Endoscopy 2020; 52(02): E47-E48
DOI: 10.1055/a-0991-7763
E-Videos
© Georg Thieme Verlag KG Stuttgart · New York

Endoscopic management of accidental portal vein puncture during endoscopic ultrasound-guided choledochoduodenostomy

Carolina Mangas-Sanjuan
Endoscopy Unit, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante, ISABIAL, Alicante, Spain
,
Maryana Bozhychko
Endoscopy Unit, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante, ISABIAL, Alicante, Spain
,
Juan Martinez
Endoscopy Unit, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante, ISABIAL, Alicante, Spain
,
Luis Compañy
Endoscopy Unit, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante, ISABIAL, Alicante, Spain
,
Francisco Ruiz
Endoscopy Unit, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante, ISABIAL, Alicante, Spain
,
Juan Antonio Casellas
Endoscopy Unit, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante, ISABIAL, Alicante, Spain
,
José Ramón Aparicio
Endoscopy Unit, Hospital General Universitario de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante, ISABIAL, Alicante, Spain
› Author Affiliations
Further Information

Corresponding author

José Ramón Aparicio, MD
Endoscopy Unit
Hospital General Universitario de Alicante
C/Pintor Baeza 12
03010 Alicante
Spain   
Fax: +34-965-933468   

Publication History

Publication Date:
09 September 2019 (online)

 

A 65-year-old woman was admitted to our department with obstructive jaundice secondary to locally advanced unresectable pancreatic adenocarcinoma. Biliary cannulation attempt was unsuccessful during endoscopic retrograde cholangiopancreatography; therefore, biliary drainage with endoscopic ultrasound (EUS)-guided choledochoduodenostomy (CDS) was planned with palliative intent ([Video 1]).

Video 1 Endoscopic management of accidental portal vein puncture during endoscopic ultrasound-guided choledochoduodenostomy.


Quality:

An upstream common bile duct (CBD) dilatation (14 mm) was visualized on EUS ([Fig. 1]). A 0.025-inch guidewire was preloaded into a lumen-apposing metal stent (LAMS) (8 × 8 mm) mounted onto an electrocautery-enhanced delivery system (Hot-AXIOS; Boston Scientific Co., Marlborough, Massachusetts, USA). The cautery-enabled access catheter was advanced through the duodenal bulb wall into the CBD using the “hybrid free-hand” insertion technique [1]; however, the portal vein was accidentally punctured. Despite this severe complication, the delivery system was carefully withdrawn upwards until the internal flange was able to be deployed into the CBD while the proximal flange was deployed into the duodenal bulb under EUS guidance ([Fig. 2]). After the LAMS had been delivered, severe bleeding was observed through the stent. Using a sphincterotome passed through a gastroscope, wire-guided access through the LAMS to the CBD was achieved ([Fig. 3]). Then, a 0.025-inch guidewire (VisiGlide; Olympus Medical Systems Corp., Tokyo, Japan) was advanced across the tumor and the papilla. Following successful biliary cannulation after EUS-guided biliary rendezvous, a fully covered self-expandable metal stent (WallFlex Biliary RX Stent; Boston Scientific Co.) (10 × 60 mm) was placed into the CBD to seal the disruption of the portal vein wall ([Fig. 4]).

Zoom Image
Fig. 1 Pancreatic head adenocarcinoma (cT4cN1M0) and common bile duct dilatation.
Zoom Image
Fig. 2 An upstream dilatation of the common bile duct (14 mm) before the insertion of the Hot-AXIOS catheter (Boston Scientific Co., Marlborough, Massachusetts, USA). CBD, common bile duct; PV, portal vein.
Zoom Image
Fig. 3 Active bleeding trough the lumen-apposing metal stent after accidental portal vein puncture.
Zoom Image
Fig. 4 View of the self-expandable metal stent (SEMS) (10 × 60 mm) delivered to seal the iatrogenic portal vein injury.

The patient was discharged home after 72 hours without further adverse events, and bilirubin levels returned to normal after 7 days.

Complications during EUS-CDS may occur [2] [3] [4] [5], and the use of electrocautery-enhanced LAMS for this procedure is still in its infancy. Pre-existing guidewire access to the CBD before the advancement of a cautery-enabled stent delivery catheter may prevent complications.

Endoscopy_UCTN_Code_CPL_1AL_2AD

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Competing interests

Dr. Aparicio is a consultant for Boston Scientific.


Corresponding author

José Ramón Aparicio, MD
Endoscopy Unit
Hospital General Universitario de Alicante
C/Pintor Baeza 12
03010 Alicante
Spain   
Fax: +34-965-933468   


Zoom Image
Fig. 1 Pancreatic head adenocarcinoma (cT4cN1M0) and common bile duct dilatation.
Zoom Image
Fig. 2 An upstream dilatation of the common bile duct (14 mm) before the insertion of the Hot-AXIOS catheter (Boston Scientific Co., Marlborough, Massachusetts, USA). CBD, common bile duct; PV, portal vein.
Zoom Image
Fig. 3 Active bleeding trough the lumen-apposing metal stent after accidental portal vein puncture.
Zoom Image
Fig. 4 View of the self-expandable metal stent (SEMS) (10 × 60 mm) delivered to seal the iatrogenic portal vein injury.