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Indian Journal of Anaesthesia 2008; 52 (4):387-396 Special Article

Intra Aortic Balloon Pump (IABP): Past, Present and

Future
Jatin D Dedhia1, Naren Chakravarthy Kotemane R2¸ Aamer B Ahmed3

Summary
Intra Aortic Balloon Pump (IABP) is the most commonly used mechanical circulatory assist device in cardiac
patients. IABP can improve ventricular function by decreasing the preload and increasing systolic output with signifi-
cant improvement in myocardial oxygen supply/demand ratio. Pre-operative IABP therapy in ‘high-risk’ coronary
patients has been shown to reduce hospital mortality and shorten ICU stay significantly, compared with controls. The
introduction of sheathless insertion kits has reduced the incidence of vascular complication rates. Pro-Active Counter
Pulsation is a new IABP system which automatically detects the irregular pattern and result is an improvement in the
haemodynamic effect of IABP during periods of arrhythmia. Today, continued improvements in IABP technology
permit safer use and earlier intervention to provide haemodynamic support. These developments have made the
IABP a mainstay in the management of ischemic and dysfunctional myocardium. This review article aims to provide
basic concept of IABP to hospital doctors especially anaesthetists, intensivists cardiologists and cardiac surgeons. It
discusses the common indications, contraindications, the physiologic aspects of IABP, the equipment needed to
facilitate IABP, the use of the IABP in special situations and complications of its use.

Key words Intra Aortic Balloon Pump, Coronary blood flow, Oxygen supply/demand, ProActive
Counter Pulsation, Console.
Introduction dependence of coronary blood flow on diastolic blood
pressure. This was achieved by rapid withdrawal of
IABP is the most common mechanical circulatory arterial blood from the femoral artery during systole
assistance device used in clinical practice since the last and by its re-infusion during diastole. Thus, systolic
35 years. unloading and diastolic augmentation were accom-
plished. This concept led to the development of the
Initially mechanical support was developed in intra-aortic balloon pump (IABP) by Moulopoulos et
1951 and was used for open intra-cardiac operations al.1,2
(heart-lung machine). This device could perform the
entire functions of the cardio-pulmonary system. Later, More recently, sophisticated and innovative de-
to help the patients with acute left ventricular systolic vices have been developed which are capable of deliv-
dysfunction in association with excessive preload, as- ering a greater degree of assistance to the failing left
sist pumps were devised, which work by temporary ventricle (LV) for a longer period (circulatory assist with
diversion of excess preload from the heart and its re- an auxiliary pump). These devices have a variety of
turn to the patient. This helps the failing heart to re- booster pumps that remove blood from the left heart
cover. or from the ascending aorta during systole and return it
to the aorta during diastole, thereby augmenting the di-
In 1960s, the concept of counter-pulsation was astolic blood pressure. An abdominal left ventricular
introduced. The fundamental basis of this concept was
1.SpR in Anaesthetics, Leicester Royal Infirmary, Leicester, LE5 1WW, 2. SpR in Anaesthetics, Leicester General Hospital,
Leicester, LE5 4PW, 3. Consultant Cardiothoracic Anaesthetist, Glenfield General Hospital, Leicester, LE3 1WW,
Correspondence to: Aamer B Ahmed, Consultant Cardiothoracic Anaesthetist, Glenfield General Hospital, Leicester, LE3 1WW,
Email: aamer.ahmed@uhl-tr.nhs.uk Accepted for publication on:22.5.08

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Indian Journal of Anaesthesia, August 2008

