Surreal illustration of air bubbles forming a heart shape during kidney stone removal, symbolizing paradoxical air embolism.

Air Bubble Alert: When Kidney Stone Removal Goes Wrong

Lena Kashyap in Health & Wellness December 2025 • 4 min read.

"A rare complication during a common procedure highlights the dangers of paradoxical air embolisms and the importance of vigilance."

Kidney stones, a common ailment, often require percutaneous nephrolithotomy (PCNL), a minimally invasive procedure to remove them. While generally safe, PCNL carries rare but serious risks. One such risk is paradoxical air embolism, a condition where air bubbles enter the bloodstream and travel to the heart and brain, potentially causing life-threatening complications.

A recent case highlights the importance of awareness and preparedness for this rare event. A 76-year-old man undergoing PCNL for a kidney stone experienced a paradoxical air embolism, leading to a cascade of complications, including a myocardial infarction (heart attack).

This article delves into the details of this case, exploring the causes, symptoms, diagnosis, and management of paradoxical air embolism during PCNL, emphasizing the need for vigilance and prompt intervention to ensure patient safety.

What Happened? A Step-by-Step Breakdown

Surreal illustration of air bubbles forming a heart shape during kidney stone removal, symbolizing paradoxical air embolism.

The patient was positioned prone, and access to the right kidney's collecting system was achieved using fluoroscopic guidance. Air was insufflated to visualize the collecting system, but despite repeated attempts, visualization remained inadequate. A total of 240 mL of air was introduced.

Suddenly, the patient's blood pressure dropped, and end-tidal CO2 levels decreased, signaling a problem. The procedure was immediately halted, and the patient was repositioned for resuscitation. A transesophageal echocardiogram (TEE) revealed air in both sides of the heart, with the intra-atrial septum (the wall between the heart's upper chambers) bowing, suggesting a right-to-left shunt.

Right-to-Left Shunt: This occurs when blood flows from the right side of the heart to the left, bypassing the lungs. In this case, it was likely due to a previously undiagnosed patent foramen ovale (PFO), a small opening between the heart's upper chambers that usually closes after birth.
Air Embolism: The air introduced during the PCNL procedure entered the venous system and traveled to the right side of the heart. Due to the PFO, the air crossed over to the left side of the heart and then to the systemic circulation, potentially affecting the brain and heart.
Myocardial Infarction: The patient subsequently experienced a self-limited ventricular tachycardia (rapid heart rate) and electrocardiogram changes indicative of a heart attack.

The patient was then transferred to the intensive care unit (ICU) for further management. He required intubation, inotropic support to maintain blood pressure, and diuretics to manage pulmonary edema (fluid in the lungs). Fortunately, he stabilized, was weaned off inotropes, extubated, and discharged three days later.

The Takeaway: Vigilance and Preparedness are Key

This case underscores the importance of being aware of the potential for paradoxical air embolism during PCNL, particularly in patients with risk factors such as a PFO. Although rare, this complication can have serious consequences.

Symptoms of air embolism can include sudden drops in blood pressure, decreased end-tidal CO2, tachycardia, and neurological changes. Prompt recognition and intervention, including immediate termination of the procedure, resuscitation, and TEE, are crucial for successful management.

While hyperbaric oxygen therapy can be beneficial, this patient was successfully managed with supportive care in the ICU. This case serves as a reminder to healthcare professionals to maintain vigilance and be prepared to manage this potentially fatal complication effectively.

About this Article -

This article was crafted using a human-AI hybrid and collaborative approach. AI assisted our team with initial drafting, research insights, identifying key questions, and image generation. Our human editors guided topic selection, defined the angle, structured the content, ensured factual accuracy and relevance, refined the tone, and conducted thorough editing to deliver helpful, high-quality information.See our About page for more information.

This article is based on research published under:

DOI-LINK: 10.5489/cuaj.2835, Alternate LINK

Title: Paradoxical Air Embolism During Percutaneous Nephrolithotomy Due To Patent Foramen Ovale: Case Report

Subject: Urology

Journal: Canadian Urological Association Journal

Publisher: Canadian Urological Association Journal

Authors: Daljeet Chahal, Vladimir Ruzhynsky, Iain Mcauley, Desmond Sweeney, Paul Sobkin, Michael Kinahan, Rich Gardiner, John Kinahan

Published: 2015-09-09

Everything You Need To Know

What exactly is a paradoxical air embolism, and why is it concerning in the context of kidney stone removal?

A paradoxical air embolism is a serious complication that can occur during procedures like percutaneous nephrolithotomy (PCNL). It happens when air bubbles enter the bloodstream and travel to the heart and brain, potentially causing life-threatening complications. In the context of kidney stone removal, it's significant because it highlights the importance of vigilance and preparedness during the procedure. This involves recognizing the potential risks, monitoring the patient closely, and being ready to intervene promptly if an air embolism occurs.

What is percutaneous nephrolithotomy (PCNL), and how does it relate to the risk of air embolism?

Percutaneous nephrolithotomy (PCNL) is a minimally invasive procedure used to remove kidney stones. While generally safe, PCNL carries the risk of complications. One of these is paradoxical air embolism, a rare but serious event. This procedure involves accessing the kidney's collecting system, and if air enters the bloodstream during this process, it can lead to an air embolism. Understanding the potential for paradoxical air embolism underscores the need for careful technique and patient monitoring during PCNL.

What is a right-to-left shunt, and how does it increase the risk of paradoxical air embolism during PCNL?

A right-to-left shunt occurs when blood flows from the right side of the heart to the left, bypassing the lungs. In the case described, this was likely due to a previously undiagnosed patent foramen ovale (PFO). The significance here is that a right-to-left shunt allows air bubbles from the venous system to bypass the lungs and enter the systemic circulation, affecting the brain and heart. The presence of a PFO, therefore, increases the risk of a paradoxical air embolism leading to complications such as a myocardial infarction.

What are the key symptoms of a paradoxical air embolism, and why is it important to recognize them quickly?

The symptoms of paradoxical air embolism can include a drop in blood pressure, decreased end-tidal CO2 levels, and changes visible on a transesophageal echocardiogram (TEE). In the scenario, the patient experienced a myocardial infarction (heart attack) as a result of the air embolism. Recognizing these symptoms promptly is crucial because they signal that air has entered the bloodstream and is affecting the heart and brain. Prompt diagnosis and intervention, such as halting the procedure and repositioning the patient, are critical to minimize the damage and improve patient outcomes.

What are the potential implications of a paradoxical air embolism, and what measures can be taken to mitigate the risks?

The implications of paradoxical air embolism during percutaneous nephrolithotomy (PCNL) are severe, potentially leading to serious complications such as myocardial infarction (heart attack), and other life-threatening conditions. This case highlights the need for vigilance during PCNL, particularly in patients with risk factors such as a patent foramen ovale (PFO). Preparedness involves careful monitoring, immediate response to symptoms, and the availability of interventions to manage the air embolism. The patient's recovery shows that prompt intervention is vital for preventing lasting damage, and emphasizing the significance of vigilance and preparedness in such procedures.