CORRESPONDENCE

Late Paraplegia Resulting from Intraaortic Balloon Pump To the Editor:

We read with interest the report by Scott and Gioti entitled "Late Paraplegia as a Consequence of Intraaortic Balloon Pump Support" (Ann Thorac Surg 40:300, 1985) because we recently treated a patient in our institution who experienced the same devastating complication after insertion of an intraaortic bal- loon pump.

A :'2-year-old woman was transferred to the University of Illinois Hospital, where she underwent urgent cardiac catheter- ization because of prolonged episodes of rest angina. The an- giogrim showed total occlusion of the right and left anterior descending coronary arteries and subtotal occlusion of the cir- cumflex artery, with anterior and inferior regional wall motion abnormalities. During the study, the patient experienced chest pain and became hypotensive (systolic blood pressure, 70 mm Hg); therefore, an intraaortic balloon pump was inserted through the right femoral artery through the previously placed arterial sheath. No undue problems were noted during passage of the balloon.

The patient was brought directly to the operating room. Al- though initially she was hemodynamically stable, the induction of anesthesia resulted in profound cardiac decompensation, which necessitated external massage and expeditious institu- tion of cardiopulmonary bypass. A triple-vessel saphenous vein bypass was performed. lnotropic support with dobutamine and 1 : 1 balloon counterpulsation were maintained for 48 hours, and the balloon was removed 54 hours after insertion.

On awakening from anesthesia, the patient was noted to have 110 spontaneous motor function in the lower extremities. Neurological examination revealed sensory deficit below the T-10 level and paraplegia. Computed tomographic scan re- vealed an aortic dissection from the mid-thoracic aorta to the aortic bifurcation. No visceral vessels were occluded, renal function was unchanged, and all lower extremity pulses were equal and full. The patient has had improvement in motor func- tion but is not ambulatory.

As the report of Scott and Gioti suggests, paraplegia follow- ing intraaortic balloon pump insertion is rare. Our patient's paraplegia most likely was due to the dissection of the thoracic aorta occluding the blood supply to the anterior spinal cord. We postulate that other instances without evidence of dissection may ble caused by embolic events due to platelet thrombi forma- tion on the intraluminal device or at the site of arterial wall trauma induced by the balloon or catheter tip. We believe that this ccimplication is underreported and would encourage fur- ther reporting of this unfortunate and devastating complication in the hope that its true incidence will become better known and a means of prevention can be devised.

Pair1 E. Seifert, M . D . Norrrinu A . Siliwiiinrr, M . D

Diuisiori of Cnrdioflrorncic Surgery Box 6998 Univer&j of llliriois College of Medicine Chicago, l L 60680

False Ascending Aortic Aneurysm To thc Editor:

The case report by Evans and colleagues and the invited com- mentary from Dr. de Leval in a recent issue of TIic. Arlrials (Ann

Thorac Surg 39:573, 1985) raise several important questions. We agree with Dr. de Leval. If the early postoperative roentgeno- gram resembled the one made five months after surgical repair, then the aneurysm may well have been present already at one month. Why both ends of the graft had dehisced is puzzling. I t is hard to understand how the child's growth would produce this effect.

Like others, we have occluded polytetrafluoroethylene (PTFE) shunts with metal clips at the time of reparative proce- dures, because i t is simple, requires a minimum of dissection, and is the only reasonable way to obliterate the shunt. There is no doubt that PTFE rapidly becomes a semirigid material after insertion and adheres densely to adjacent structures. It is difficult to envisage separation of the cut ends after the material has been divided. Moreover, the material rapidly becomes difficult to suture or ligate, except by clips. Thus, it has very different physical characteristics a month or so after insertion from those at the time of shunting. I would very much like to know what experience others havt: had in shunt occlusion at the time of reparative procedures.

Incidentally, we have had a similar experience to that of Dr. Evans. Without warning, the subclavian end of a PTFE shunt spontaneously disconnected itself with false aneurysm three months after insertion (Figure). We found no evidence of infec- tion. The aneurysm filled the apex of the left chest and leaked into the pleural cavity. Salvage of the situation was complete.

/ [ i / i t i Wright , M.B.B.S. , F.R.A.C.S. Virrinla Nnyariar, M . B.B.S. , M.R.A.C.R. , D. D. U.

The Prifice of wales Childreti 's Hospitd High St Rnriiirc~ick, N S W 2031 Austrnlia

Reference 1. Evans VL, Hallman GL, Vargo TA, Gutgesell HP: False an-

eurysm of the ascending aorta lrom an expanded polytet- rafluoroethylene (Gore-Tex) aortopulmonary shunt. Ann Thorac Surg 39:573-5, 1985

700 A.nn Thorac Surg 41:700-702, June 1986