assist device (LVAD) is capable of assisting the left This review article discusses the common indica-
ventricle three to five times as much as an IABP. tions and contraindications (Table 1), the physiologic
aspects of IABP, the equipment needed to facilitate
Despite the increasing popularity of using circula- IABP, the use of the IABP in special situations and
tory assist devices with an auxiliary pump, these were complications of its use.
associated with few drawbacks - like lack of control
over the after load and the neurohormonal component, Establishing intra-aortic balloon counterpulsation
which occurs due to changes in stroke volume, asso- requires the insertion of the catheter and connecting it
ciation with trauma to blood elements and haemolysis. to the console.
But IABP offers a simple method of circulatory assist
that can achieve ventricular improvement (decrease in Balloon Pump Console (Fig 1):
preload) and increase in systolic output with significant
The drive console consists of a pressurized gas
improvement in myocardial oxygen supply/demand ra- reservoir, a monitor for ECG and pressure wave re-
tio. Today, continued improvements in IABP technol-
cording, adjustments for inflation/deflation timing and
ogy permit safer use and earlier intervention to provide
triggering selection switches. It is portable, light weight
haemodynamic support. Preoperative IABP-therapy in and has the option of mains and battery operation. There
‘high-risk’ coronary patients have been shown to re- are two types of consoles, Stationary and Portable.
duce hospital mortality and shorten ICU stay signifi-
Stationary consoles are used at the bedside and for
cantly, compared with controls. 3 These developments
short distance transport. Portable consoles are used
have made the IABP a mainstay in the management of
for long distance transfer. The gases used for inflation
ischemic and dysfunctional myocardium.
are either helium or carbon dioxide. Helium has low
Table 1 Indications and Contraindications of IABP density and rapid diffusion coefficient. However car-
Indications Contra-indications
bon dioxide has an increased solubility in blood, which
4
reduces the potential consequences of gas emboliza-
Left ventricular failure Aortic dissection
tion following a balloon rupture. A standard console
Acute myocardial infarction Severe aortic insufficiency
Cardiogenic shock Severe peripheral vascular
Refractory unstable angina disease
Failure to wean from Irreversible brain damage
cardiopulmonary bypass
High-risk PTCA 5
Failed PTCA
Thrombolytic therapy
Bridge to cardiac transplantation
Stunned myocardium
Stabilisation of high risk patients
for general anaesthesia
Low cardiac output syndrome
Others
Cardiomyopathy
Myocarditis Fig 1 Console for intra-aortic balloon counter-
Severe myocardial contusion pulsation (By permission of ARROW International,
Inc.)

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Jatin D Dedhia et al. Intra aortic balloon pump (IABP): past, present and future

comprises the following features:

• Rear panel which consists of DC input, IAB fill

and drain port, helium supply, and patient con-
nections
• Monitor which displays alarms, ECG , IAB sta-
tus, pressure source, operation mode, battery and
helium indicators,
• Key pad controls
• Recorder to record ECG, pressure and balloon
pressure waveform
• System battery which displays charge status and
portable operation
• Doppler storage facility
Fig 2 Insertion of IABP
Balloon catheters
rect placement of the IAB is in the descending aorta
Balloon catheters are presented in a sterile inser- with its tip at the distal aortic arch (below the origin of
tion kit and are disposable and single use only. Balloon the left subclavian artery).
catheters are made of polyurethane and are manufac-
tured in sizes varying from 8.5F to 10.5F. For children Doppler ankle pressures should be monitored and
sizes are available between 4.5F to 7F. The adult cath- compared with the pre-insertion value. Vascular com-
eters have a standard length of 32.5 inches. The vol- plication rates are lower after IABP insertion using
ume of the balloon is 30-40 ml in adults and 2.5-25 ml smaller sized catheter and a sheathless technique. The
in children. sheathless method of insertion should be preferred in
patients with diabetes mellitus and peripheral vascular
Insertion technique disease6,7.

The balloon catheter is placed via the femoral ar-
tery using a modified Seldinger technique. The patient
is heparinised prior to insertion of catheter providing
there are no contra-indications such as recent surgery.
After cardiac surgery patient should be given low-mo-
lecular weight dextran at 20ml.hr-1 instead of heparin.
The balloon is fully collapsed applying 30ml vacuum
with 60ml syringe. The femoral artery is punctured and
a J-shaped guide wire is inserted to the level of the
aortic arch and then the needle is removed. An 8Fr to
10.5Fr dilator/sheath combination is used to enlarge
the arterial puncture side. The balloon is threaded over
the guide wire into the descending aorta just below the
left subclavian artery (Fig 2). The sheath is pulled back
to connect with the cuff on the balloon hub. The cor-
Physiology of coronary circulation
Myocardial blood supply is from the right and left
coronary arteries. The dependence of coronary blood
flow on diastolic pressure is due to the mechanical com-
pression of coronary blood vessels within the myocar-
dium during systole. Left heart pressures are much
higher than the right side. As a result the right side of
the heart is better perfused during systole compared to
the left side. The coronary vascular bed is auto regu-
lated balancing myocardial oxygen supply and demand
(Table 2). Coronary vascular resistance is influenced
by neural, metabolic and haemodynamic factors. The
coronary arteries are innervated by the sympathetic and
parasympathetic nervous systems. Alpha receptor

