Coronary air embolism: Incidence, severity, and suggested approaches to treatment

Khan, Miqdad; Schmidt, Donald H.; Bajwa, Tanvir; Shalev, Yoseph

doi:10.1002/ccd.1810360406

Cited by 68 publications

(50 citation statements)

References 8 publications

(1 reference statement)

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“…There are hardly few reports of AE during aortography or ventriculography. [1][2][3] Our report differs from previous cases by presenting the largest amount of air injected into aortic root during angiography (20 -25 mL).…”

Section: Case Reportscontrasting

confidence: 75%

Massive Systemic Air Embolism During Aortic Root Angiography

et al. 2012

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A ir embolism (AE) is an uncommon but potentially catastrophic complication of angiography. Although coronary AE is a well-known complication of coronary angiography, which occurs in 0.27% of cases, 1 incidence and consequences of systemic massive AE are largely unknown. However, case reports are important to discuss reasons, management, and consequences of this complication. Case ReportsA 46-year-old woman with uncontrolled hypertension, thoracic aortic aneurysm, and anginal episodes at rest was referred for coronary angiography. The procedure was uneventful until the aortic root angiogram, during which 40 mL of contrast agent was intended to be injected with 14 mL/s flow and a maximum pressure of 1200 psi. On injection of contrast media into aortic root, a massive influx of air bubbles was observed (Figure and Movie I in the online-only Data Supplement). Instantly, the patient collapsed with pulseless electric activity. Meanwhile, it was realized that a large amount of air was injected into aortic root. Shortly after cardiopulmonary resuscitation, her blood pressure and pulse recovered. She became conscious, with good cooperation and orientation. However, she had a garbled speech, left hemiplegia, and partial weakness and paresthesia in right leg and arm. Under oxygen administration with mask in the 15th minute there was significant weakness in the left arm and shallow weakness in the left leg. Serial electrocardiograms revealed transient ST segment elevation of 0.05 mV in inferior derivations. Brain CT scan revealed no air bubbles, and the patient was emergently transferred to the nearest center with facility of hyperbaric oxygen chamber treatment (HBOT). At the 5th hour of the event, HBOT was started. After HBOT, left lower extremity motor and sensory functions recovered and her speech had become fluent with persisting slight paresthesia in left arm. In the next day neurological examination was completely normal. Electroencephalography and brain CT control in the third day of event were normal.Initially troponin I showed acute elevation at 0.363 ng/mL, not accompanied by creatine kinase-MB elevation, which declined on subsequent tests. Her left ventricular wall motion was normal after HBOT. No deterioration in function of other organ systems was found. In the third year of the event, her neurological examination was still normal. This is the first case reporting accidental injection of massive air during aortic root angiography effecting both coronary and cerebral vasculature. There are hardly few reports of AE during aortography or ventriculography. 1-3 Our report differs from previous cases by presenting the largest amount of air injected into aortic root during angiography (20 -25 mL).Immediate treatment aims to interrupt the intervention that caused the embolic event. It was our only experience of massive AE ever, and nobody in the team was familiar with the image of massive AE. Unfortunately, AE was not noticed

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Section: Case Reportscontrasting

confidence: 75%

Massive Systemic Air Embolism During Aortic Root Angiography

et al. 2012

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“…Symptomatic air embolism 15 and thromboembolism 16 are recognized complications known to occur after various angiographic procedures, including coronary angiography. However, little is known about the frequency of procedurerelated subclinical ischemic tissue damage.…”

