Air embolism as a rare complication of lung biopsy: A case report

Lung biopsy is an important interventional radiology procedure allowing the characterization of lesions with suspected malignancy. The most frequent complications are pneumothorax and hemorrhage. Air embolism is a rare but potentially fatal occurrence. In this case report, we present an air embolism after core needle CT-guided biopsy showing CT and MRI features that radiologists should expect in the everyday clinical practice.

Venous air emboli during esophagoscopy confirmed by computed tomographic pulmonary angiography -a case report

BACKGROUND

Esophagogastroduodenoscopy (EGD) is vital for the diagnosis and treatment of various gastrointestinal conditions but carries a low risk of venous air embolism (VAE). We report a case of VAE during EGD, confirmed by computed tomographic pulmonary angiography (CTPA).

CASE

A 56-year-old male with a history of hypopharyngeal cancer underwent EGD for dysphagia-related esophageal dilation. Signs of VAE were noted, prompting swift interventions, including oxygen therapy, positional changes, and CTPA. CTPA revealed the Mercedes-Benz sign, pneumomediastinum, and a minimal pneumothorax. The patient's oxygen saturation improved within 30 min before undergoing CTPA, and he was discharged on postoperative day 4.

CONCLUSIONS

Timely recognition of VAE, resulting in appropriate interventions supported by CTPA, resulted in favorable patient outcomes.

Secondary deterioration in a patient with cerebral and coronary arterial gas embolism after brief symptom resolution: a case report

Introduction

Hyperbaric oxygen treatment (HBOT) is recommended for arterial gas embolism (AGE) with severe symptoms. However, once symptoms subside, there may be a dilemma to treat or not.

Case presentation

A 71-year-old man was noted to have a mass shadow in his left lung, and a transbronchial biopsy was performed with sedation. Flumazenil was intravenously administered at the end of the procedure. However, the patient remained comatose and developed bradycardia, hypotension, and ST-segment elevation in lead II. Although the ST changes spontaneously resolved, the patient had prolonged disorientation. Whole- body computed tomography revealed several black rounded lucencies in the left ventricle and brain, confirming AGE. The patient received oxygen and remained supine. His neurological symptoms gradually improved but worsened again, necessitating HBOT. HBOT was performed seven times, after which neurological symptoms resolved almost completely.

Conclusions

AGE can secondarily deteriorate after symptoms have subsided. We recommend that HBOT be performed promptly once severe symptoms appear, even if they resolve spontaneously.

Acute Coronary Artery Air Embolism Complicating a CT-guided percutaneous lung biopsy: A case report

Systemic air embolism is a fatal complication of computed tomography-guided percutaneous lung biopsy. Here, we report a case of acute coronary artery air embolism following computed tomography (CT) guided percutaneous lung biopsy. The patient exhibited cardiac symptoms, and CT showed air density in left ventricle and aorta, indicating air embolism. Trendelenburg positioning and coronary angiography were performed during the treatment, and the patient was discharged without obvious complications.

Air Embolism-Induced Ischemic Stroke Following Orthognathic Surgery in a Patient With Goldenhar Syndrome

Goldenhar syndrome, a rare congenital anomaly, manifests as craniofacial malformations often necessitating intricate surgical interventions. These procedures, though crucial, can expose patients to diverse postoperative complications, including hemorrhage or infection. A noteworthy complication is stroke, potentially linked to air embolism or local surgical trauma. We highlight a case of a male patient, aged 20 years, who experienced a significant postoperative complication of an ischemic stroke, theorized to be due to an air embolism, after undergoing orthognathic procedures for Goldenhar syndrome. The patient was subjected to LeFort I maxillary osteotomy, bilateral sagittal split ramus osteotomy of the mandible, and anterior iliac crest bone grafting to the right maxilla. He suffered an acute ischemic stroke in the left thalamus post-surgery, theorized to stem from an air embolism. Advanced imaging demonstrated air pockets within the cavernous sinus, a rare and concerning finding suggestive of potential air embolism. This case underscores the intricate challenges in treating Goldenhar syndrome patients and the rare but significant risk of stroke due to air embolism or surgical trauma. Limited literature on managing air embolism complications specific to Goldenhar syndrome surgeries exists. Generally, management includes immediate recognition, positional adjustments, air aspiration via central venous catheters, hyperbaric oxygen therapy, hemodynamic support, and high-flow oxygen administration to expedite air resorption. Our patient was conservatively managed post-surgery, and at a 3-month neurology follow-up, he showed significant improvement with only residual right arm weakness. It emphasizes the imperative of a comprehensive, multidisciplinary approach.

An unexpected complication: Air embolism during contrast-enhanced computed tomography

Air embolism is often an iatrogenic complication that may occur in venous or arterial circulation depending on the port of entry. We present a case of a 40-year-old female who had a venous air embolism in the pulmonary artery as a consequence of the injection of a contrast agent. She experienced dyspnea and chest pain following a contrast-enhanced chest computed tomography imaging. She was successfully treated and discharged from our hospital. Early detection of this clinical condition is essential to prevent morbidity and mortality.

Intraoperative vascular air embolism and intracardiac thrombosis complicating liver transplantation: a case report

BACKGROUND

Intracardiac thrombus and vascular air embolism represent rare complications in the context of orthotopic liver transplantation. While isolated reports exist for intracardiac thrombus and vascular air embolism during orthotopic liver transplantation, this report presents the first documentation of their simultaneous occurrence in this surgical setting.