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Indian Journal of Anaesthesia, August 2008

stimulation causes vasoconstriction while stimulation of

the beta-2 receptor and the vagus nerve causes va-
sodilatation. Regional perfusion is regulated by meta-
bolic factors. Several mediators such as carbon diox-
ide, adenosine, hydrogen ions, phosphate, prostaglan-
dins and potassium cause vasodilatation. When coro-
nary perfusion pressure falls to below 60 mmHg, auto
regulation is lost, the coronary vessels become maxi-
mally dilated and blood flow depends only on perfu-
sion pressure. Haemodynamic factors that affect coro-
nary perfusion include arterial pressure (diastolic pres-
sure), diastolic time and the intra-ventricular pressure.

Table 2 Determinants of myocardial oxygen supply

and demand
Oxygen Supply Oxygen Demand
Autoregulation Heart rate
Diastolic perfusion gradient Contractility
Diastolic time interval Afterload
Patency of coronary arteries Pre-load
Physiologic effects of IABP therapy:
After confirming the correct placement, the bal-
loon is connected to a drive console. The IABP is a
volume displacement device designed to provide par-
tial assistance to the left ventricle by inflation and defla-
tion of IAB catheter synchronized to the patient’s car-
diac cycle (Fig 3 ).
By deflating the balloon just prior to the ventricu-
lar systole, inertial resistance to blood flow is reduced
and left ventricular afterload falls. This results in in-
creased stroke volume and cardiac output (10-40%),
decrease in heart rate and pulmonary artery wedge
pressures.
Inflation of the balloon at the commencement of
the diastole results in increased aortic diastolic pres-
sure (up to 70%). Since diastolic blood flow is respon-
sible for 70% of cardiac perfusion, coronary and car-
diac flow should theoretically increase. There is a fall in
peak systolic arterial pressure of 5%-15%, with no
change in mean arterial pressures.
Fig 3 IABP Augmentation.
(a) The balloon is timed to inflate just after the
dicrotic notch, and deflation is triggered by
the R wave of the ECG.
(b) Large arrow indicate IAB pumping. Small
arrows indicate diastolic augmentation.
The ultimate aim is to increase myocardial oxy-
gen supply and decrease myocardial oxygen demand.
Triggering:
Inflation and deflation need to be correctly timed
to the patient’s cardiac cycle. There are seven trigger-
ing modes on the Arrow International IABP console.
a. ECG PATTERN: The height, width and slope of
a positively or negatively deflected QRS com-
plex are analysed by the IABP machine. This is
the preset (default) trigger mode.
b. ECG PEAK: The height and slope of a positively
or negatively deflected QRS complex are analysed
by the IABP machine. This is the trigger mode of
choice in wide complex rhythms.
c. A-FIB: The QRS complex is analysed in the same
manner as in the peak mode. This is the trigger
mode of choice in varying R-R intervals as in atrial
fibrillation.

