“Double trouble”: embedded lumen-apposing metal stent and embolization coils

A 56-year-old man with history of alcoholic pancreatitis complicated by chronic pseudocyst in the pancreatic head presented with abdominal pain and enlarging pseudocyst. He underwent endoscopic ultrasound-guided cystogastrostomy and placement of an AXIOS 15 × 10 mm lumen-apposing metal stent (LAMS; Boston Scientific, Marlborough, Massachusetts, USA). He presented at the emergency department 2 weeks later with melena and a 4-g drop in hemoglobin. Computed tomography angiogram followed by visceral angiogram confirmed inferior pancreaticoduodenal artery (PDA) pseudoaneurysm, which was treated with coil embolization ([Fig. 1], [Fig. 2]). No further episodes of melena occurred and the patient was discharged in a stable condition.

Fig. 1 Computed tomography angiogram showing distal pancreaticoduodenal artery pseudoaneurysm (arrows).

Fig. 2 Visceral angiography showing distal pancreaticoduodenal artery pseudoaneurysm.

Six weeks after cystogastrostomy, attempted LAMS removal during esophagogastroduodenoscopy (EGD) was unsuccessful as the stent had migrated inside the collapsed cavity and become embedded in the gastric wall. Repeat EGD at a tertiary center showed that the embolization coils had migrated into the decompressed cavity in the middle of the distal embedded flange of the stent ([Fig. 3], [Fig. 4]). The LAMS was extracted using rat-tooth forceps and gentle evulsion of the embedded proximal flange; the coils were left in place ([Video 1]).

Fig. 3 Migrated and embedded stent in the gastric wall.

Fig. 4 Migrated stent and embolization coils.

Video 1 Removal of lumen-apposing metal stent (LAMS) following migration and embedding of LAMS and embolization coils.

Endoscopic placement of fully covered self-expandable metal stents/LAMS is the mainstay of therapy for pancreatic fluid collections (PFCs) [1] [2]. LAMS migration occurs in up to 6.5 %, usually when stents are left in situ for > 6 weeks [3]. Pancreatitis-associated PDA pseudoaneurysms are extremely rare, but could lead to hemorrhage, with a mortality rate > 25 % [4]. Therefore, regardless of size, active treatment of PDA pseudoaneurysms is recommended [5]. Concomitant coil and stent migration and embedding is an extremely rare complication. Efforts should be made for early (< 4 weeks) LAMS removal to prevent embedding. Endoscopists should be mindful of these rare events in patients with complicated pancreatitis with PFCs and treated pseudoaneurysms to prevent blind stent extraction and complications.

Endoscopy_UCTN_Code_CPL_1AL_2AG

• References

• 1 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
• 2 Bang JY, Hasan MK, Navaneethan U. et al. Lumen-apposing metal stents for drainage of pancreatic fluid collections: when and for whom?. Dig Endosc 2017; 29: 83-90
• 3 Bang JY, Navaneethan U, Hasan MK. et al. Non-superiority of lumen-apposing metal stents over plastic stents for drainage of walled-off necrosis in a randomised trial. Gut 2019; 68: 1200-1209
• 4 Yanagaki S, Yamamoto Y, Nagasawa T. Ruptured pseudoaneurysm in the inferior pancreaticoduodenal artery. Intern Med 2016; 55: 3233-3234
• 5 Tulsyan N, Kashyap VS, Greenberg RK. et al. The endovascular management of visceral artery aneurysms and pseudoaneurysms. J Vasc Surg 2007; 45: 276-283