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Anesthetic management for transcatheter coil embolization in a parturient with hereditary hemorrhagic telangiectasia (HHT)
Abstract Number: T-08
Abstract Type: Case Report/Case Series
HHT is an uncommon genetic condition characterized by epistaxis, telangiectasias and arteriovenous malformations (AVMs) of various vascular beds. We present the anesthetic management of a parturient undergoing transcatheter coil embolization of several pulmonary AVMs.
Case report: 23yo, G4P2Ab2 at 23 weeks gestation presented with worsening dyspnea and poor exercise tolerance. After having an ischemic CVA, she was recently diagnosed with HHT with multiple pulmonary AVMs and a PFO. Upon admission her room air (RA) SpO2 was 91% sitting and 96% supine. After placing venous and arterial lines, standard ASA monitors and noninvasive cardiac output (CO) monitor (ICON™, Osypka medical) were applied. Oxygen was delivered by face mask and moderate sedation was achieved with 1mg of midazolam and dexmedetomidine infusion at 0.2-0.4 mcg/kg/h. Phenylephrine infusion was titrated to keep MAP >70mmHg. CO ranged from 4.1-5.3 L/min. Pulmonary MAP was 20mmHg and the pressure inside the largest AVM was 23/15mmHg. The procedure was staged due to concerns of excessive radiation and contrast exposure to fetus, with a 2nd procedure 4 weeks later. A similar anesthetic was used except CO was measured with Nexfin™ (Edwards Lifesciences) and moderate sedation was achieved with dexmedetomidine 0.4-0.8 mcg/kg/h. CO ranged from 4.3-7.2 L/min. Initial RA ABG showed PO2 of 79.9mmHg and post procedure RA PO2 was 87.7mmHg. Patient’s symptoms improved and she delivered at 38 weeks via cesarean section.
Discussion: The increased blood volume and CO that accompanies pregnancy may predispose parturients to deterioration in the setting of PAVMs. Additionally, high progesterone and increased venous distensibility may further worsen the clinical picture. Potentially lethal complications such as hemorrhage may occur, requiring emergent surgical treatment. Also, the hypercoagulable state of pregnancy increases risk of thrombus formation with subsequent pulmonary embolism or paradoxical emboli. Symptomatic PAVM during pregnancy can be managed successfully using transcatheter coil or balloon embolization, which usually resolve hypoxemia and high-output cardiac failure. The procedure can be done under local anesthesia however our patient requested sedation. Dexmedetomidine was chosen because of its analgesic and sedative properties with minimal respiratory depression. Avoidance of general anesthesia was preferred due to risk of increased pulmonary shunt with positive pressure ventilation. Limited literature is available on the anesthetic management of HHT in pregnancy. Most of the case reports discuss anesthesia for delivery, where regional anesthesia is preferable.
References: Anesth Analg 1990;71:96-9. Int J Obstet Anesth 2009;18:176-81. Chest 2001;119(2):470-7. Respir Care 2012;57(11):1967-9