When in Trouble Think of the Bubble: Paradoxical Cerebral Arterial Gas Embolism after Endoscopic Retrograde Cholangiopancreatography

Abstract

Air embolism (a result of direct communication with the vasculature and an external pressure gradient from the gastrointestinal or the biliary tract), although rare, is a potentially devastating adverse event seen in endoscopic retrograde cholangiopancreatography (ERCP) procedures. Whether venous, arterial, or paradoxical, the clinical presentation ranges from asymptomatic patients to cardiorespiratory arrest. This is of particular importance because it makes the diagnosis of air embolism even more difficult in an already sedated patient. Since early recognition increases the chances of patients’ survival, endoscopists should be highly motivated and trained to recognize this complication as early as possible. With only 60 cases of air embolism reported (and even fewer related to paradoxical air embolism), we aimed to report a case of paradoxical cerebral air embolism in a patient undergoing ERCP due to a common bile duct stricture and to provide a mini-review of this clinical entity that can serve as a bedside quick reference guide for endoscopists worldwide.

Outcomes of balloon vs basket catheter for clearance of choledocholithiasis: a systematic review and meta-analysis

“…All studies were prospective, single country RCTs. The study by Ekmektzoglou et al was a single-center RCT at a high-volume center in Greece with two participating endoscopists with > 20 years’ experience 9 . Studies by Ozawa et al and Ishiwatari et al were multicenter RCTs conducted in Japan 10 14 .…”

“…Secondary endpoints included adverse events as defined by the ASGE Standards of Practice Committee 15 16 . Two studies recorded time taken to complete the procedure 9 14 . One study recorded radiation exposure 9 .…”

“…Two studies recorded time taken to complete the procedure 9 14 . One study recorded radiation exposure 9 . For Ozawa et al, complete stone extraction in one endoscopic session, irrespective of initial extraction device, was a secondary endpoint.…”

“…Balloon catheters can be deflated and easily removed in such a situation. In addition, small stones can slip through the wires of basket catheters 9 . Balloon catheters are inflated to occlude the CBD, and hence, may be better suited for smaller stones or sludge.…”

“…ESGE does not have any preference. Many European and Japanese centers actually prefer basket catheters because they provide better traction, while balloon catheters can slip past stones, or push stones into the intrahepatic duct, cystic duct or the corner pocket at the lower end of the CBD during extraction 1 9 10 11 . Basket catheters are considered more durable, while balloons can rupture 1 11 .…”