NM-321
Anesthetic Management of Endovascular Embolization of a Mycotic Aneurysm in a patient with Hypoplastic Left Heart Syndrome
1Davanzo md L, 2Blasiole md phd B
1University of Pittsburgh Medical Center, Pittsburgh, Pennsylvan, United states of america; 2Children's Hospital of Pittsburgh, Sewickley, Pennsylvan, United states
We report a case of a two-year-old male with a history of hypoplastic left heart syndrome status post bi-directional Glenn procedure who developed a mycotic aneurysm in the basilar artery and underwent Pipeline embolization. The patient presented to the hospital with emesis and behavioral changes while 10 days into a 28-day course of ceftriaxaone and lovenox for Gemella endocarditis. Imaging studies demonstrated non-occlusive cerebral basilar artery thrombosis. Serial imaging over the next 5 days revealed new Subarachnoid Hemorrhage (SAH) with increased ventricular size and interval development of a basilar apex aneurysm, likely consistent with a mycotic aneurysm in the context of recent endocarditis. Ultimately there was rapid progression of the aneurysm and treatment options were considered. Given the high risk of morbidity and mortality associated with an open aneurysm repair, the decision was made to attempt an endovascular repair. The Pipeline Embolization Device (PED) is currently approved for patients twenty-two years and older,1 however there are a paucity of case reports of use of the PED in the pediatric population. Interestingly, there are no case reports describing the anesthetic management of the PED placement for cerebral aneurysm in a patient with complex congenital heart disease, specifically bi-directional Glenn physiology.
In anticipation of significant SAH from the planned endovascular intervention, an elective External Ventricular Drain (EVD) was placed and clamped. The patient was taken to the interventional radiology suite where an arterial line was placed for hemodynamic monitoring and repeated blood gas measurements. Anesthesia was induced with propofol and rocuronium, and maintained with isolflurane and air, Special attention was given to ventilation strategies with a focus on management of pH and PaCO2 and their effects on balancing pulmonary vascular resistance and cerebral perfusion pressure. The PED was successfully placed across the left P1 segment to the upper basilar artery with resultant stagnant flow in the aneurysm. The patient was extubated immediately following the procedure. The patient’s neurologic exam remained unchanged and repeat imaging revealed decreased size of aneurysm. . Ultimately the EVD was removed and the patient was discharged in stable condition.
Patients with congenital heart disease (CHD) undergoing non-cardiac surgery are at an increased risk for complications under anesthesia compared with patients without CHD.2 The goal of this case report is to review the physiology of the cavo-pulmonary anastomosis and the anesthetic implications for non-cardiac surgery, to discuss the anesthetic management of endovascular repair of an intracerebral aneurysm, and to specifically discuss the unique anesthetic considerations in a patient with bi-directional Glenn physiology undergoing Pipeline Embolization of cerebral aneurysm.
1 Medtronic. “Pipeline Flex Embolization Device | Medtronic.†Hemorrhagic Stroke Devices - Pipeline Flex | Medtronic, Medtronic, 1 Jan. 2017,
2 Brown, M. L., DiNardo, J. A. and Odegard, K. C. (2015), Patients with single ventricle physiology undergoing noncardiac surgery are at high risk for adverse events. Paediatr Anaesth, 25: 846–851.
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