Rapid cardiac ventricular pacing to facilitate embolization of vein of Galen malformations: technical note

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OBJECTIVE

Vein of Galen aneurysmal malformations (VGAMs) in infancy have a poor natural history if left untreated. Their high-flow nature can preclude safe and accurate therapeutic vessel occlusion and the risk of inadvertent pulmonary embolism is predominant. The authors describe the technique of rapid cardiac ventricular pacing for inducing transient hypotension to facilitate the controlled embolization of VGAMs.

METHODS

Initial transjugular venous access was obtained for placing temporary pacing leads for rapid cardiac ventricular pacing immediately prior to embolization. Definitive transarterial embolization procedures for the VGAMs were then performed in the same setting in which liquid embolic agents or coils were used.

RESULTS

Beginning in 2010, a total of five procedures were performed in three infants. Transvenous rapid cardiac ventricular pacing was successfully achieved to induce systemic transient flow arrest in all but two attempts, and facilitated partial embolization with n-butyl cyanoacrylate (n-BCA) and coils in all procedures. Ventricular fibrillation occurred twice in one patient and was successfully reversed with defibrillation on both occasions. One patient failed to improve and died from refractory heart failure. Two patients stabilized following staged embolization.

CONCLUSIONS

Rapid transvenous cardiac ventricular pacing can be considered to induce transient hypotension and facilitate controlled embolization in challenging high-flow VGAMs.

ABBREVIATIONS AVM = arteriovenous malformation; MAP = mean arterial pressure; n-BCA = n-butyl cyanoacrylate; NICU = neonatal intensive care unit; RVOT = right ventricle outflow tract; VGAM = vein of Galen aneurysmal malformation.

Article Information

Correspondence John H. Wong: Foothills Medical Centre, Calgary, AB, Canada. jwong@ucalgary.ca.

INCLUDE WHEN CITING Published online October 5, 2018; DOI: 10.3171/2018.7.PEDS1852.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Frontal spot film obtained during fluoroscopy demonstrating the tip of the fixed pacing wire (arrow) at the expected location of the RVOT.

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    Electrocardiography tracings demonstrating baseline tracing with onset of rapid pacing (A) and sustained capture during embolization (B) followed by return to spontaneous rhythm following cessation of pacing (C). In case 2 ventricular fibrillation occurred following cessation of rapid pacing (D).

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    Case 2. First embolization procedure in 10-day-old neonate with type IV Yaşargil VGAM. Anteroposterior (A) and lateral (B) projections of a right internal carotid artery injection showed a high-flow arteriovenous fistula ultimately draining into a dilated vein of Galen. After institution of rapid cardiac ventricular pacing, n-BCA material was injected into the distal right anterior choroidal artery feeding the fistula, in a controlled manner, as seen in the anteroposterior (C) and lateral projections (D). After 2 additional embolizations of arterial feeders, final right internal carotid artery injection anteroposterior (E) and lateral (F) projections showed decreased flow into the fistula.

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