A 53 year-old woman reported progressive diarrhea, flushing, and weight loss over several years. Her medical history was significant for hypertension and seizure disorder. In December of 2006, she underwent a CT scan of the abdomen as part of a workup for abdominal pain; she was found to have a large mass in the left lobe of the liver. A biopsy was obtained which demonstrated metastatic well differentiated neuroendocrine carcinoma. Follow-up colonoscopy showed a 2.5 cm mass in her terminal ileum. Somatostatin receptor scintigraphy showed marked bilobar hepatic uptake consistent with metastatic carcinoid but no extrahepatic metastatic disease. In March 2007, she underwent a right hemicolectomy to remove the presumed primary lesion. Intraoperatively, her hepatic disease was felt to be too extensive for resection. Pathology showed a 3.2 cm well-differentiated neuroendocrine carcinoma of the terminal ileum with lymphatic and vascular invasion, and 8/25 lymph nodes tested positive for metastatic disease. She was started on long acting somatostatin analog therapy post-operatively, which controlled her symptoms of flushing and diarrhea. After her exploration, she developed post-operative hypoxia necessitating a transthoracic echocardiogram shortly after surgery. The echocardiogram showed normal left ventricular systolic function and severe tricuspid regurgitation. Heart catheterization demonstrated significantly elevated right atrial pressures and a patent foramen ovale (PFO). The foramen ovale was temporarily occluded with a 7-French balloon, and her oxygen saturation increased from 88% to 99%, confirming the presence of a severe right to left atrial shunt. She experienced a drop in cardiac output; therefore, a permanent solution was not sought. In July 2007, she was found to have progressive hepatic metastases after being referred to the Neuroendocrine Tumor Clinic at Ohio State University for further management. Transarterial Chemoembolization (TACE) was recommended and a vena cava filter was placed to prevent a paradoxical embolus during her post-procedure convalescence. Whole liver TACE was undertaken in August 2007 with Cisplatin AQ 50 mg, Doxorubicin 30 mg, Mitomycin 20 mg, Iodixanol 3200 mg, and 300–500 and 500–700 micron embospheres. As per institutional protocol, somatostatin analog (octreotide) was continuously infused before, during, and after TACE. In the first 12 hours following TACE, the patient had two seizures and mental status changes. Brain imaging did not demonstrate acute changes so the patient was treated for encephalopathy. Over the ensuing 24 hours, she became progressively more somnolent and developed worsening abdominal tenderness. She was transferred to the intensive care unit and intubated for airway protection. Once placed on positive pressure ventilation, she became hypotensive and hypoxic, necessitating large volume resuscitation and vasopressor therapy. Her hypoxia was unresponsive to increases in oxygen supplementation and positive end expiratory pressure (PEEP). Pulmonary artery catheter measurement demonstrated moderate pulmonary hypertension with pulmonary artery pressures as high as 70 mmHg and depressed cardiac output of 3–3.5 liters per minute. During this time, she developed abdominal tenderness. Computed tomography (CT) scan demonstrated pneumatosis intestinalis involving the small bowel without evidence of perforation. At that time, her abdominal examination was benign; she showed no systemic signs of infection, including negative cultures from blood, urine, and sputum. Broad spectrum antibiotics were started, and she was kept on bowel rest. Echocardiogram demonstrated pulmonary hypertension, severe right-to-left shunting across her PFO and left ventricular ejection fraction of 35% (compared to 65% pre-TACE). Efforts were made to minimize her PEEP and accept lower arterial oxygen saturations of 85 to 88%. As the acute inflammatory response abated over the next 72 hours, the patient's mental status cleared and her abdominal pain resolved. She rapidly weaned from the ventilator and tolerated enteral feeding. She was ultimately discharged to home 10 days after her TACE without residual sequelae. After discharge, the patient completely recovered and had significant serologic, radiographic, and symptomatic response to TACE. At eight month follow-up, the patient showed marked reduction in hepatic tumor burden and near-total resolution of her carcinoid syndrome symptoms. Her serum pancreastatin levels decreased from 13,400 pg/mL (normal <135 pg/mL) prior to TACE to 1,230 pg/mL. She has undergone subsequent echocardiography with improvement in her pulmonary hypertension and restoration of a normal ejection fraction.