Hemodynamic Instability Induced by Superselective Angiography of the Ophthalmic Artery

Retinoblastoma is one of the most common ophthalmic neoplasms affecting children worldwide. Since its recent introduction, superselective ophthalmic artery injection of chemotherapy with melphalan has significantly reduced the need for enucleation in patients with advanced disease and also shown to have minimal adverse effects on visual acuity as compared to the conventional therapy. Although no severe complications resulting in strokes or deaths have been reported, this treatment modality is not without difficulties. In this case discussion, we describe an event that has occurred to several pediatric patients undergoing superselective angiography of the ophthalmic artery that may be due to an oculopulmonary type reflex causing significant hemodynamic instability and hypoxemia. 1. Introduction Intra-arterial chemotherapy infusion of the ophthalmic artery is a relatively new endovascular procedure for the treatment of retinoblastoma and is always performed under general anesthesia [1, 2]. We describe a cardiovascular reflex in the pediatric retinoblastoma population during superselective angiography of the ophthalmic artery. 2. Case Presentation This is an account of a typical response noted in multiple cases. A two-year-old boy was diagnosed with retinoblastoma involving the right eye. Following consultation with the pediatric oncology and ophthalmology oncology services, the patient was referred for intra-arterial chemotherapy infusion of Melphalan to the right ophthalmic artery. General anesthesia was induced with Propofol 3？mg/kg, Midazolam 0.2？mg/kg, and Rocuronium 0.6？mg/kg. After induction, the patient was successfully intubated with a 4.5 cuffed endotracheal tube and pressure controlled ventilation was initiated. Sevoflurane (1.6？Vol%), oxygen (0.5？L/min), and air (1.5？L/min) were administered for maintenance of general anesthesia. Femoral access was obtained and a 4-French sheath was placed and perfused with heparinized saline. A 4-French Terumo angle glide catheter was navigated to the right internal carotid where cerebral angiograms were obtained. Under magnified roadmap guidance, a microcatheter was navigated into distal supraclinoid carotid. The microwire was withdrawn into the lumen of the microcatheter, and the microcatheter was slowly withdrawn within the carotid, thus selecting the ostium of the ophthalmic artery. Superselective angiography was performed demonstrating successful ophthalmic catheterization. Two minutes later, the patient’s end tidal CO2 (EtCO2) decreased from 35？mmHg to 21？mmHg (normal 33–40？mmHg) followed by a subsequent