Endoscopic retrograde cholangiopancreatography (ERCP) is a pivotal endoscopic technique for hepatobiliary and pancreatic diseases. Although rare, air embolism during ERCP carries a high risk of mortality and disability, with significant challenges in timely recognition. Current understanding of its pathogenesis, clinical manifestations, and emergency management remains insufficient. Air embolism requires two prerequisites: an open vascular pathwayand abnormal pressure gradients. It can be classified into venous, arterial, and paradoxicalsubtypes based on the embolized vasculature. Clinical presentations are nonspecific and heterogeneous, oftenmasked by sedation or anesthesia, leading to delayed diagnosis. Key risk factors include prior biliary surgery, sphincterotomy, biliovenous fistula formation, and biliary stent placement. Diagnosis relies on integrating intraoperative vital sign monitoring, imagingexamination, and cardiocirculatory/neurological assessments. Timely recognition and intervention are critical, includingprocedure termination, 100% oxygen therapy, positional adjustment, and hemodynamic stabilization. Preventive strategies involve strict adherence to ERCP indications, preoperative screening of high-risk patients, CO₂ insufflation instead of air, and enhanced intraoperative real-time monitoring. Clinicians should maintain a high alert for air embolism, optimize procedural protocols, implement surveillance, and establish emergency response plans to mitigate this life-threatening complication.