CASE PRESENTATION

This case report outlines the clinical course of a 60-year-old white female patient with end-stage liver disease complicated by portal hypertension, ascites, and hepatocellular carcinoma. The patient underwent orthotopic liver transplantation and encountered concurrent intraoperative complications involving intracardiac thrombus and vascular air embolism. Transesophageal echocardiography revealed the presence of air in the left ventricle and a thrombus in the right atrium and ventricle. Successful management ensued, incorporating hemodynamic support, anticoagulation, and thrombolytic therapy, culminating in the patient's discharge after a week.

CONCLUSIONS

This report highlights the potential for simultaneous intraoperative complications during orthotopic liver transplantation, manifesting at any phase of the surgery. It underscores the critical importance of vigilant monitoring throughout orthotopic liver transplantation to promptly identify and effectively address these rare yet potentially catastrophic complications.

Pulmonary abscess combined with pulmonary vein thrombosis and stroke: A case report

BACKGROUND

Although most stroke patients have underlying vascular risk factors, it is important to consider infectious causes of stroke in young adults without traditional risk factors or patients with cryptogenic stroke. Pulmonary vein thrombosis and air embolism can potentially cause cerebral infarction. However, the association between infection and pulmonary vein thrombosis or air embolism is often overlooked. In this case, we present a rare infectious cause of stroke and air embolism involving a pulmonary abscess and pulmonary vein thrombosis.

CASE PRESENTATION

A 37-year-old male patient initially presented with right-sided pneumonia. During treatment at a local hospital, he developed headaches and left limb weakness. Subsequently, he was transferred to our hospital due to septic shock. Neurological evaluations revealed multiple brain foci and thrombosis in the right superior pulmonary vein. Following treatment with broad-spectrum antibiotics and anticoagulants, the patient's clinical symptoms and inflammatory markers showed improvement. However, a computed tomography scan revealed the formation of a pulmonary abscess, and the patient experienced coma and epilepsy after severe coughing with massive hemoptysis. Multiple air embolisms were observed in the brain computed tomography. Eventually, the patient's family chose to discharge him from the hospital.

CONCLUSIONS

This case highlights the rare and complex etiologies of stroke associated with infection in a young patient. Early detection, diagnosis, and appropriate treatment of infected systemic embolism in young patients are crucial to prevent serious complications.

Pulmonary vein perforation into the respiratory tract with systemic air embolism: a rare complication of left atrial appendage closure

BACKGROUND

Pulmonary vein perforation is an uncommon complication during cardiac intervention. We present a rare case of pulmonary vein perforation into the respiratory tract with systemic air embolism during left atrial appendage closure (LAAC).

CASE PRESENTATION

A 77-year-old man with persistent nonvalvular atrial fibrillation was referred for percutaneous LAAC under local anaesthesia (CHA2DS2-VASc score of 4, HAS-BLED score of 3, and prior ischaemic stroke). During the procedure, after delivering a super-stiff guidewire into the left superior pulmonary vein (LSPV), the patient suddenly developed a severe cough with haemoptysis upon advancement of a delivery sheath along the guidewire. Fluoroscopy showed signs of blood entering the left main bronchus, and fast transthoracic echocardiography revealed bubbles in the left heart without pericardial effusion. The procedure was terminated because of a major complication indicated by the repeated haemoptysis and headache, and haemostatic drugs were immediately administered. Subsequent chest computed tomography angiography (CTA) revealed a filling defect in the LSPV branches and bubbles in the aorta. The patient was transferred to the critical care unit for haemostasis and antibacterial treatment. Transthoracic echocardiography later that day showed no bubbles in the heart. The headache and haemoptysis significantly abated the following day. The bubbles in the aorta disappeared on chest CTA 7 days later.

CONCLUSIONS

Interventional cardiologists should pay attention to anatomical variations of the pulmonary vein, which are associated with a high risk of complications of pulmonary vein perforation during LAAC. Preoperative CTA examination and intraoperative transoesophageal echocardiography might be helpful to avoid this complication.

Acute and subacute neurovascular impact of cryptogenic air emboli

Background

Cerebral air embolism is a rare cause of acute ischemic stroke that is becoming increasingly well-described in the literature. However, the mechanism and severity of this type of injury can vary, with ischemia typically emerging early in the course of care. To the best of our knowledge, delayed ischemia in this setting has not yet been described.

Case Description

A stroke code was called for an unresponsive, hospitalized, 75-year-old man. A computerized tomography (CT) scan of the head revealed air within the right greater than left hemispheric cortical veins with loss of sulcation, concerning for developing ischemia, and CT angiography revealed absent opacification of the distal cortical vessels in the right anterior cerebral artery and middle cerebral artery territories. Magnetic resonance imaging (MRI) of the brain was obtained 5.75 h after the patient's last known well-showed small areas of subtle cortical diffusion restriction. Follow-up CT head within 24 h showed near-complete resolution of the air emboli after treatment with 100% fraction of inspired oxygen on mechanical ventilation. Subsequent MRI, performed 4 days after the initial event, showed extensive cortical diffusion restriction and cerebral edema crossing vascular territories.

Conclusion

This case highlights that cerebral air emboli can cause delayed ischemia that may not be appreciated on initial imaging. As such, affected patients may require intensive neurocritical care management, close neurologic monitoring, and repeat imaging irrespective of initial radiographic findings.