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Jatin D Dedhia et al. Intra aortic balloon pump (IABP): past, present and future
d. V PACE: Ventricular signal is used as the trigger
signal. This is the trigger mode of choice in 100%
ventricular or AV paced rhythms.
e. A PACE: Atrial spike is used as the trigger signal.
This is the trigger mode of choice in 100% atrial
paced rhythms.
f. ARTERIAL PRESSURE: Systolic upstroke of the
arterial pressure waveform as the trigger signal.
This is the trigger mode of choice where ECG
signals are distorted or unavailable.
g. INTERNAL: The balloon inflates and deflates at
a preset rate regardless of the patient’s cardiac
activity. This mode is used in situations where
there is no cardiac output or ECG is unavailable.
Timing and weaning
Inflation of the IAB should occur at the beginning
of diastole, coinciding with the dicrotic notch on the
arterial waveform. Deflation of the balloon should oc-
cur immediately prior to the arterial upstroke. Balloon
synchronization starts usually at a beat ratio of 1:2.
Weaning from the IABP may begin by gradually de-
creasing the balloon augmentation ratio. It must be en-
sured that the patient has a sufficiently high platelet count
(>100 000/mm3) prior to removal. Direct pressure to
the arterial puncture site should be applied for duration
of 30 minutes after removal.
ProActive Counter Pulsation:
Fig 4 WAVE timing algorithm converts Aortic
Pressure to Aortic Flow. The lowest point of the
flow wave corresponds to the AVC event (By
permission of ARROW International, Inc.)
391
ProActive Counter Pulsation is a new IABP sys-
tem which incorporates two new and unique technolo-
gies, the WAVE timing algorithm and the ability to moni-
tor the Arterial Pressure (AP) signal from a Fibre Op-
tic Source (FOS) using the Fiber Optix™ IAB cath-
eter. WAVE is an acronym for the Windkessel Aortic
Valve Equation, which automatically sets inflation tim-
ing to occur precisely at the time of the Aortic Valve
Closure (AVC).
The WAVE algorithm converts the arterial pres-
sure (AP) waveform to understand the patient’s aortic
flow in the cardiac cycle (Fig 4). Aortic valve closure
occurs at the lowest point in the flow wave, after peak
flow occurs. Timing is set within each beat (intra-beat)
for that specific beat, as it occurs. This results in highly
accurate inflation timing, which is specific to that beat,
for that patient at that moment in time.
For setting deflation timing, during an arrhythmia
the IABP system automatically detects the irregular
pattern and sets a conservative deflation to occur while
assessing the balloon’s performance in relation to the
patient’s cardiac cycle. The combination of the WAVE
inflation timing with automatic ‘R’-Wave deflation tim-
ing results in real-time, beat to beat timing, which cor-
responds to the changes in the patient’s cardiac cycle.
The result is an improvement in the haemodynamic ef-
fect of IABP during periods of arrhythmia.
The Fiber Optix™ IAB catheter (Fig 5) incorpo-
Fig 5 Fiber Optix IAB catheter (By permission of
ARROW International, Inc.)
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Indian Journal of Anaesthesia, August 2008

rates fibre optic sensor technology into the tip of the circulation by palpating pedal pulses and documenting
IAB catheter. Once zeroed prior to insertion, it does ankle pressures on hourly basis. 10 Absent pulses after
not require any further maintenance, such as re-zeroing IAB removal may need thrombectomy. In the event of
or flush systems. It is immune to electrical interference, visceral arterial occlusion therapy is dictated by spe-
patient movement or activities that interfere with the cific end organ dysfunction. False aneurysm which are
quality of the arterial pressure signal, such as transport. generally associated with previous wound infection,
require operative repair.
AutoPilot automatically:
Balloon rupture is attributed to rough handling and
• Selects ECG and AP signal sources upon connection is recognised by failure to achieve diastolic augmenta-
• Changes ECG and AP sources as required to main- tion and by appearance of blood in balloon shaft.
tain triggering Prompt recognition of cerebral air embolism second-
ary to IABP rupture requires a high level of suspicion
• Selects trigger mode based on patient conditions such and is confirmed by CT scan of Head. 11 Treatment
as heart rate and rhythm consists of immediate discontinuation of counter pulsa-
• Selects timing method based on available signals tion, the application of suction to the balloon, placing
• Sets and adjusts timing in response to patient’s needs. the patient in Trendelenburg’s position, and IAB re-
placement. IAB entrapment is unusual sequela of bal-
Use of low molecular weight dextran and pro- loon membrane rupture and needs open removal.12
phylactic heparin will reduce the incidence of IABP Excessive advancement of balloon causes intermittent
related vascular complications, the majority of which obstruction of arch vessels. When the caudal end of
are thromboembolic in nature. Other complications are the IAB is located within the abdominal aorta, renal
listed in Table 3. and mesenteric obstruction can occur. The use of fluo-
roscopy during balloon placement and chest roentgeno-
Table 3 Complications of IABP gram should eliminate this problem.
Vascular Balloon Miscellaneous
Related Septic complications include fever, bacteremia, su-
Arterial injury Rupture Infection perficial and deep wound infection. Positive blood cul-
Aortic perforation Tear Acute hepatic failure 8
tures will guide to appropriate antibiotic therapy. Wound
infections may need surgical intervention.
Aortic dissection Perforation Entrapment
Peripheral Gas Haemorrhage Haemorrhagic complications results from bleeding
embolization embolization from insertion site or systemic anticoagulation therapy.
False aneurysm. Incorrect Sepsis Groin wound hemorrhage can often be controlled with
positioning compressive dressing. Complication due to systemic anti-
Limb ischemia Thrombocytopenia coagulation therapy consists of correcting the coagulopathy
Visceral ischemia and removing IAB. Balloon-dependent patients can be
Femoral vein cannulation adequately protected with low molecular weight dextran.

