (LA) and returning it to the systemic arterial circulation via the femoral artery. It can provide flows ranging from 2.5-5 L/min depending on the size of the cannula. Here, we discuss the mechanism of action of LAFAB, available clinical data, indications for its use in cardiogenic shock, steps of implantation, post-procedural care, and complications associated with the use of this device and their management.
We also provide a brief video of the procedural component of device therapy, including the pre-placement preparation, percutaneous placement of the device via transseptal puncture under echocardiographic guidance and the post-operative management of device parameters.

The following article describes the stepwise procedure for placement of a device (e.g., Tandemheart) in cardiogenic shock (CS) that is a percutaneous left ventricular assist device (pLVAD) and a left atrial to femoral artery bypass (LAFAB) system that bypasses and supports the left ventricle (LV) in CS.

The left atrial to femoral artery bypass (LAFAB) system is a mechanical circulatory support (MCS) device used in cardiogenic shock (CS) that bypasses the ...

Insertion, Maintenance, and Removal of the Percutaneous Dual Lumen Cannula Right Ventricular Assist Device

Right ventricular (RV) shock, classically characterized by elevated central venous pressure (CVP) with&#160;normal to low pulmonary artery (PA) and pulmonary capillary wedge pressures (PCWP),&#160;remains a significant cause of morbidity and mortality worldwide if left untreated.&#160;Therapies for the treatment of RV shock range&#160;from medical management to durable or percutaneous mechanical circulatory support (MCS). A unique MCS device, a percutaneous right ventricular assist device (pRVAD), approved for use by the Food and Drug Administration (FDA) in 2014, works by temporarily off-loading the RV through a single, dual lumen catheter with extracorporeal mechanical support and is capable of shunting blood from the right atrium (RA) to the main PA. Although initially approved as venous-venous extracorporeal membrane oxygenation (VV-ECMO) device, this work will focus on the use of RV support, as ambulatory VV-ECMO strategies have been described previously. The catheter is most commonly inserted through the right internal jugular (IJ) vein into the PA and connected to an external pump, allowing flow up to 5 L/min. This device may be an attractive choice for the treatment of RV shock due to its percutaneous, minimally invasive insertion and removal and its ability to allow patient ambulation while the device is in place. This protocol discusses in detail the equipment, hemodynamic effects, indications, contraindications, complications, currently available research in the literature, and step-by-step instructions on how to implant, manage, and extract the device, along with the guidance on use and troubleshooting complications from one of the largest, single-center experiences with the device.

The present protocol provides a detailed description of a percutaneous dual lumen right ventricular assist device and illustrates step-by-step instructions on the safe implanting, managing, and removing the device. Guidance on its use and troubleshooting complications from one of the most significant single-center experiences is also included.

Right ventricular (RV) shock, classically characterized by elevated central venous pressure (CVP) with&#160;normal to low pulmonary artery (PA) and ...

Intravascular Lithotripsy-Assisted Transfemoral Transcatheter Aortic Valve Implantation

During the last decade, transcatheter aortic valve implantation (TAVI) has evolved as a well-established therapy for aging patients suffering from symptomatic severe aortic valve stenosis. This is also reflected in the recently updated international guidelines on managing patients with valvular heart disease. A transfemoral&#160;(TF) TAVI&#160;approach has proven superior to alternative access strategies. With the introduction of intravascular lithotripsy (IVL), patients with calcified iliofemoral vascular disease and borderline intraluminal diameters have also become candidates for percutaneous TF-TAVI. Moreover, IVL reduces the risk of major vascular complications by modifying the superficial and deep vascular calcium, thereby changing the vessel compliance and controlling luminal expansion. In this way, IVL has shown to safely facilitate TF delivery of TAVI devices in patients with calcified peripheral artery disease. The present article aims to provide a detailed step-by-step description on how to perform IVL-assisted TF-TAVI safely and efficiently. Furthermore, a literature review on the outcomes obtained with this technology is included, along with a concise discussion on this unique TAVI approach.

Transcatheter aortic valve implantation (TAVI) has been shown to generate the best clinical outcomes when performed by the percutaneous transfemoral approach. Intravascular lithotripsy (IVL) can facilitate a transfemoral process in patients with calcified iliofemoral vascular disease and borderline intraluminal diameters. The present protocol describes IVL-assisted transfemoral TAVI.

During the last decade, transcatheter aortic valve implantation (TAVI) has evolved as a well-established therapy for aging patients suffering from ...

Complete and Partial Resuscitative Endovascular Balloon Occlusion of the Aorta for Hemorrhagic Shock

Resuscitative endovascular balloon occlusion of the aorta (REBOA) devices grew out of a military-civilian partnership to develop new capabilities for hemorrhage control. With the advent of purpose-built devices, REBOA has become increasingly common in civilian trauma and acute care settings. Currently available REBOA catheters were designed as complete aortic occlusion devices. However, the therapeutic window for complete aortic occlusion is time-limited due to ischemia-reperfusion injury. The partial procedure allows blood flow past the level of occlusion while maintaining targeted proximal pressure, which has been shown to reduce distal ischemia and adjunctive resuscitation requirements in preclinical studies with prolonged occlusion times as compared to traditional complete occlusion.
pREBOA-PRO is the first catheter designed to enable partial and complete aortic occlusion and is currently in limited market release at seven Level I trauma centers in North America. This paper will focus on procedural considerations for REBOA, including patient selection criteria and a comparison of complete and partial aortic occlusion in a simulator, along with highlighting critical steps to improve clinical outcomes. Additionally, this paper reviews a contrast-enhanced CT scan from a trauma patient that shows distal perfusion after 2 h of partial aortic occlusion using this newly designed catheter and discusses representative results from the limited market release to highlight the profound effect of technological innovation on outcomes in vascular emergencies.

A commercial catheter was designed to facilitate true partial resuscitative endovascular balloon occlusion of the aorta (REBOA) and address the complications associated with complete aortic occlusion. Initial clinical reports indicate that partial REBOA improves transition to reperfusion, reduction of distal ischemia, and extension of safe occlusion time compared to complete occlusion.

Resuscitative endovascular balloon occlusion of the aorta (REBOA) devices grew out of a military-civilian partnership to develop new capabilities for ...

The Intra-Aortic Balloon Pump

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