SCLEROTHERAPY OR SCLERODISTRESS? ARDS CAUSED BY SCLEROSING AGENTS USED FOR ROUTINE ARTERO-VENOUS MALFORMATION (AVM) EMBOLIZATION

Abstract

SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: AVM embolization is a routine outpatient procedure believed to have minimal risks. While local complications have been described, including bleeding, nerve injury, and skin necrosis, it is important that we keep in mind that major, sometimes catastrophic complications could arise. Here we present a case of ARDS that developed in a patient undergoing routine outpatient embolization of an upper extremity AVM. CASE PRESENTATION: A 50-year-old male presented to the outpatient suite for an elective angiography and embolization of his left forearm AV malformation that was symptomatic. His past medical history was significant for HIV (Last CD4 of 278 on Triumeq), ESRD previously on hemodialysis now status post a renal transplant, hypertension. A successful embolization was carried out with ethanol, sodium tetradecyl sulfate, and coils, following which the patient was transferred to the PACU. Approximately one-hour post-procedure, he was noted to have increased work of breathing requiring to be placed on BiPAP with a chest X-ray done at the time revealing bilateral interstitial infiltrates. Given further deterioration within the next hour, the patient was intubated and transferred to the ICU, with an initial PaO2: FiO2 ratio of <100. Given this severity, he was started on lung-protective strategy, paralyzed, placed prone, and given inhaled epoprostenol. He remained intubated for a total of nine days and discharged fourteen days after his procedure. Of note, his course was complicated by methicillin-resistant staphylococcus aureus (MRSA) which grew in his bronchial brush done 24 hours post-intubation, for which he was treated with Linezolid. His renal function significantly deteriorated requiring several sessions of hemodialysis while hospitalized. DISCUSSION: This case report attempts to identify ARDS caused in the setting of sclerosing agents. Although this patient did grow MRSA in his bronchial brush, he was documented to be completely symptom-free, afebrile, and without a white count on arrival for the procedure. Moreover, the temporal association between the embolization and respiratory collapse points us to the main inciting factor in his case. Ethanol and sodium tetradecyl sulfate are among the most commonly used sclerosing agents for AVM and esophageal varices. The risk is the escape of these agents into the systemic circulation. A study done injecting these agents intravenously in sheep showed an immediate severe fall in respiratory compliance and arterial oxygen tension, with the proposed mechanism of action being increased microvascular permeability causing alveolar damage and destruction of the blood-gas barrier of the lung.1 CONCLUSIONS: Further studies are needed to determine the extent and prevalence of major complications involved with routinely used sclerosing agents, risk factors contributing to these if any, so as to enable patients and providers to make an informed decision. Reference #1: Vallgren S, Sigurdsson GH, Moberger G, Christenson JT. Influence of intravenous injection of sclerosing agents on the respiratory function. Acta Chir Scand. 1988;154(4):271-276. DISCLOSURES: No relevant relationships by Jojo Alunilkummannil, source=Web Response No relevant relationships by Shireen George, source=Web Response No relevant relationships by Tariq Sallam, source=Web Response