Vascular complication rates vary from 6%-24%. Haemodynamic monitoring

Patients with longer balloon duration have increased
risk of a major complication.9 Limb ischemia leads to
fasciotomy or amputation. Aortic dissection is man-
aged by balloon removal. Thromboembolic complica-
tion can be reduced by proper evaluation of peripheral
392
Haemodynamic monitoring plays an important
role in the management of patients with heart failure.
The variables which help in assessment include heart
rate, central venous pressure, arterial blood pressure,
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Jatin D Dedhia et al. Intra aortic balloon pump (IABP): past, present and future
pulmonary artery pressure, pulmonary capillary wedge
pressure and cardiac output.
Heart rate reflects cardiac performance, bearing
in mind it may also be affected by other factors. Cen-
tral arterial blood pressure such as that from the femo-
ral artery is more accurate in the presence of periph-
eral vasoconstriction. Central venous pressure (CVP)
is usually reliable in the absence of heart failure. Pul-
monary artery pressure (PAP) and pulmonary capil-
lary wedge pressure (PCWP) are very useful in the
presence of heart failure. They are measured using a
Swan-Ganz pulmonary artery flotation catheter. The
device helps to measure left and right sided filling pres-
sures and diagnose rare complications. Variations in
central venous oximetry reflect changes in cardiac out-
put in a linear fashion in the presence of stable oxygen
consumption. Cardiac output measurements are under-
taken by the thermo-dilution technique and are taken
at 6 to 8 hour intervals and at any time when the plan of
therapy or the patient condition is changed.
Data Acquisition
Data acquisition includes calculation of clinically useful
data. They are cardiac index, left to right shunt, stroke
volume, stroke index, stroke work, left ventricular stroke
work index and systemic vascular resistance. These pa-
rameters can be calculated using appropriate formulas. 13
1) Cardiac index = CI (l/min/m2) = cardiac out
put /body surface area
2) Stroke volume = SV (ml) = cardiac output /
heart rate
3) Stroke work = SW (g.m) = MAP – PCWP
CO 0.0136 HR
4) Left ventricular stroke work index = LVSWI
(g.m/m2) = SW
BSA
5) Systemic vascular resistance = SVR (dyne/sec/
cm-5) = (MAP – CVP) 80
CO
(MAP – mean arterial blood pressure, PCWP –
393
pulmonary capillary wedge pressure, CO – cardiac
output, HR – heart rate, BSA – body surface area,
CVP – central venous pressure)
Haemodynamic assessment
It may be best to position the patients horizontally
to gain the full benefits of balloon counterpulsation to the
coronary circulation. 14 The efficacy of diastolic augmen-
tation can be assessed by clinical improvement in patient’s
condition and haemodynamic parameters. Clinically, an
awake comfortable patient with reduced frequency and
severity of angina is a good sign. Other signs include a
change in skin temperature, reduction in sweating, a de-
crease in heart rate and episodes of arrhythmia, an im-
provement in urine output and the appearance of pe-
ripheral pulses. Haemodynamic parameters include a
reduction in PCWP, an increase in arterial blood pres-
sure, cardiac output and stroke work index.
Systemic management of patients on IABP
Other systems need careful attention and man-
agement in patients on IABP. These include renal, res-
piratory, haematological, nutritional and neuropsychi-
atric management. A decrease in cardiac output and
blood pressure due to cardiac failure results in decrease
in renal plasma flow and renal impairment. In high-risk
patients undergoing OPCAB (off pump coronary ar-
tery bypass), routine preoperative insertion of IABP
electively reduces the incidence of acute renal failure.
15
. Haemodialysis may be required in patients with high
potassium, uraemia, fluid overload and severe acido-
sis. Patients admitted with acute myocardial infarction
frequently have pulmonary congestion. Mechanical ven-
tilation is required for patients with respiratory failure
secondary to cardiac failure, after general anaesthesia
and cardiac or respiratory arrest.
The presence of central lines and invasive cath-
eters need antibiotic prophylaxis.16 Hyperthermia in-
creases myocardial oxygen consumption and should be
treated aggressively. Anticoagulant therapy should be
instituted in patients on IABP. Neuro-psychiatric prob-
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Indian Journal of Anaesthesia, August 2008