Early hyperbaric oxygen therapy is associated with favorable outcome in patients with iatrogenic cerebral arterial gas embolism: systematic review and individual patient data meta-analysis of observational studies

BACKGROUND

Iatrogenic cerebral arterial gas embolism (CAGE) caused by invasive medical procedures may be treated with hyperbaric oxygen therapy (HBOT). Previous studies suggested that initiation of HBOT within 6-8 h is associated with higher probability of favorable outcome, when compared to time-to-HBOT beyond 8 h. We performed a group level and individual patient level meta-analysis of observational studies, to evaluate the relationship between time-to-HBOT and outcome after iatrogenic CAGE.

METHODS

We systematically searched for studies reporting on time-to-HBOT and outcome in patients with iatrogenic CAGE. On group level, we meta-analyzed the differences between median time-to-HBOT in patients with favorable versus unfavorable outcome. On individual patient level, we analyzed the relationship between time-to-HBOT and probability of favorable outcome in a generalized linear mixed effects model.

RESULTS

Group level meta-analysis (ten studies, 263 patients) shows that patients with favorable outcome were treated with HBOT 2.4 h (95% CI 0.6-9.7) earlier than patients with unfavorable outcome. The generalized linear mixed effects model (eight studies, 126 patients) shows a significant relationship between time-to-HBOT and probability of favorable outcome (p = 0.013) that remains significant after correcting for severity of manifestations (p = 0.041). Probability of favorable outcome decreases from approximately 65% when HBOT is started immediately, to 30% when HBOT is delayed for 15 h.

CONCLUSIONS

Increased time-to-HBOT is associated with decreased probability of favorable outcome in iatrogenic CAGE. This suggests that early initiation of HBOT in iatrogenic CAGE is of vital importance.

Myocardial Enhancement Following Agitated Saline Contrast Study in a Boxer Dog

•Myocardial enhancement after agitated saline contrast study in a dog is described. •Suspect air microemboli can inadvertently be introduced into coronary vasculature. •Air microemboli are a theoretic risk of saline contrast echocardiography.

Risk factors for air embolism following computed tomography-guided percutaneous transthoracic needle biopsy: a systematic review and meta-analysis

To quantitatively analyze the risk factors for air embolism following computed tomography (CT)-guided percutaneous transthoracic needle biopsy (PTNB) and qualitatively review their characteristics. The databases of PubMed, Embase, Web of Science, Wanfang Data, VIP information, and China National Knowledge Infrastructure were searched on January 4, 2021, for studies reporting the occurrence of air embolisms following CT-guided PTNB. After study selection, data extraction, and quality assessment, the characteristics of the included cases were qualitatively and quantitatively analyzed. A total of 154 cases of air embolism following CT-guided PTNB were reported. The reported incidence was 0.06% to 4.80%, and 35 (22.73%) patients were asymptomatic. An unconscious or unresponsive state was the most common symptom (29.87%). Air was most commonly found in the left ventricle (44.81%), and 104 (67.53%) patients recovered without sequelae. Air location (P < 0.001), emphysema (P = 0.061), and cough (P = 0.076) were associated with clinical symptoms. Air location (P = 0.015) and symptoms (P < 0.001) were significantly associated with prognosis. Lesion location [odds ratio (OR): 1.85, P = 0.017], lesion subtype (OR: 3.78, P = 0.01), pneumothorax (OR: 2.16, P = 0.003), hemorrhage (OR: 3.20, P < 0.001), and lesions located above the left atrium (OR: 4.35, P = 0.042) were significant risk factors for air embolism. Based on the current evidence, a subsolid lesion, being located in the lower lobe, the presence of pneumothorax or hemorrhage, and lesions located above the left atrium were significant risk factors for air embolism.

Eliminating transseptal sheath exchange for pulsed field ablation procedures using a direct over-the-needle transseptal access with the Faradrive sheath

AIMS

Pulsed field ablation (PFA) for pulmonary vein isolation (PVI) combines the benefits of high procedural efficacy and safety. Transseptal puncture (TSP) to obtain left atrial (LA) access during PVI remains an important source of complications during LA procedures. For PFA procedures, TSP is generally performed using a standard transseptal sheath that is then exchanged over the wire for a dedicated PFA sheath, which might be a potential source for air embolism. We aimed to prospectively evaluate the feasibility and safety of a simplified workflow using the PFA sheath (Faradrive, Boston Scientific) directly for TSP.

METHODS AND RESULTS

We prospectively enrolled 100 patients undergoing PVI using PFA at two centres. TSP was performed using the PFA sheath and a standard 98 cm transseptal needle under fluoroscopic guidance. TSP via the PFA sheath was successfully performed in all patients and no complications occurred. The median time from the first groin puncture to the completed LA access was 12 min (IQR 8-16 min).

CONCLUSION

An over-the-needle TSP directly with the PFA sheath proved feasible and safe in our study. This simplified workflow has the potential to reduce the risk of air embolism, to shorten procedure time, and to reduce cost.

Clinical Characteristics, Imaging Findings, and Outcomes of Cerebral Air Embolism

BACKGROUND

Arterial cerebral air embolism (CAE) is an uncommon but potentially catastrophic event. Patients can present with focal neurologic deficits, seizures, or coma. They may be treated with hyperbaric oxygen therapy. We review the causes, radiographic and clinical characteristics, and outcomes of patients with CAE.