Section: Discussionmentioning

confidence: 99%

Heparin and Air Filters Reduce Embolic Events Caused by Intra-Arterial Cerebral Angiography

et al. 2004

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Background-Intra-arterial cerebral angiography is associated with a low risk for neurological complications, but clinically silent ischemic events after angiography have been seen in a substantial number of patients. Methods and Results-In a prospective study, diffusion-weighted magnetic resonance imaging (DW-MRI) before and after intra-arterial cerebral angiography and transcranial Doppler sonography during angiography were used to evaluate the frequency of cerebral embolism. One hundred fifty diagnostic cerebral angiographies were randomized into 50 procedures, each using conventional angiographic technique, or systemic heparin treatment throughout the procedure, or air filters between the catheter and both the contrast medium syringe and the catheter flushing. There was no neurological complication during or after angiography. Overall, DW-MRI revealed 26 new ischemic lesions in 17 patients (11%). In the control group, 11 patients showed a total of 18 lesions. In the heparin group, 3 patients showed a total of 4 lesions. In the air filter group, 3 patients exhibited a total of 4 lesions. The reduced incidence of ischemic events in the heparin and air filter groups compared with the control group was significantly different (Pϭ0.002).Transcranial Doppler sonography demonstrated a large number of microembolic signals that was significantly lower in the air filter group compared with the heparin and control groups (PϽ0.01), which did not differ from each other. Conclusions-Air filters and heparin both reduce the incidence of silent ischemic events detected by DW-MRI after intra-arterial cerebral angiography and can potentially lower clinically overt ischemic complications. This may apply to any intra-arterial angiographic procedure.

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“…Massive air embolism seems to be a rare event. 1 Coronary air embolism has been reported to cause chest pain, ST segment elevation, bradycardia, hypotension, and ventricular fibrillation. 2 Our case demonstrates that hemodynamic compromise can occur within seconds and may resolve within a few minutes after prompt treatment, which includes aspiration of the air if possible, 100% oxygen administration and (often intracoronary) atropine, and epinephrine injections.…”

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confidence: 99%

Hemodynamic Consequences of Massive Coronary Air Embolism

2007

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A 60-year-old man underwent coronary angiography because of exertional angina and was found to have a 90% mid-left anterior descending artery lesion ( Figure 1A). A 2.5ϫ20-mm paclitaxel-eluting stent was positioned in the lesion. When contrast was injected to verify the stent position, air was introduced into the guide catheter through a loose manifold connection, resulting in a massive coronary air embolism (Movie and Figure 1B). Because the undeployed stent was occlusive, there was no bubble embolization in the distal left anterior descending artery. After 20 s, the patient developed ST elevation and hypotension (Figure 2A), followed by a short period of pulseless electrical activity ( Figure 2B). The guide was vigorously aspirated and the stent was deployed. The patient received chest compressions, oxygen and intracoronary atropine, and epinephrine, resulting in complete hemodynamic recovery (5 minutes after initial air embolism) and TIMI (Thrombolysis In Myocardial Infarction) 3 flow in the left coronary artery. The patient had an uneventful recovery, and his troponin-T level increased from Ͻ0.01 ng/mL before the procedure to 0.23 ng/mL the following day. Left ventricular wall motion was normal as assessed by transthoracic echocardiography.There are few case reports of coronary artery air embolization in the literature, likely because of the underreporting of this complication. Massive air embolism seems to be a rare event. 1 Coronary air embolism has been reported to cause chest pain, ST segment elevation, bradycardia, hypotension, and ventricular fibrillation. 2 Our case demonstrates that hemodynamic compromise can occur within seconds and may resolve within a few minutes after prompt treatment, which includes aspiration of the air if possible, 100% oxygen administration and (often intracoronary) atropine, and epinephrine injections. 3,4 Careful preparation of the manifold angioplasty balloons and guiding catheters is crucial to prevent this potentially life-threatening complication. DisclosuresNone. References

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Coronary air embolism: Incidence, severity, and suggested approaches to treatment

Cited by 68 publications

References 8 publications

Massive Systemic Air Embolism During Aortic Root Angiography

Massive Systemic Air Embolism During Aortic Root Angiography

Heparin and Air Filters Reduce Embolic Events Caused by Intra-Arterial Cerebral Angiography

Hemodynamic Consequences of Massive Coronary Air Embolism

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