CathLabHub

CathLabHub complications toolkitcathlabhub.com/toolkit/air-embolismIn review, October 24, 2026

Recognize

The signs on the monitor, the image and the patient.

  • ImageRound lucent bubbles in the vessel on the cine, or flow that stops abruptly after an injection 12.
  • MonitorSudden ST elevation, bradycardia or heart block (often in the right coronary), hypotension, or VF with a large bolus 2.
  • PatientAbrupt chest pain right after a hand injection, a manifold refill, a device exchange or a balloon rupture 2.
  • ImageAir in the manifold or the injector line, a damped pressure before the injection, or a trapping exchange without back bleeding 2.

Act now

In the order the operator does them. The first three come first, whatever else is happening.

  1. Stop all injections through that manifold until it is cleared 2.
  2. Give 100 percent oxygen by non rebreather mask; it helps the air resorb 21.
  3. Call for help and treat the rhythm and pressure at once: atropine for bradycardia, vasopressors, defibrillation for VF 2.
  4. Aspirate through the guide; for a large volume, aspirate with an aspiration thrombectomy catheter 2.
  5. Pass a workhorse wire to the distal vessel and into the side branches to break up remaining bubbles 2.
  6. Clear the manifold and the guide: aspirate until blood returns, then flush and inspect for bubbles 1.
  7. Intracoronary epinephrine if the patient arrests 2.
  8. Systemic or cerebral air: hyperbaric oxygen can be considered; Trendelenburg is controversial 2.

Equipment

From the complications cart. Linked items open in the equipment directory.

Drugs

Adult doses as the cited source gives them. Check your formulary and the label.

  • Oxygen100 percent by non rebreather mask 2.
  • Atropine0.5 mg IV, repeat to 3 mg total 3; 1 mg every 3 to 5 minutes, maximum 3 mg, in the 2020 AHA guideline 4.
  • Epinephrine, cardiac arrest1 mg IV every 3 to 5 minutes 43; intracoronary epinephrine is described for arrest from air 2.

Who to call

The escalation ladder, first call first.

  1. Second operator: to manage the wire and aspiration while you run the code.
  2. Code team: for VF or arrest.
  3. Anesthesia: for the airway and oxygen.
  4. Hyperbaric medicine and neurology: for cerebral or systemic air 2.

The bailout step by step

Aspirating coronary air 21

  1. Stop injecting; close the manifold to the patient.
  2. Aspirate the guide with a dry syringe until blood returns, discard it.
  3. If flow does not return, advance an aspiration catheter over the wire into the vessel and aspirate along its length.
  4. Pass the wire into each side branch to fragment bubbles distally.
  5. Clear the manifold: remove the syringe, back bleed, refill with no air, tap out bubbles.
  6. Inject gently once the system is clean and confirm flow.

Prevent

  • Meticulous manifold or injector preparation and clearing after the catheter crosses the aorta 2.
  • Back bleed the Y connector after every trapping exchange 2.
  • Prepare balloons and large devices to remove all air 2.
  • Never inject on a damped pressure 2.

After care and documentation

  • ECG and troponin; neurologic check if air may have reached the aorta.
  • Document when it happened, the source and what restored flow.
  • Review the manifold setup with the team.

Practice

Emergency simulator cases in the Cath Trainer app. The link opens Cases; type the case number in the search box.

  • EMG-0016: An injection followed by pain and bradycardia
  • EMG-0041: Chest pain after a device exchange
  • EMG-0091: Chest pain after a balloon bursts at high pressure

References

  1. Berg R, Lim MJ. Complications of percutaneous coronary interventions. In: Kern MJ, ed. The Interventional Cardiac Catheterization Handbook. 3rd ed. Saunders, Elsevier; 2013. Chapter 4.
  2. Brilakis ES. Manual of Percutaneous Coronary Interventions. Elsevier; 2021. Chapter 25, Acute vessel closure.
  3. Brilakis ES. Manual of Percutaneous Coronary Interventions: A Step-by-Step Approach. Academic Press, Elsevier; 2021. Chapter 3, Medications.
  4. Panchal AR, Bartos JA, Cabanas JG, et al. Part 3: adult basic and advanced life support. 2020 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation 2020;142(suppl 2):S366-S468.
  5. CathLabHub Cath Trainer app, emergency simulator: case library (cathlabhub.com/app, Cases).

Educational reference for cath lab teams, not medical advice and not a standard of care. Your local policy, the device instructions for use and current guidelines govern. Verify every dose before use. Printed from cathlabhub.com/toolkit/air-embolism. First version, in clinical review: an interventional cardiologist is checking every card before it is final. Every number cites its source on the card.