eComment: Right axillary artery as an alternative route for intraaortic balloon pump catheter insertion in severe aortoiliac pathologies

I read with great interest the paper by Zattera et al. [1] regarding the left axillary artery approach as an alternative technique for intraaortic balloon pump (IABP) catheter insertion in a patient with severe peripheral vascular disease. First of all, I congratulate the authors for their successful effort in this complicated case. I would also like to share additional contribution on this subject. Percutaneous femoral IABP catheter insertion for hemodynamic support is widely used as an accepted route in patients with preoperative and postoperative cardiogenic shock by most cardiovascular surgeons. Nevertheless, this approach is not suitable in patients with severe aortoiliac pathology such as severe atherosclerotic (calcific) aorta, severe occlusive aortoiliac disease or aortic and iliac aneurysmal disease. The axillary arterial route should be considered as an alternative for patients in these complicated conditions [2]. Possible other alternative insertion sites of IABP catheter are the ascending aorta, the aortic arch, thoracic aorta, the common iliac artery (retroperitoneal approach), and the subclavian and brachial arteries. The best access site is clearly unknown and depends on the surgeon's experience. In our clinic, we have routinely used direct cannulation of the right axillary artery for arterial inflow during cardiopulmonary bypass in surgery of the ascending aorta and aortic arch [3]. Finally, the right axillary artery may be used safely as an alternative site for access in those settings in which severe aortoiliac occlusive disease and aortic aneurysmal disease prevent percutaneous femoral IABP catheter insertion. As described by Zattera et al. [1], we also recommend that this access site should be added to the surgical armamentarium in severe aortoiliac pathologies, particularly in the prolonged use of IABP.