METHODS

We performed a retrospective chart review via an existing institutional database at Mayo Clinic to identify patients with arterial CAE. Demographic data, clinical characteristics, and diagnostic studies were extracted and classified on predefined criteria of diagnostic confidence, and descriptive and univariate analysis was completed.

RESULTS

Fifteen patients met criteria for inclusion in our study. Most presented with focal deficits (80%) and/or coma (53%). Seven patients (47%) had seizures, including status epilepticus in one (7%). Five presented with increased muscle tone at the time of the event (33%). Computed tomography (CT) imaging was insensitive for the detection of CAE, only identifying free air in 4 of 13 who underwent this study. When obtained, magnetic resonance imaging typically showed multifocal areas of restricted diffusion. Six patients (40%) were treated with hyperbaric oxygen therapy. Age, Glasgow Coma Scale score at nadir, and use of hyperbaric oxygen therapy were not associated with functional outcome at 1 year in our cohort. Twenty-six percent of patients had a modified Rankin scale score of 0 one year after the event, and functional improvement over time was common after discharge.

CONCLUSIONS

A high index of clinical suspicion is needed to identify patients with CAE because of low sensitivity of free air on CT imaging and nonspecific clinical presentation. Acute alteration of consciousness, seizures, and focal signs occur frequently. Because improvement over time is possible even among patients with severe presentation, early prognostication should be approached with caution.

Technical and anatomic considerations of skin flap elevation in bilateral axillo-breast insufflation robotic-assisted neck dissection

We have divided the chest and neck flap elevation for neck dissection into four steps. The flaps are divided into three zones corresponding to the vascular structures, which can be injured in this area. Our modifications outline safe techniques of flap elevation for robotic neck dissection.

Before the Knife: A Detailed Step-by-Step Description of an Optimized Semi-Sitting Position in Posterior Fossa Surgery

BACKGROUND

In an ample armamentarium in neurosurgery, the semi-sitting position has produced debate regarding its benefits and risks. Although the position is apparently intuitive, many have abandoned its use since its initial inception, because of reported complexity and potential complications, leading to impracticality. However, through standardization, it has been shown not only to be safe but to carry with it many advantages, including less risk of secondary neurovascular injuries and better visualization of the surgical field. As with any surgical technical nuance, the semi-sitting position has advantages and disadvantages that must be weighed before the decision is made to adopt it or not, not only in a case-by-case scenario but also from a departmental standpoint. As we attempt to show, the advantages from a standardized approach for the semi-sitting position in experienced institutions may be more than sufficient to significantly outweigh the disadvantages, making it the preferable option for most, although not all, posterior fossa surgical interventions.

METHODS

In the present study, we aim to elaborate a straightforward narrative of the steps before incision, in an attempt to simplify the complexity of the position, alleviating its disadvantages and exponentially concentrating on its benefits. In nearly 100 steps, we carefully describe the points that culminate with the skin incision, initiating the intraoperative part of the procedure. Each step, therefore, is detailed in full, not in an effort to create a strict manual of the semi-sitting position but rather to facilitate understanding and put the technique into effect in a real-life scenario, thus simplifying what some depict as complex and time consuming.

CONCLUSIONS

Although several of the steps described are also relevant and integral parts of other surgical positioning, we intend to create a protocol, in a stepwise fashion, to allow facilitated following, to be easily implemented in departments with different levels of experience. The steps comprise nursing care through to electrophysiologic and anesthesiologic approaches, along with neurosurgical cooperation, making it a team approach, not only to avoid position-related complications but also to optimize preoperative standardization, constructing a safe, efficient, and patient-centered scenario, to set the best possible stage for the next step: the intraoperative part of the intervention.

Acute Ischaemic Stroke by a Different Mechanism

Central venous lines are often inserted but their removal requires some precautions. We describe a 51-year-old female patient who was due for discharge but had an unfortunate event arising from removal of her central venous line even though the appropriate measures had been taken. She experienced an acute ischaemic stroke secondary to air embolism. The deficits persisted even though extensive efforts were made to reverse them. This case reminds clinicians that bedside procedures can result in devastating complications even if all precautions have been followed. We review the mechanisms of air embolism, provide suggestions to limit its incidence following central line removal, and recommend therapeutic measures.

LEARNING POINTS

Precautions should be taken when removing a central venous line to reduce the risk of air embolism.Air embolism can manifest with acute stroke.Acute stroke in this setting requires hyperbaric oxygen therapy.

Carbon Monoxide poisoning and Air Embolism following Hysteroscopic Myomectomy: a case report

INTRODUCTION

Uterine myomas are the most common benign uterine tumors. Hysteroscopic myomectomy has grown as a standard minimally invasive surgical procedure, but this technique is not free from complications.

CASE

An hysteroscopic myomectomy was performed on a 38 years-old woman. During the awakening after the procedure, she presented focal neurological deficits, thus arterial blood gas test and total body computerized tomography (CT) scan were urgently carried out. They revealed a very high carboxyhemoglobin level and abdominal venous air embolism. The patient stayed in Trendelenburg position and under mechanical ventilation with 100% oxygen concentration. Fortunately, a few hours later she was fully awake and was able to be successfully extubated, being discharged to the surgical ward three days later fully recovered.

