UCTN – Unusual cases and technical notes E111 Fatal venous air embolism during upper endoscopy in a patient with percutaneous transhepatic cholangiography (PTC) catheter Venous air embolism is a rare complica- created a vasculobiliary fistula. The pres- tion of endoscopic procedures reported ence of a widely patent hepaticojejunos- with colonoscopy, esophagogastroduode- tomy, blind intestinal limb, and air insuf- noscopy, endoscopic ultrasound with fine flation created a pressure gradient allow- needle aspiration and endoscopic retro- ing air flow into the venous circulation. grade cholangiography with sphincterot- The fluoroscopic images confirmed air – omy [1 5]. We report a case of a fatal within the hepatic veins and inferior Fig. 1 Endoscope advanced through the venous air embolism during upper endos- vena cava (●" Fig. 2). General endotracheal afferent limb to the hepaticojejunostomy. copy in a patient with prior pancreatico- anesthesia and close monitoring of endo- duodenectomy and recent percutaneous tracheal carbon dioxide in patients with transhepatic cholangiography (PTC) cath- known risk factors may improve clinical eter placement. outcomes. A 52-year-old man underwent pancreati- coduodenectomy for pancreatic adeno- Endoscopy_UCTN_Code_CPL_1AH_2AB carcinoma and PTC catheter placement Endoscopy_UCTN_Code_CPL_1AK_2AH for ascending cholangitis. An upper en- doscopy under fluoroscopy was per- C. B. Meier1, A. J. Moser2, M. K. Sanders3 formed after the patient developed mele- 1 University of Colorado Health Sciences na. The endoscope was advanced to the Center – Gastroenterology, Hepatology, hepaticojejunostomy (●" Fig. 1), when the Aurora, Colorado, USA patient suddenly became hypoxic, brady- 2 Department of Surgery, University of cardic, and developed pulseless electrical Pittsburgh Medical Center, Pittsburgh, activity. Despite prolonged cardiopul- Pennsylvania, USA monary resuscitation, the patient expired. 3 Division of Gastroenterology, Hepa- Fig. 2 Venous air embolism. An autopsy was declined by the family, tology, and Nutrition, University of however, review of the intraprocedural Pittsburgh Medical Center, Pittsburgh, fluoroscopic images revealed an air veno- Pennsylvania, USA 9 Katzgraber F, Glenewinkel F, Rittner C, Beule J. gram, consistent with a fatal venous air Fatal air embolism from gastroscopy [letter]. Lancet 1995; 346: 1714– 1715 embolism (●" Fig. 2). References 10 Barthet M, Membrini P, Bernard J-P, Sahel J. 1 Huycke A, Moeller DD. Hepatic portal venous Occurrence of venous air embolism during Hepatic portal venous gas after endoscopic gas after colonoscopy in granulomatous co- endoscopy requires communication be- biliary sphincterotomy. Gastrointest Endosc litis. Am J Gastroenterol 1985; 80: 637– 638 tween the air source and vasculature as 1994; 40: 261– 263 2 Akhtar N, Jafri W, Mozaffar T. Cerebral artery 11 Lowdon Jd, Tidmore TL. Fatal air embolism well as a pressure gradient favoring pas- air embolism following an esophagogastros- after gastrointestinal endoscopy. Anesthe- sage of air into the venous circulation. Air copy: a case report. Neurology 2001; 56: siology 1988; 69: 622– 623 136– 137 usually enters through a mucosal defect or 12 Desmond PV, MacMahon RA. Fatal air embo- 3 Patel RT, Deen KI, Fielding JW. Portal pyaemia vasculoenteric fistula, aided by positive lism following endoscopy of a hepatic por- following flexible sigmoidoscopy. Br J Surg toenterostomy [letter]. Endoscopy 1990; pressure from insufflation. Clinical mani- 1995; 82: 422– 423 22: 236 festations include sudden decrease in 4 Pfaffenbach B, Wegener M, Bohmeke T. He- end-tidal carbon dioxide or oxygen satura- patic portal venous gas after transgastric This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. tion, cyanosis, hypotension, bradycardia or EUS-guided fine-needle aspiration of an ac- Bibliography cessory spleen. Gastrointest Endosc 1996; DOI 10.1055/s-0029-1243942 tachycardia, and a mill-wheel murmur. 43: 515– 518 Endoscopy 2010; 42: E111 Initial management consists of provision 5 Kennedy C, Larvin M, Linsell J. Fatal hepatic © Georg Thieme Verlag KG Stuttgart · New York · of high-flow oxygen, Trendelenburg posi- air embolism following ERCP. Gastrointest ISSN 0013-726X tion, and insertion of a central venous Endosc 1997; 45: 187– 188 6 Demaerel P, Gevers AM, De Bruecker Y et al. catheter for aspiration of gas bubbles. Corresponding author Stroke caused by cerebral air embolism dur- Although venous air embolism may occur C. B. Meier ing endoscopy. Gastrointest Endosc 2003; – in patients without risk factors [6,7], dis- 57: 134– 135 University of Colorado Health Sciences Center ruption of mucosal barriers (ulcerations, 7 Chorost MI, Wu JT, Webb H, Ghosh BC. Verte- Gastroenterology, Hepatology trauma, dilation, sphincterotomy), pres- bral venous air embolism: an unusual com- 12631 East 17th Avenue MS B158 Aurora ence of blind intestinal limbs (hepaticoje- plication following colonoscopy: report of a case. Dis Colon Rectum 2003; 46: 1138 – Colorado 80045 junostomy), and bowel directly apposed 1140 USA to venous structures (varices) are known 8 Huycke A, Moeller DD. Hepatic portal venous +1-720-848-2756 risk factors [8–12]. In the present patient, gas after colonoscopy in granulomatous co- [email protected] placement of the PTC catheter probably litis. Am J Gastroenterol 1985; 80: 637– 638 Meier CB et al. Fatal venous air embolism during upper endoscopy… Endoscopy 2010; 42: E111.