Fatal Venous Gas Embolism During Endoscopic Retrograde Cholangiopancreatography After Simultaneous Deployment of 2 Self-Expandable Metallic Stents.

ABSTRACT

Gas embolisms are a rare complication of endoscopic retrograde cholangiopancreatography (ERCP). While there have been multiple reports of ERCP-associated air embolisms, only 2 case reports using oral cholangioscopy and CO2 insufflation have been reported in the literature. We present a unique case of a fatal CO2 venous air embolism during ERCP without using cholangioscopy and with no intentional CO2 insufflation of the biliary tree.