CONCLUSION

Carbon monoxide poisoning during hysteroscopic resection is a rare but potentially fatal complication that anesthetists, gynecologists, and critical care physicians should be aware of.

Use of a novel integrated dilator-needle system in cryoballoon procedures: a zero-exchange approach

BACKGROUND

Recently, a novel integrated dilator-needle system (AcQCross Qx, Acutus Medical) was introduced to reduce the number of exchanges for a transseptal access. This system can be used in combination with large bore sheaths. In this pilot study, we evaluated the safety and efficacy of a zero-exchange approach with the AcQCross system in cryoballoon procedures.

METHODS

In this retrospective single-center study, we included 40 patients (AcQCross: n = 20; control group: n = 20) who underwent a cryoballoon procedure for the treatment of atrial fibrillation. In the AcQCross and control group, patients underwent ablation with POLARx (Boston Scientific) and Arctic Front Advance Pro (AFA-Pro, Medtronic) in equal numbers (n = 10). In the AcQCross group, the AcQGuide Max sheath (Acutus Medical) was used in all POLARx cases.

RESULTS

The baseline characteristics of the study population were comparable between groups. In the AcQCross group, there was a reduction in procedure time (49.7 ± 9.0 min vs. 59.6 ± 8.1 min, P < 0.001) and time from puncture until balloon delivery (15.5 ± 6.8 min vs. 21.5 ± 7.4 min, P = 0.01) in comparison with the control group. The balloon in body time, fluoroscopy time, number of cryoapplications, and biophysical parameters were similar between groups. There was one temporary phrenic nerve injury in the AcQCross group. Importantly, no signs of air embolism were noted with the AcQGuide Max sheath.

CONCLUSIONS

The use of the novel AcQCross system improves procedural efficacy in cryoballoon procedures by reducing the number of exchanges.

Paradoxical venous air embolism detected with point-of-care ultrasound: a case report

Venous air embolism (VAE) is an uncommon event consistent in the entrainment of air from any communication between the environment and the venous vasculature that could occur during central venous catheter (CVC) manipulation, and might trigger circulatory shock within minutes depending on the amount of air embolized. We present a case of a critical care patient who presented sudden clinical hemodynamic deterioration after the removal of central venous catheter. Hemodynamic evaluation with point-of-care ultrasound (POCUS) showed bubbles in both right and left heart cavities wherewith air embolism facilitated by heart septal defect was suspected. Therefore, the patient was reintubated, supported with vasopressors and a new CVC was inserted to proceed with air aspiration. Shortly after, the patient’s hemodynamic status improved in terms of vital signs stabilization. 6 h after the event with optimal perfusion markers and diminished sedation, the patient showed left hemiparesis therefore a cerebral magnetic resonance (MRI) was also performed showing hyperintensity in the right precentral gyrus, so ischemic stroke without hemorrhagic transformation diagnosis was made, because of paradoxical embolism. This case report demonstrates the value of POCUS application as a diagnostic tool in the hemodynamically unstable patient.

Showering gas bubbles within the inferior vena cava detected sonographically can unmask a hidden infection: a case report of a rare presentation in a patient with emphysematous cystitis

We present a case of incidentally discovered gas bubbles flowing within the inferior vena cava during a routine abdominal sonographic examination, that subsequently unmasked a previously undiagnosed emphysematous cystitis.

[Rare but frequently lethal complication of pulmonary vein isolation]

A 65-year-old patient perceived dysphagia 4 days after uncomplicated pulmonary vein isolation; there were no other symptoms or complaints such as fever or malaise. Despite prophylactic treatment, a severe complication evolved which could be detected in time only by close control, allowing early treatment.

Clostridium septicum-induced gangrene in the right lower extremity complicating pneumatosis in the right ventricle and the pulmonary artery and occlusion of right femoral artery: a case report

BACKGROUND

Gas gangrene is usually manifested as myonecrosis and subcutaneous gas accumulation, but rarely manifested as arterial occlusion or pneumatosis in the right ventricle and the pulmonary artery.

CASE PRESENTATION

We report a case of gas gangrene caused by Clostridium septicum. The patient developed gas gangrene after being pecked by a chicken but turned for the better following antibiotic treatment and debriment. Imaging test revealed a rare occlusion of the right femoral artery and pneumatosis in the right ventricle and the main pulmonary artery.

CONCLUSIONS

In the presence of gas gangrene, special care must be taken to prevent against the formation of circulatory air embolism. The gas gangrene-induced gangrene in the limb of this patient might be attributed to the combined action of infection and arterial occlusion. MDT (Multidisciplinary team)-Green Channel mode is conductive to treatment success of gas gangrene.

[Suicidal gas embolism in hospital]

Luftembolien sind im klinischen Alltag nach traumatischen oder iatrogenen Ereignissen eine häufig zu beobachtende Entität. Fälle einer in suizidaler Absicht herbeigeführten Luftembolie sind selten. Die Konnektivität von luft- und flüssigkeitsführenden Schlauchsystemen ermöglicht die Zufuhr großer Gasmengen in kurzer Zeit mit häufig tödlichem Ausgang. Der Einsatz einer Computertomographie vor der Obduktion ist in solchen Fällen obligat und ermöglicht eine umfassende Darstellung der zugeführten Gasmengen. Wir präsentieren den ungewöhnlichen Fall einer suizidalen venösen Gaszufuhr mittels eines stationären Sauerstoffgerätes in einem Krankenhaus.

