An 86-year-old woman with distal bile duct cancer and obstructive cholangitis presented
with jaundice and a 5-kg weight loss over 1 month. She underwent endoscopic retrograde
cholangiopancreatography (ERCP) for biliary decompression ([Fig. 1 ]). Initial selective biliary cannulation failed, prompting placement of a plastic
pancreatic duct stent followed by transpancreatic septotomy. A guidewire was advanced
in the presumed direction of the bile duct and contrast injection suggested biliary
opacification. Assuming correct guidewire placement, a fully covered self-expandable
metal stent (FCSEMS) (HANAROSTENT Biliary Full Cover Benefit, 8 mm × 6 cm; M.I. Tech,
Pyeongtaek, South Korea) was deployed. Substantial resistance was encountered during
stent deployment, and the contrast rapidly washed out, raising suspicion of extrabiliary
placement. A contrast-enhanced computed tomography (CECT) performed 2 hours later
revealed that the FCSEMS had traversed the distal bile duct mass and had been inadvertently
placed in the portal vein, resulting in acute portal vein thrombosis ([Fig. 2 ]).
Fig. 1 Coronal contrast-enhanced computed tomography images showing an enhancing mass (white
arrow) in the distal common bile duct with upstream dilation of the intrahepatic (black
arrow heads) and extrahepatic bile ducts (black arrow), suggestive of distal bile
duct cancer.
Fig. 2 Contrast-enhanced computed tomography obtained 2 hours post-endoscopic retrograde
cholangiopancreatography showing maldeployed fully covered self-expandable metal stent
(white arrow) in the portal vein via the distal bile duct mass, with associated portal
vein thrombosis (black arrow).
An emergency ERCP was performed, during which selective biliary cannulation was achieved
via needle-knife precutting. The misplaced stent was retrieved, and a new FCSEMS (HANAROSTENT
Biliary Lasso Full covered, 10 mm × 6 cm; M.I. Tech) and plastic stents were successfully
deployed into the bile duct ([Fig. 3 ], [Video 1 ]). The patient recovered uneventfully and was discharged 10 days later. Follow-up
CECT 7 days later showed portal vein thrombosis, which had resolved spontaneously
by Day 153 without anticoagulation ([Fig. 4 ]).
Fig. 3 Retrieval and replacement of the fully covered self-expandable metal stent (FCSEMS).
a Endoscopic image showing selective bile duct cannulation with subsequent retrieval
of the maldeployed FCSEMS using forceps during emergency endoscopic retrograde cholangiopancreatography.
b Fluoroscopic image demonstrating correct placement of a new FCSEMS within the bile
duct.
Endoscopic rescue and spontaneous resolution of thrombosis after inadvertent portal
vein stenting during endoscopic retrograde cholangiopancreatography for distal bile
duct cancer.Video 1
Fig. 4 Contrast-enhanced computed tomography. a At 7 days post- endoscopic retrograde cholangiopancreatography, demonstrating portal
vein thrombosis (black arrow). b The portal vein thrombosis had spontaneously resolved by follow-up imaging on Day
153 without anticoagulant therapy.
Portal vein injury is a rare but potentially fatal complication of ERCP [1 ]
[2 ]. This case underscores the importance of recognizing signs of vascular misplacement,
such as rapid contrast washout and deployment resistance. Early recognition and prompt
endoscopic management are critical to avoiding serious complications. Notably, the
spontaneous resolution of portal vein thrombosis without anticoagulation suggests
that conservative management may be appropriate in selected patients with localized,
nonocclusive thrombosis.
Endoscopy_UCTN_Code_TTT_1AR_2AZ
E-Videos is an open access online section of the journal Endoscopy , reporting on interesting cases and new techniques in gastroenterological endoscopy.
All papers include a high-quality video and are published with a Creative Commons
CC-BY license. Endoscopy E-Videos qualify for HINARI discounts and waivers and eligibility is automatically checked during the submission
process. We grant 100% waivers to articles whose corresponding authors are based in
Group A countries and 50% waivers to those who are based in Group B countries as classified
by Research4Life (see: https://www.research4life.org/access/eligibility/ ).https://mc.manuscriptcentral.com/e-videos .
