Recurrent Bronchospasm During Intra-arterial Chemotherapy via IMAX Access for Retinoblastoma: A Case Report

Intra-arterial chemotherapy (IAC) has become an increasingly popular approach for treating advanced retinoblastoma. It offers targeted drug delivery and reduced systemic toxicity when compared to systemic chemotherapy. Respiratory complications are rare, but this case presents a patient who experienced recurrent episodes of intraoperative bronchospasm possibly linked to an anatomical variation. A six-month-old female with Group D retinoblastoma in her right eye underwent five cycles of IAC within six months of diagnosis. Due to failed visualization of the right ophthalmic artery during angiography, all infusions were delivered through the anastomosis of the internal maxillary artery (IMAX) with the ophthalmic circulation. The patient experienced intraoperative bronchospasm during the first, second, and fifth cycles, each time occurring after chemotherapy administration. Each episode presented with oxygen desaturation, increased airway pressures, and diminished breath sounds and was resolved with epinephrine and albuterol. No mechanical airway issues or systemic allergic responses were present, and cycles 3 and 4 proceeded without bronchospasms. Intraoperative bronchospasm during pediatric IAC has been rarely reported and remains poorly understood. This case adds to the body of literature describing severe and sometimes repeat, respiratory complications in IAC. Additionally, in our patient, drug delivery was always via an alternate route through the IMAX. The IMAX lies adjacent to branches of the trigeminal nerve path. We hypothesize that the pulsatile IAC administration near these sensory centers may have triggered a trigeminocardiac reflex, resulting in parasympathetic activation, bronchospasm, and bradycardia. This highlights a risk of IAC and the importance of perioperative preparedness when standard access is not possible during ophthalmic IAC, especially for patients with anatomic variations.