Air-embolism in the semi-sitting position for craniotomy: A narrative review with emphasis on a single centers experience

Albeit the semi-sitting position in neurosurgery has been in use for several decades, its application remains controversial in the neurosurgical and neuro-anaesthesia communities. The imminent and most feared risk of the sitting position is air entry into the vascular system due to the negative intravascular pressure leading to potentially life-threatening air embolism with its consequences. Recent advents in neurosurgical (improvement of the operating microscope, employment of intra-operative neurophysiological monitoring) and neuro-anaesthesia care (new anaesthetics, advanced monitoring modalities) have significantly impacted the approach to these surgeries. Vigilant intra-operative observation by an experienced team and peri-operative patient management guided by institutional protocols improves the safety profile of these surgeries. This review outlines the workflow and protocols used in our institution for all cases of semi-sitting position for skull base neurosurgery.

PICC entrapment and air embolism on veno-venous extracorporeal membrane oxygenation: A case report

Extracorporeal membrane oxygenation (ECMO) is an incredible, life-sustaining intervention for patients suffering from a variety of cardiopulmonary insults. However, its use comes with a unique set of risks and potentially devastating complications, including air entrainment and embolism. We present a case of recurrent air entrainment in a patient on veno-venous ECMO after her peripherally inserted central catheter became entrapped within the lumen of her bi-caval, dual lumen ECMO cannula. We briefly discuss considerations for air embolism on ECMO and recommend general strategies to avoid this potentially catastrophic complication.

Coronary artery air embolism complicating a CT-guided percutaneous lung biopsy

Coronary arterial air embolism is an extremely rare but readily recognizable condition on computed tomography (CT) that may complicate a lung biopsy. We present an incidence of symptomatic air embolism into the right coronary artery during a percutaneous CT-guided lung biopsy that was successfully recognized during the procedure and managed accordingly. An active search for this complication should be made when the patient deteriorates on table and the usual complications (pneumothorax, vasovagal shock, etc.) are ruled out, as immediate resuscitative measures could be life-saving.

Cerebral arterial air embolism after endobronchial electrocautery: a case report and review of the literature

Background

Endobronchial electrocautery is a common and safe therapeutic endoscopic treatment for malignant airway obstruction. Cerebral arterial air embolism (CAAE) is a rare but potentially fatal complication of endobronchial electrocautery.

Case presentation

We present the first case of cerebral arterial air embolism after endobronchial electrocautery. A 56-year-old male with a pulmonary tumour in the right upper lobe received repeated endobronchial electrocautery. During the procedure, he experienced unresponsiveness, hypoxemia and bradycardia, and he developed tetraplegia. Brain computed tomography showed several cerebral arterial air emboli with low-density spots in the right frontal lobe. He received hyperbaric oxygen therapy with almost full recovery, except for residual left-sided weakness.

Conclusions

General physicians should realize that CAAE may be a possible complication of endobronchial electrocautery. Several measures, including avoiding positive pressure, lowering ventilatory pressures if possible, avoiding advancing the bronchoscope to occlude the bronchus and using the non-contact technique, should be used to prevent this devastating complication.

Two cases of fatal iatrogenic air embolism confirmed by autopsies

The occurrence of air embolism is highly related to medical operations, and air embolism can cause sudden death. Such situations require attention in forensic work. This article reports two cases of iatrogenic air embolism confirmed by autopsy. In case 1, air embolism occurred after hydrogen peroxide was used to irrigate and disinfect a wound on the patient's left forearm. Approximately 90 ml of 3% hydrogen peroxide solution was used in case 1, and this volume can produce approximately 890 ml of oxygen by complete decomposition, which is far more than the average lethal air embolism volume. Attention should be given to the risk of air embolism when using hydrogen peroxide for irrigation and disinfection. In case 2, air embolism occurred during left ureteroscopy and stent placement. Due to inappropriate processing, the normal saline pump infused air into the patient at a high pressure of 120 mmHg. Based on our autopsy findings, we discuss the pathways of arterial air embolism and cerebral air embolism. In addition to the air entrainment volume and accumulation rate, the location of air accumulation also significantly impacts the risk of air embolism. After an arterial air embolus develops into a coronary and/or cerebral air embolus, the lethal air volume drops to only a few milliliters.

A rare appearance of the trigeminocardiac reflex during resection of posterior parasagittal meningioma

Background:

Although a well-recognized phenomenon of the tentorium and posterior fossa, the trigeminocardiac reflex (TCR) has been rarely reported during surgery involving the posterior falx cerebri.

Case Description:

We present the case of a 63-year-old woman who underwent repeat resection of an atypical parasagittal meningioma involving the posterior falx. During resection, TCR was repeatedly elicited during manipulation and coagulation of the falx. Air embolism and cardiac etiologies were initially considered while TCR was not suspected, given the location. Ultimately, TCR was recognized when asystole self-resolved upon cessation of stimulus and due to its reproducibility.

Conclusion:

Awareness by the anesthesiologist and neurosurgeon of the possibility of TCR during falcine procedures can help with rapid identification to avoid a potentially catastrophic outcome.

