Coronary Artery Air Embolism in the Non–operating room Anesthesia Setting

Abstract

C oronary artery air embolism is a rare complication in the non-operating room anesthesia environment. In this setting, coronary artery air embolism is generally caused by communication between the atmosphere and the pulmonary venous system or by the creation of a bronchialvenous or alveolar-venous fistula during lung biopsy. 1 Typical presentation is a result of the ensuing myocardial ischemia, and includes chest pain, arrhythmia, ST segment changes, bradycardia, hypotension, and cardiovascular collapse. 2 Figure 1 represents the intraprocedural computed tomography imaging of a 74-yr-old woman who underwent percutaneous lung biopsy. Clearly visible is the airfluid level in the ascending aorta, just distal to the right coronary artery ostia. Figure 2 shows air in the proximal right coronary artery. This patient's procedural course was complicated by profound bradycardia, arrhythmia, and cardiogenic shock secondary to acute myocardial ischemia.Risk of coronary artery air embolism is underappreciated outside the cardiac operating room; thus, the anesthesiologist must maintain a high degree of suspicion and closely monitor the electrocardiogram for change. Risk factors include coughing, positive pressure ventilation, biopsy of cavitary lesions, and use of needle-within-needle biopsy systems. 3 In supine patients, the right ventricle is particularly vulnerable to coronary artery air embolism secondary to the anterior takeoff of the right coronary. Treatment involves immediate Trendelenburg positioning to prevent cerebral air embolism, an inspiratory oxygen fraction of 1.0, central access, and catecholamine support of cardiac function and coronary perfusion pressure. Transcutaneous or transvenous pacing, as well as coronary angiography, aspiration, and localized vasodilator injection have also been trialed successfully in the catheterization laboratory. 3 Finally, extracorporeal membrane oxygenation or cardiac bypass may be indicated if other measures fail.

Coronary Artery Air Embolism in the Non–operating room Anesthesia Setting: Comment

“…We read with interest the description by Oesterling et al 1 of a case of coronary artery air embolism. Their article nicely showed imaging confirming arterial gas embolism, demonstrated one of the risks of percutaneous lung biopsy and factors that may increase that risk.…”

Coronary Artery Air Embolism in the Non–operating room Anesthesia Setting: Reply

“…Moon and Camporesi in the field of undersea and hyperbaric medicine and thank them for their input on this topic. 1,2 We readily acknowledge that the Trendelenburg position is detrimental to patients with intracranial hypertension and known cerebral air embolism. Our recommendation focused on the use of the Trendelenburg position for the prevention of cerebral air embolism in the setting of aortic air embolism, acknowledging that the data on this topic are sparse.…”