Igor Areinamo, MD. FAAP
Assistant Professor of Pediatrics/Cardiac Critical Care
University of Texas, Austin
Austin, Texas, United States
Disclosure information not submitted.
Jenna Miller, MD
Associate Professor of Pediatrics
Children's Mercy Hospital, United States
Disclosure information not submitted.
Jay Rilinger, MD
Assistant Professor of Pediatrics
Children's Mercy Hospital Kansas City, United States
Disclosure information not submitted.
Marita Thompson, MD
Associate Professor of Pediatrics
University of Missouri Kansas City School of Medicine, United States
Disclosure information not submitted.
Title: Pediatric Pulmonary Artery Aneurysms causing Pulmonary Hemorrhage while on VA ECMO Support
Introduction: The incidence of pulmonary artery aneurysm (PAA) in children remains unknown. Management of PAAs while on VA ECMO has not been described in pediatrics. We share a less invasive management approach to be considered for this type of pathology.
Description: A 9-year-old previously healthy male who presented with florid Multi Drug Resistant Staphylococcus Aureus associated Acute Respiratory Distress Syndrome and sepsis. He had a recent leg injury from a bicycle accident and right femoral venous thrombosis identified while admitted to an outside hospital for two days. He presented to our institution on high dose inotropes and desaturated on maximal conventional ventilator settings. He was cannulated for VA ECMO via the right neck. Chest CT on ECMO day 22 showed right sided PAAs. He had an episode of life threatening pulmonary hemorrhage and an angiogram demonstrated two right PAAs with active parenchymal bleeding. Given that he was fully anticoagulated, the risk of bleeding during a possible surgical resection was considered to be too high for which the decision to proceed with a catheter-based intervention was made. He underwent occlusion of the aneurysms with Amplatzer® devices in the catheterization lab while on VA ECMO. Intervention was complicated by flail tricuspid valve. He then was able to separate from ECMO and ultimately discharged without neurologic or respiratory deficits.
Discussion: Our report demonstrates the feasibility of a percutaneous interventional procedure to address life-threatening PAAs while on VA ECMO. While there was concern for devices becoming infected and for cessation of pulmonary blood flow to the right lower lobe, these risks were deemed acceptable in the face of a life-threatening hemorrhage. Vascular occlusion devices can be considered an approach for pediatric patients with this rare complication and coils or other vascular occlusion devices could be used in smaller lesions. Successful management of these complex patients requires an organized multidisciplinary approach.