Stroke rate after thoracic endovascular aortic repair using de-airing of stentgrafts with high-volume of saline solution

Background: Our aim was to determine the rate of ischemic stroke following thoracic endovascular aortic repair (TEVAR) after reducing gas volume released during stentgraft deployment by de-airing of thoracic stentgrafts with high-volume of 0.9% heparinized saline solution. Patients and methods: A single center retrospective analysis of all consecutive patients undergoing TEVAR from 2014 to 2019 was performed. All thoracic stentgrafts were flushed with 120 ml 0.9% heparinized saline solution before implantation, according to our institutional protocol. Endpoints were in-hospital rates of ischemic stroke and spinal cord ischemia (SCI), and all-cause mortality. Results: One hundred and fifty-four patients (mean age: 66.8 ± 13.6 years, 64.9% males) were treated with TEVAR during the study period. Indications for treatment were thoracic aortic aneurysms (n = 75, 48.7%), acute type B aortic dissections (n = 46, 29.9%), aortic arch aneurysms and penetrating aortic ulcers (n = 28, 18.2%), and blunt traumatic aortic injuries (n = 5, 3.2%). Timing of procedure was urgent in 75 patients (48.7%). Proximal landing zone were zone 0-1-2 (n = 75, 48.7%), zone 3 (n = 66, 42.9%) and zone 4 (n = 13, 8.4%). Supra-aortic vessels were revascularized with custom-made fenestrated stentgrafts in 9 patients (5.8%), using chimney technique in 4 patients (2.6%), and with debranching procedures in 19 patients (12.3%). Left subclavian artery was covered without revascularization in 46 patients (29.9%). In-hospital stroke occurred in two patients (1.3%) and SCI in another two patients (1.3%). In-hospital mortality rate was 0.6%. No further in-hospital events were noted. Conclusions: De-airing of stentgrafts with high-volume of 0.9% heparinized saline solution seems to be safe and can be used as an adjunct to keep occurrence of neurological events after TEVAR as low as possible.

Air in the right ventricle and vein after basilar skull fracture: a case report

Background

Air in the venous system may cause vascular air embolism, which is a potentially life-threatening event. The presence of air in venous system after basilar skull fracture is very rare.

Case presentation

A 77-year-old man fell from a truck bed and suffered head and neck trauma. On hospital arrival, his consciousness was clear and his vital signs were stable. His chief complaint was pain in the back of his head and neck. Head CT showed traumatic subarachnoid hemorrhage in the right frontal area and basilar skull fracture of the occipital bone. Whole body CT showed pneumocephalus and air in the jugular vein and right ventricle. The patient was placed in the supine position in a state of absolute rest to prevent vascular air embolism and was treated conservatively. On hospital day 3, CT was reperformed, revealing disappearance of air in the right ventricle and decreased air in the veins of the head and neck. On hospital day 4, the air in the veins disappeared completely on CT. He did not experience vascular air embolism after increasing of his activity level (e.g., raising his head on hospital day 3 and standing and walking alone on day 5). He was discharged 34 days after admission without sequelae.

Conclusions

Head trauma patients with basilar skull fracture might develop vascular air embolism if physicians fail to detect air in the venous system on hospital arrival. A high degree of suspicion regarding air in venous system or heart is required when patients present with such injuries.

Arterial gas embolism breathing compressed air in 1.2 metres of water

Arterial gas embolism (AGE) may result when diving while breathing compressed gas and ascending rapidly or with a closed glottis. Pulmonary over-pressurisation can result in lung stretch injury with entry of bubbles into the pulmonary venous circulation and subsequently the systemic arterial circulation. We present the case of an individual who suffered AGE while breathing compressed air at 1.2 metres' fresh water (mfw) in a swimming pool and discuss the factors determining the depth at which this form of injury may occur. This case serves to underscore the fact that risk of AGE exists at shallow depths.

Vaginal laceration leading to air embolism during consensual sexual intercourse

Vaginal injuries with clinical complications apart from local bleeding following sexual intercourse are thought to be rare events that have recently fostered a discussion on the topic. We report a case of a vaginal laceration resulting in death caused by air embolism in a non-pregnant woman during consensual sexual intercourse with digital and penile penetration. Hysterectomy and a preexisting vaginal injury were additional risk factors present in this case. Besides case history and autopsy findings, histological examination of the vaginal lesion and postmortem computer tomography (PMCT) helped in diagnosing the cause of death and underlying pathophysiological mechanisms.

Potentially fatal complications of systemic air embolism after computed tomography-guided transthoracic needle biopsy in lung cancer harboring epithelial growth factor receptor mutation: A case report

Air embolism is a rare, fatal complication of computed tomography (CT)‐guided transthoracic needle biopsy (TTNB) of the lung. Here, we report a patient who developed an air embolism after CT‐guided TTNB, which led to ST‐elevation myocardial infarction and acute cerebral ischemia. The patient recovered completely without critical sequelae and was diagnosed with adenocarcinoma harboring activating epidermal growth factor receptor (EGFR) mutation. The patient responded to subsequent treatment with gefitinib.

Key points

Signficant findings of the study

Air embolism is a rare, fatal complication of CT‐guided transthoracic lung biopsy. Only a few cases have been previously reported where myocardial and cerebral infarction occurred after TTNB, demonstrated not only on CT scan, but also electrocardiogram and electroencephalogram.

What this study adds

Detection of driver gene mutation is crucial for planning lung cancer treatment. Despite the need for tissue biopsy, air embolism propagation to vital organs could result in severe end‐organ damage and multidisciplinary approaches are needed to improve initial outcomes.

