Massive air embolism complicating Nd‐YAG laser endobronchial photoresection

Abstract

A 63 year old male underwent 6,900 rads of external radiation for a squamous cell carcinoma of the left main bronchus. Recurrence of the tumor 8 months later was treated with 6,618 joules and patency of the left main bronchus was restored. Four months later, he developed complete atelectasis of the left lung requiring repeat laser. During the procedure he became hypotensive, bradycardic, and hypoxic due to a tension pneumothorax. Although treated promptly with thoracostomy tube drainage, the patient never awakened. CT scan of the brain demonstrated anoxic encephalopathy with air present in the right frontal lobe. Brain death was confirmed by an EEG and cerebral angiogram. Air embolism has been reported in conjunction with diagnostic procedures including therapeutic pneumothorax for tuberculosis, transthoracic needle biopsy of the lung, and positive pressure ventilation with or without pneumothorax. The only reported case of air embolism associated with laser was a small middle cerebral artery cerebro-vascular accident which was self limited. Its mechanism is unclear, but it is suspected to be due to a communication between a pulmonary vein and the atmosphere. A greater volume of air will enter the damaged vessel in the setting of positive pressure ventilation and/or a tension pneumothorax. When neurologic manifestations are present, hyperbaric oxygen therapy is the treatment of choice. Prompt institution in hemodynamically stable patients can minimize neurologic sequelae.

Argon Plasma Coagulation: Elucidation of the Mechanism of Gas Embolism

“…Another is that the highly pressurized gas exiting the tip of the APC catheter crosses the mucosa and enters the vasculature via bronchovascular fistulae formed during tissue desiccation and coagulation. This mechanism has additionally been postulated in cases of gas embolism following laser therapy [9]. Tellides et al [5] proposed that systemic embolism during bronchoscopic laser procedures occurred due to laser fiber air coolant used at high flow settings as well as in contact fashion and recommended using noncontact mode whenever possible.…”

Venous air embolism during the use of a Nd YAG laser

“…Venous air embolism (VAE) has been reported during the use of the Nd YAG laser during different types of surgical procedures [1–6]. The possible mechanism is the entry of air into the venous circulation from the active co‐axial cooling system in the ruby tip of the laser probe.…”