Eiran Z. Gorodeski

Intra-aortic balloon pumps (IABPs), designed for femoral access, are increasingly used in the axillary position to support patients awaiting advanced heart failure (HF) therapies. These devices often migrate, requiring radiographic surveillance-based repositioning. We evaluated how often axillary IABPs (ax-IABPs) require repositioning and whether repositioning worsens outcomes. We conducted a single-center retrospective cohort study of patients with advanced HF and cardiogenic shock supported by ax-IABPs. The primary outcome was a composite of ax-IABP–related complications: device malfunction requiring exchange, bacteremia, vascular complications, pneumothorax, and stroke. Thirty-eight patients received 55 ax-IABPs. Mean age was 50.7 years, 71% male; non-ischemic cardiomyopathy predominated (51%). Repositioning was required in 49% of devices (mean 2.2 events each). Complications occurred more frequently in repositioned devices (22 vs . 14 events), most commonly pump malfunction requiring exchange, followed by axillary artery thrombosis/upper-extremity ischemia and bacteremia. Repositioning was associated with higher odds of complications in unadjusted (OR: 5.9; 95% confidence interval [CI]: 1.7–20.0; p = 0.005) but not adjusted analysis (OR: 3.5; 95% CI: 0.7–17.4; p = 0.13). Competing-risks analysis showed a time-dependent increase in complication risk during prolonged support. Nearly half of ax-IABPs require repositioning, which is associated with worse outcomes. Findings call for vigilance and improved ax-IABP design and durability.