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LETTERS TO EDITOR
Year : 2020  |  Volume : 21  |  Issue : 1  |  Page : 75-77
 

Pulmonary embolization of high-flow massive peripheral arteriovenous malformation with isobutyl-2-cyanoacrylate glue


Department of Anaesthesiology, M. S. Ramaiah Medical College, Bengaluru, Karnataka, India

Date of Submission12-Sep-2019
Date of Decision31-Oct-2019
Date of Acceptance20-Nov-2019
Date of Web Publication13-Feb-2020

Correspondence Address:
Dr. K B Nalini
No. 20, Tiru Nivas, Lottegollahally, R M V 2nd Stage, Bengaluru - 560 094, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/TheIAForum.TheIAForum_68_19

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How to cite this article:
Jayaprakash S, Nalini K B, Kandasamy P, Nagaraj MC. Pulmonary embolization of high-flow massive peripheral arteriovenous malformation with isobutyl-2-cyanoacrylate glue. Indian Anaesth Forum 2020;21:75-7

How to cite this URL:
Jayaprakash S, Nalini K B, Kandasamy P, Nagaraj MC. Pulmonary embolization of high-flow massive peripheral arteriovenous malformation with isobutyl-2-cyanoacrylate glue. Indian Anaesth Forum [serial online] 2020 [cited 2020 Jul 5];21:75-7. Available from: http://www.theiaforum.org/text.asp?2020/21/1/75/278188




Sir,

Vascular malformations can be arterial, venous, lymphatic, or a combination of these.[1] Arteriovenous malformations (AVMs) may involve any vascular bed of the body, and the mainstay of the treatment is embolization.

A 7-year-old girl weighing 11 kg with multiple peripheral AVMs in the left lower limb and groin [Figure 1] was scheduled for angioembolization. She had previously undergone angioembolization of the same feeding vessels under general anesthesia which was uneventful. The child was malnourished with hemoglobin of 8 mg/dl and had hyperdynamic circulation, palpable thrill, and continuous machinery murmur in the left lower limb. The echocardiogram revealed cardiomegaly, good biventricular function, and sinus tachycardia.
Figure 1: Massive angiofibroma

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Angioembolization was planned under general anesthesia after the parents' consent. In the catheterization laboratory, after connecting electrocardiography, pulse oximetry, noninvasive blood pressure, and end-tidal CO2, the patient was induced with fentanyl 2 μg/kg and propofol 2 mg/kg through a 20-Gauge cannula. The trachea was intubated with a 5.5-mm cuffed endotracheal tube after paralyzing with atracurium 0.5 mg/kg and was connected to ventilator. The anesthesia was maintained with sevoflurane 2% in 50:50 oxygen and air.

Angioembolization of the feeding vessel was done with 2 ml of isobutyl-2-cyanoacrylate (IBCA) glue diluted in 5 ml of lipiodol. Vaso-occlusive coils were used for the angioembolization by the interventional radiologist through the right femoral artery. At the end of 1 h of the procedure, when the guidewire was pulled out, the child developed sudden bradycardia to 20–30/min from 130–140/min. Atropine 0.02 mg/kg was administered. Carotid pulse was not felt. Chest compressions were given for over a minute and adrenaline 1 mg was given. Consequently, the heart rate picked up to 120–130/min and the right femoral invasive blood pressure to 118/70 mmHg.

This case was discussed with a cardiologist and the complication was suspected to be glue induced pulmonary embolism (PE) or vasovagal stimulation; hence, it was decided to electively ventilate the child in the pediatric intensive care unit, but after about 45 min, the child once again developed bradycardia followed by asystole. Cardiopulmonary resuscitation was initiated. However, despite all the measures, the child could not be revived.

There are several embolic agents available for endovascular treatment of peripheral AVMs such as ethanol, IBCA, polyvinyl alcohol particles, ethylene vinyl alcohol copolymer (Onyx), and endovascular coils.[2] IBCA is a liquid-casting adhesive agent generally considered to be safer than ethanol. It is preferred in large AVMs or in the pediatric population where ethanol dosing needs to be limited. To minimize premature polymerization, IBCA is usually diluted with nonionic solvent (lipiodol) and the catheter flushed with 5% dextrose solution. PE may result from these particulate materials, especially during the embolization of massive AVM lesions containing large fistulae.[3] Inferior vena cava filter has an effective role in preventing PE in these patients who are at a potentially high risk of PE.[4]

Acknowledgment

We would like to thank our radiologist, Dr. Pannag Desai at M S Ramaiah Medical College, India, for his valuable suggestions.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Saleh O, Baluch A, Kaye AJ, Kaye A. Arteriovenous malformation, complications, and perioperative anesthetic management. Middle East J Anaesthesiol 2008;19:737-56.  Back to cited text no. 1
    
2.
Srinivasan KG, Vidyadharan R, Patel N, Khan A, McCafferty I, Monaghan A, et al. Embolisation of high flow extracranial/peripheral arteriovenous malformations (AVMs) with ethylene vinyl alcohol copolymer (ONYX®) in children – Birmingham children's hospital experience. Eur J Plast Surg 2014;37:129-34.  Back to cited text no. 2
    
3.
Hwang SS, Kim HH, Park SH, Kim SE, Jung JI, Ahn BY, et al. N-butyl-2-cyanoacrylate pulmonary embolism after endoscopic injection sclerotherapy for gastric variceal bleeding. J Comput Assist Tomogr 2001;25:16-22.  Back to cited text no. 3
    
4.
Mismetti P, Laporte S, Pellerin O, Ennezat PV, Couturaud F, Elias A, et al. Effect of a retrievable inferior vena cava filter plus anticoagulation vs. anticoagulation alone on risk of recurrent pulmonary embolism: A randomized clinical trial. JAMA 2015;313:1627-35.  Back to cited text no. 4
    


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