Biliary Metal Stents and Air Embolism: A Note of Caution

Metal stents are a valuable treatment modality for patients with biliary obstruction. However, we present here two patients whose cases may serve as a warning about an unusual complication associated with these stents. We encountered this complication after endoscopic retrograde cholangiography for obstructed metal biliary stents. The first patient, an 87-year-old man with a benign biliary stricture, failed to regain consciousness after clearing of his stent using a Dormia basket and balloon catheter. Cerebral air embolism was diagnosed on cerebral computed tomography, and transesophageal echocardiography revealed a patent foramen ovale as a precipitating factor for paradoxical air embolism. He survived and was discharged with a residual hemiparesis. In the second patient, a 54-year-old man who had a history of a Billroth II operation and chronic pancreatitis and who had a portal cavernoma with biliary obstruction due to collateral veins, electromechanical dissociation complicated the balloon-catheter stent revision. Echocardiography performed during cardiopulmonary resuscitation showed major air embolism to the right heart. The patient died. These cases demonstrate that air may gain access to the venous system during therapeutic endoscopic procedures of this type. It is likely that the large diameter of metal stents and the potential for these stents to lacerate venous structures facilitate the entry of air into the venous circulation, an event which may have life-threatening consequences.

References

• 1 Neuhaus H, Schumacher B. Use of metal stents in gastroenterology [in German, abstract in English].  Z Gastroenterol. 1998;  36 121-134
• 2 Katzgraber F, Glenewinkel F, Rittner C, Beule J. Fatal air embolism resulting from gastroscopy.  Lancet. 1995;  346 1714-1715
• 3 Katzgraber F, Glenewinkel F, Fischler S, Rittner C. Mechanism of fatal air embolism after gastrointestinal endoscopy.  Int J Legal Med. 1998;  111 154-156
• 4 Herron D M, Vernon J K, Gryska P V, Reines H D. Venous gas embolism during endoscopy.  Surg Endosc. 1999;  13 276-279
• 5 Butler B D, Hills B A. Transpulmonary passage of venous air emboli.  J Appl Physiol. 1985;  59 543-547
• 6 Akhtar N, Jafri W, Mozaffar T. Cerebral artery air embolism following an esophagogastroscopy: a case report.  Neurology. 2001;  56 136-137
• 7 Raju G S, Bendixen B H, Khan J, Summers R W. Cerebrovascular accident during endoscopy: consider cerebral air embolism, a rapidly reversible event with hyperbaric oxygen therapy.  Gastrointest Endosc. 1998;  47 70-73
• 8 Heckmann J G, Lang C J, Kindler K. et al . Neurologic manifestations of cerebral air embolism as a complication of central venous catheterization.  Crit Care Med. 2000;  28 1621-1625