Massive bleeding on removing a stent placed during endoscopic ultrasound-guided transluminal drainage

A 67-year-old man with pancreatic head cancer developed acute pancreatitis due to obstruction of the main pancreatic duct. He subsequently developed an infected walled-off necrosis (WON) ([Fig. 1]). Endoscopic ultrasound-guided transluminal drainage (EUS-TD) was performed using a 6-Fr endoscopic nasobiliary drainage catheter (SilkyPass; Boston Scientific, Tokyo, Japan) as an external drainage tube and a 7-Fr/7-cm double-pigtail plastic stent (DPS) (Zimmon biliary stent; Cook Medical, Tokyo, Japan) as an internal drainage tube ([Fig. 2]). Subsequently, the patient’s condition improved, and the external drainage tube was removed. Computed tomography (CT) performed 4 months after EUS-TD revealed that the WON had disappeared. The DPS was in place until pancreaticoduodenectomy after neoadjuvant chemotherapy and was removed endoscopically 8 months after EUS-TD because of the risk that the DPS could cause infection during adjuvant chemotherapy. At the time the stent was removed, massive arterial bleeding occurred from the fistula ([Video 1]). Since endoscopic hemostasis was difficult, urgent interventional radiology was performed, and a splenic artery pseudoaneurysm causing massive bleeding was detected ([Fig. 3]). Hemostasis was achieved using coil embolization ([Fig. 4]).

Fig. 1 An abdominal computed tomography image shows walled-off necrosis (arrows). The diameter of the lesion is approximately 8 cm.

Fig. 2 Endoscopic ultrasound-guided transluminal drainage was performed using a 6-Fr endoscopic nasobiliary drainage catheter (white arrowheads) as an external drainage tube and a 7-Fr/7-cm double-pigtail plastic stent (yellow arrowheads) as an internal drainage tube.

Video 1 Massive bleeding caused by the removal of a double-pigtail plastic stent after its prolonged placement for internal drainage of a walled-off necrosis.

Fig. 3 Interventional radiology detected a splenic artery pseudoaneurysm. a Selective angiogram of the celiac artery showed pooling of contrast medium (arrow), indicating the presence of a splenic artery pseudoaneurysm. b A computed tomography image detected the splenic artery pseudoaneurysm (arrowhead).

Fig. 4 Angiogram after coil embolization for hemostasis shows no pooling of the contrast medium (arrow).

WON is a late complication of acute necrotizing pancreatitis. Currently, EUS-TD is the best therapeutic option for WON [1]. Although lumen-apposing covered self-expanding metal stents have been introduced, EUS-TD with DPS remains the main endoscopic therapy for WON. DPS is associated with lower rates of procedure-related bleeding, such as serious pseudoaneurysm bleeding [2] [3]. Nevertheless, in this case, massive bleeding due to a pseudoaneurysm occurred after stent removal. The pseudoaneurysm may have been formed by the long period of stent placement and contact, causing arteritis. When removing a plastic stent after a long period of placement, it is crucial to consider that serious complications can occur, and contrast-enhanced CT should be performed to check for the presence of a pseudoaneurysm before stent removal.

Endoscopy_UCTN_Code_TTT_1AO_2AD

Publication History

Article published online:
04 August 2022

• References

• 1 Ang TL, Teoh AYB. Endoscopic ultrasonography-guided drainage of pancreatic fluid collections. Dig Endosc 2017; 29: 463-471
• 2 Brimhall B, Han S, Tatman PD. et al. Increased incidence of pseudoaneurysm bleeding with lumen-apposing metal stents compared to double-pigtail plastic stents in patients with peripancreatic fluid collections. Clin Gastroenterol Hepatol 2018; 16: 1521-1528
• 3 Lang GD, Fritz C, Bhat T. et al. EUS-guided drainage of peripancreatic fluid collections with lumen-apposing metal stents and plastic double-pigtail stents: comparison of efficacy and adverse event rates. Gastrointest Endosc 2018; 87: 150-157