Use of the Valsalva Maneuver in Addition to Controlled Hypotension During Endovascular AVM Embolization: A Novel Approach to Reducing Distal Particle Embolization?

Abstract

Study Objective: To report the use of a sustained Valsalva maneuver during deliberate hypotension in order to reduce the incidence of distal particle embolization during the neuroangiographic embolization of intracranial arteriovenous malformations (AVMs). Design: Retrospective case series. Patients: 54 cases were studied involving 46 unique patients (20 male, 26 female) seen between January 1, 2007 and December 31, 2008. All patients were ASA class II-III and were undergoing neuroangiographically-assisted embolization for intracranial AVMs. Intervention: Immediately prior to the injection of the embolic substance, each patient received a dose of nitroglycerin to lower their systolic blood pressure from baseline (112-146 mm Hg) to a target of 55 mm Hg. Next, mechanical ventilation was suspended and manual pressure was applied to the ventilation bag of the anesthesia circuit to maintain a constant airway pressure of 20 cm H2O. This simulated Valsalva maneuver was maintained for 15 seconds after the injection of the embolic material, at which point mechanical ventilation was resumed. Main Results: All patients tolerated the deliberate hypotension/Valsalva protocol well. 2 patients experienced a rupture of the AVM during the procedure. Conclusions: The distal embolization of the embolic material during intracranial AVM embolization is a potentially fatal complication of this procedure. Although our results represent a small case series, they suggest that the use of deliberate arterial hypotension in addition to a simulated Valsalva maneuver may enhance the safety and efficacy of intracranial AVM embolization. Further study, with rigorous control standards and monitoring, is warranted.