Cerebral Air Embolism and Vasospasm after Carotid Revascularization: A Case Report

Cerebral air embolism can be of venous and arterial origin and cause severe medical complication. Vasospasm is a severe complication of carotid artery stenting. We report a 63-year-old male with severe carotid artery stenosis who suddenly died due to acute myocardial infarction during carotid artery stenting. His brain computed tomogram showed a remarkable amount of air in the gyriform spaces, and the cerebral angiogram showed vasospasm in the internal carotid artery resulting from stent manipulation. Presence of gyriform air could be caused by air entering the catheter due to sudden collapse after acute myocardial infarction and severe carotid vasospasm.

The AirSeal® insufflation device can entrain room air during routine operation

Background

Surgical procedures that use insufflation carry a risk of gas embolism, which is considered relatively harmless because of the high solubility of carbon dioxide. However, an in vitro study suggested that valveless insufflation devices may entrain non-medical room air into the surgical cavity. Our aim was to verify if this occurs in actual surgical procedures.

Methods

The oxygen percentage in the pneumoperitoneum or pneumorectum/pneumopelvis of eight patients operated with use of the AirSeal® was continuously measured, to determine the percentage of air in the total volume of the surgical cavity.

Results

Basal air percentage in the surgical cavity was 0–5%. During suctioning from the operative field air percentage increased to 45–65%.

Conclusions

The AirSeal® valveless insufflation device maintains optimal distension of the surgical cavity not only by insufflating carbon dioxide, but also by entraining room air, especially during suctioning from the operative field. This may theoretically lead to air embolism in patients operated on with this device.

Massive air embolism during off-pump CABG: A case report

Off-pump coronary artery bypass grafting (OPCAB), although devoid of the morbidity associated with cardiopulmonary bypass (CPB), has its own technical difficulties. Achieving optimum tissue stabilization on a beating heart along with hemodynamic fragility due to extreme positioning also complicates the anesthetic management. In addition, it is difficult to obtain a clear surgical field in the presence of arteriotomy. The use of catheter-directed high-flow gas blower (mister blower) helps achieve a clear surgical field to a great extent. However, there have been reported cases of arterial and pulmonary embolism caused by these high-flow gas blowers. The present case reports a case of massive venous air embolism caused by the use of mister blower.

The First Case of Impella RP Use in Acute Right Ventricular Failure From Air Embolism

BACKGROUND

Air embolism can cause the following catastrophic complications that must be avoided: cardiogenic shock (from right heart failure), obstructive shock, myocardial infarction, stroke, RVOT obstructions, and pulmonary embolism. Currently there is a paucity of data on Impella RP use in rare causes of acute right ventricle (RV) failure, especially if caused by air embolism.

CASE REPORT

We report a case of a patient with acute RV failure due to air embolism who recovered from temporary use of Impella RP.

DISCUSSION

This case highlights the utility of right-sided mechanical support (MCS) devices for acute RV failure.

Fatal craniofacial circular-saw-related injury: a rare case of accidental death

Fatal injuries caused by circular saws are rare and mainly self-inflicted. To the best of our knowledge this is the first recorded case of accidental death of a woman caused by an injury to the head region inflicted by a saw blade. The autopsy showed a 35 cm long wound, stretching from the right half of the jaw along the right side of the face and the right temporal region up to the parietal region. The cut went through the right hemisphere of the brain in the temporal and parietal lobe regions, damaging the sagittal sinus. Air embolism was considered to be the cause of death. Fatalities involving power tools, such as a circular saw, warrant a high degree of suspicion of criminal activity and require a comprehensive medicolegal investigation. Placing guards over the blade and around the driving system, i.e. the motor, belt, arbor, is of great importance for the prevention of potentially fatal injuries.

Cerebral Air Embolism and Cardiomyopathy Secondary to Large Bulla Rupture during a Pulmonary Function Test

Cerebral air embolism combined with cardiomyopathy secondary to pulmonary barotrauma is rare. Here, we report an unusual case of cerebral air embolism combined with transient cardiomyopathy secondary to large bulla rupture during a pulmonary function test after lung cancer surgery. The patient experienced loss of consciousness. Computed tomography and magnetic resonance imaging suggested a cerebral air embolism. Electrocardiography showed ST-segment elevation and abnormally high plasma levels of cardiac enzymes. Echocardiography and coronary angiography suggested cardiomyopathy. The patient was discharged with no sequelae.

Air embolism during percutaneous nephrolithotomy using air pyelogram during initial access: Does it really occur?

INTRODUCTION

In the present era, percutaneous nephrolithotomy (PCNL) is the standard treatment for large (>2 cm) renal or staghorn renal stones. Both air and iodinated contrast has been used to opacify the pelvicalyceal system (PCS) before the dilatation of the tract. There are rare reports of air embolism following air pyelogram on mere presumptions.

MATERIALS AND METHODS

This is a prospective observational study. A total of 164 patients underwent PCNL in which air was used to opacify the PCS by placing a ureteric catheter for initial access.

RESULTS

None of our patients developed any complication during the procedure or in the postoperative period, which could be attributed to air embolism.

CONCLUSIONS

The present study ascertains that using air for opacification of PCS for initial puncture access is a safe and acceptable alternative to iodinated contrast.