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.