Secondary deterioration in a patient with cerebral and coronary arterial gas embolism after brief symptom resolution: a case report.

Introduction: Hyperbaric oxygen treatment (HBOT) is recommended for arterial gas embolism (AGE) with severe symptoms. However, once symptoms subside, there may be a dilemma to treat or not. Case presentation: A 71-year-old man was noted to have a mass shadow in his left lung, and a transbronchial biopsy was performed with sedation. Flumazenil was intravenously administered at the end of the procedure. However, the patient remained comatose and developed bradycardia, hypotension, and ST-segment elevation in lead II. Although the ST changes spontaneously resolved, the patient had prolonged disorientation. Whole- body computed tomography revealed several black rounded lucencies in the left ventricle and brain, confirming AGE. The patient received oxygen and remained supine. His neurological symptoms gradually improved but worsened again, necessitating HBOT. HBOT was performed seven times, after which neurological symptoms resolved almost completely. Conclusions: AGE can secondarily deteriorate after symptoms have subsided. We recommend that HBOT be performed promptly once severe symptoms appear, even if they resolve spontaneously.

Transarterial embolization to treat a massive hemothorax during mechanical circulatory support via puncturing of the extracorporeal membrane oxygenation circuit.

BACKGROUND: Current guidelines recommend the use of mechanical circulatory support (MCS) for patients with cardiogenic shock that is refractory to medical therapy. Bleeding is the most common complication of MCS. Transarterial embolization (TAE) is often performed to treat this complication, because it is a less invasive hemostatic procedure. However, the TAE option needs to be carefully considered during MCS, as the access route may be limited during MCS. CASE PRESENTATION: A man in his 70 s was diagnosed with acute myocardial infarction and underwent percutaneous coronary intervention via venoarterial extracorporeal membrane oxygenation (VA-ECMO) and Impella. During treatment in the intensive care unit, he suffered damage to a branch of the internal thoracic artery during a cardiac drainage procedure, which was subsequently treated via emergency TAE. An ECMO return cannula and an Impella sheath were inserted into the patient's right and left femoral arteries, respectively. An approach from the left brachial artery was selected, and the left internal thoracic artery was embolized. Subsequently, the patient required re-intervention to treat re-bleeding from another artery. Because it was difficult to target the target artery from the brachial one, owing to interference from the Impella catheter, the ECMO circuit near the return cannula was punctured and a guiding sheath was inserted. The ECMO flow and the patient's blood pressure decreased following placement of this guiding sheath. We were thus able to maintain the patient's blood pressure by increasing the infusion fluids and Impella flow, and embolize the target artery using a gelatin sponge to achieve hemostasis. CONCLUSION: When TAE is difficult to perform during MCS using an approach from the upper extremities, a lower extremity approach with a sheath inserted into the ECMO circuit may represent a viable alternative.