Cardiac Arrest after Transbronchial Lung Cryobiopsy in Systemic Sclerosis-associated Interstitial Lung Disease, Attributed to Pulmonary Embolism and Managed with Venoarterial Extracorporeal Membrane Oxygenation: A Case Report

Abstract

Transbronchial lung cryobiopsy is increasingly adopted to evaluate diffuse lung disease, yet rare catastrophic complications can occur. We describe a 64-year-old woman with systemic sclerosis-associated interstitial lung disease in whom cardiopulmonary arrest developed shortly after the procedure. High-resolution computed tomography showed only mild subpleural ground-glass opacity and reticulation in the lower lobes without honeycombing. Pre-procedural functional data showed forced vital capacity 74.8% predicted, diffusing capacity 58.1% predicted, and six-minute walk desaturation from 96% to 82%; transthoracic echocardiography was not performed under our care. The event was clinically attributed to acute pulmonary embolism. Cryobiopsy specimens obtained before the embolic event showed minimal fibrosis without inflammation or granulomas, airway-centered fibrosis suggestive of hypersensitivity pneumonitis, and vascular remodeling consistent with Heath-Edwards grade III arteriopathy. Prompt venoarterial extracorporeal membrane oxygenation enabled survival with good neurological recovery. This case offers endoscopy-centered lessons: when limited radiographic evidence of disease coexists with disproportionate gas-exchange impairment or exertional desaturation, a risk-based, targeted cardiopulmonary assessment should be considered to refine the decision to perform cryobiopsy and to pre-define escalation pathways, ensuring timely access to advanced hemodynamic support. We emphasize the need for individualized pre-assessment and institutional preparedness for rare but life-threatening deterioration.