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Monday, December 9, 2013


Portal venous air embolization.

Turk J Gastroenterol. 2013 Aug;24(4):374-5.

Source

Institute of Liver and Biliary Sciences, Department of Radiodiagnosis, New Delhi, India.

Abstract

To the Editor 

A 74-year-old lady was diagnosed with an inoperable gallbladder carcinoma with peritoneal deposits and acute cholangitis. 

As a palliative procedure, the patient was taken up for endoscopic retrograde cholangiopancreatography (ERCP) which was performed under conscious sedation with the patient placed in a semi-prone position.
 7F-biliary stents were successfully placed in the bile duct, however, note was made of inadvertent air entry into the portal vein. 
Spot-radiograph taken with the patient in semi-prone position (Figure-1) reveals an iatrogenic pneumovenogram (arrows). The procedure was immediately abandoned, and highflow supplemental oxygen was administered after placing the patient in a Trendelenburg position.

 The patient fortunately remained stable with steady vital parameters during and post-procedure (BP: 130/86 mm of Hg, pulse-rate: 70 per minute, and respiratory rate: 16 per minute). She was kept under strict surveillance, and her symptoms of cholangitis rapidly improved following which she was discharged on post-procedure day 4. Portal vein air embolization is a rare, potentially fatal, complication of ERCP. Although many of these cases go unnoticed with no grave consequences, the entity remains potentially fatal (1-3). The proposed mechanism of venous air embolization is dissection of insufflated air through the inadvertently injured duodenal wall. The air via the venous duodenal radicles gains access into the mesenteric circulation and the portal vein (3). Another probable mechanism is the creation of a biliaryvascular fistula wherein insufflated air through an already weakened biliary radicle escapes into the portal vein branch (1). The outcomes chiefly depend upon the amount and the rate at which the air is insufflated (1). Small volumes of air in the venous system can get absorbed spontaneously (2). However, larger quantity or rapid rate-of-delivery can lead to systemic (cerebral or pulmonary) embolism with catastrophic consequences in the form of arrhythmia, acute cor pulmonale, asystole, hypoxia, shock, stroke, or sudden death (1-3). The lack of clinical suspicion frequently adds to the clinical quandary. Awareness of such a possibility and high index of clinical suspicion is required to prompt suitable investigations and commence appropriate therapy (1-3). Any suggestion of venous air embolization during ERCP should instigate instantaneous termination of the procedure (1). The therapeutic options depend on the severity of air embolism and range from hyperbaric oxygen therapy, high-flow oxygen supplementation, patient repositioning (left lateral decubitus and Trendelenburg positions), closed chest cardiac massage, to aspiration of air from the right ventricle through an acutely floated pulmonary artery catheter (2).

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