lems can be challenging to deal with and are usually
due to prolonged cardiopulmonary bypass. In ITU,
haloperidol is used successfully in the treatment of these
problems. In patients receiving IABP therapy for more
than 2 days nutritional support should be instituted as
soon as possible.17 Ambulation of patients should be
use of IABP has been recommended for patients with
blunt cardiac injury and overdose of certain drugs, who
fail to respond to conventional treatment. 21-22 IABP in
conjunction with cardiopulmonary resuscitation has
been shown to improve coronary perfusion pressure.
23

instituted as soon as the IABP catheter is removed.

IABP in special circumstances
Patients with impaired cardiac function are at high-
risk of developing complications when undergoing gen-
eral anaesthesia and surgery. Use of IABP support pre-
operatively for non-cardiac surgery in high-risk patients
may be useful in providing haemodynamic stability. 18-
19
IABP increases coronary blood flow and improves
tissue perfusion in patients with septic shock. 20 The
IABP therapy has been used in children with car-
diac anomalies and heart failure. IABP therapy can serve
as an alternative to ECMO- membrane oxygenators.24
Trouble shooting when using IABP
Problems may arise while using the equipment for
counterpulsation. A knowledge of the basic problem
encountered will increase efficiency in management
(Table 4).

Table 4 Trouble shooting during counterpulsation

Problem
ECG Trouble shooting
•Interference on ECG
•Intermittent ECG
•Weak ECG signal
Trigger Trouble shooting
•System does not trigger
•System triggers erratically
•System triggers every other
cardiac cycle in pressure trigger resynchronisation
Balloon Trouble shooting
•Balloon requires frequent
pre-loading
• Poor augmentation
pressure regulators
• Cannot auto-fill
Power-up Trouble shooting
•Cannot pump in portable mode Low battery charge
Causes Action
Faulty lead/electrodes Check electrode contact, replace electrode
Faulty lead/electrodes/patient cable Check electrode contact, replace electrode
Electrode position or poor quality Try alternate lead configuration. Adjust
ECG gain to increase size
ECG signal too small Increase ECG gain
Large A-pacer tails in ECG trigger Select A Pacer trigger
Demand Pacer in V/A-V mode Select ECG or pressure trigger
Pressure trigger needs Start resynchronisation
Leak in safety disc Check and replace
Loose attachment of patient balloon or fill hose Check and tighten
Leak in balloon Replace if necessary
Clogged filter, mufflers, faulty Call service representative
Leak in balloon, safety disk Check and replace
No Helium Replace Helium cylinder
Malfunction in auto-fill Use Manual fill
Recharge battery to full

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Jatin D Dedhia et al. Intra aortic balloon pump (IABP): past, present and future
Recent advances and conclusion
IABP therapy for patients with cardiovascular and
systemic conditions is currently well established. Pre-
operative intra aortic balloon pump therapy in high risk
patients has been significantly cost-beneficial. 25 In the
modern-day practice of IABP therapy, complication
rates are generally low. 26 Advances in technology have
permitted patients to be treated with greater safety and
effectiveness. Recently IABP balloon catheter which
can be used in patients irrespective of their physical
size has been developed. A long soft tip is used, which
is designed to avoid damage to blood vessels and the
catheter can be used as a multifunctional balloon cath-
eter, that allows simultaneous percutaneous coronary
intervention (PCI). The safety of this catheter has been
proven in scientific studies.27 Reports show that spe-
cially trained critical care paramedics can safely trans-
fer IABP dependant patients to definitive cardiac sur-
gical care without additional medical escorts.28 IABP
therapy will continue to have a lead role in providing
temporary mechanical cardiovascular support in near
future.
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PREPARATION OF THE MANUSCRIPT

The text of original articles should be divided into sections with the headings: Sum-
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report, Discussion, Reference, Tables and Legends in that order. Do not use subhead-
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Abstract Maximum Text Maximum No. of Maximum No.

Word Length Word Length Figures/Tables of References

Review Article 250 4000 8 90

Special Article 250 3500 5 50

Clinical Investigation 250 3000 5 30

Case Report 100 1000 3 10

Letter to Editor N/A 500 1 5

Pramila Bajaj
Editor, IJA
Email: bajajpramila@hotmail.com

396