Arterial bleeding during endoscopic ultrasound-guided pancreatic pseudocyst drainage using a novel ultrasound processor

Bleeding during endoscopic ultrasound-guided pancreatic pseudocyst drainage (EUS-PPD) is most often associated with electrocautery puncture or tract dilation [1] [2] [3] [4] [5]. Conversely, bleeding caused solely by fine-needle puncture is rare. We report a case of arterial bleeding induced by fine-needle puncture performed using a novel ultrasound processor ([Video 1]).

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Arterial bleeding induced by fine-needle puncture performed using a novel ultrasound processor, followed by endoscopic hemostasis.Video 1

A 61-year-old man with a 9-cm pseudocyst in the pancreatic head underwent EUS-PPD ([Fig. 1]). After Doppler evaluation confirmed no intervening vessels, the pseudocyst was punctured from the duodenum with a 22-gauge needle (EZ Shot 3 Plus, Olympus) under the guidance of a novel ultrasound processor (EU-ME3, Olympus, Japan) and an ultrasound endoscope (GF-UCT260, Olympus). We inserted a 0.018-inch guidewire and subsequently removed the needle. We then immediately observed marked arterial spurting into the cyst cavity on gray-scale imaging ([Fig. 2] a). Color Doppler confirmed pulsatile flow from the puncture site into the cyst cavity ([Fig. 2] b). Despite inserting a 7-Fr dilator (ES Dilator, Zeon Medical Co., Japan) for compression hemostasis, bleeding recurred upon its withdrawal. Therefore, a 10-mm fully covered self-expandable metal stent (FCSEMS; HILZO biliary stent, ABIS Inc., Japan) was deployed across the EUS-guided created route, resulting in complete hemostasis. Then, a nasal catheter was placed through the FCSEMS ([Fig. 3]). Postprocedural computed tomography showed no extravasation; however, injury to the posterior superior pancreaticoduodenal artery was suspected ([Fig. 4]). The patient experienced no further bleeding, and 1 month later, the FCSEMS was removed without complications.

Fig. 1 Computed tomography showing a 9-cm pseudocyst in the pancreatic head.

Fig. 2 a Gray-scale ultrasound showing marked arterial spurting from the puncture site into the cyst cavity immediately after the withdrawal of the needle. b Color Doppler imaging confirming the presence of pulsatile arterial flow.

Fig. 3 a Placement of a fully covered self-expandable metal stent deployed across the bleeding site resulting in complete hemostasis. b A nasal catheter inserted through the stent.

Fig. 4 a Postprocedural computed tomography (CT) showing no extravasation. b The reconstructed CT image suggesting injury to the posterior superior pancreaticoduodenal artery (arrow).

This case highlights the possibility of bleeding during EUS-PPD even when Doppler imaging reveals no visible vessels and a thin needle is used. Compared with its predecessor (EU-ME2 model), the EU-ME3 processor detected certain small areas near the gastrointestinal wall lacking blood-flow signals ([Fig. 5]). Thus, caution must be exercised to avoid inadvertent vessel injury near the gastrointestinal wall.

Fig. 5 Color Doppler imaging comparison between the (a) EU-ME3 and (b) EU-ME2 ultrasound processors. The EU-ME3 processor displays a slightly reduced color Doppler imaging area (yellow highlight) near the gastrointestinal wall compared with the EU-ME2.

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Contributorsʼ Statement

Junya Sato: Data curation, Investigation, Methodology, Writing – original draft. Kazunari Nakahara: Conceptualization, Funding acquisition, Investigation, Methodology, Project administration, Writing – review & editing. Yosuke Igarashi: Data curation, Investigation. Yusuke Satta: Data curation, Investigation. Akihiro Sekine: Data curation, Investigation. Yu Matsuda: Data curation, Investigation. Keisuke Tateishi: Funding acquisition, Project administration, Supervision, Writing – review & editing.

Conflict of Interest

The authors declare that they have no conflict of interest.

• References

• 1 Itoi T, Itokawa F, Sofuni A. et al. Late bleeding after EUS-guided transjejunal drainage of a pancreatic pseudocyst in a Roux-en-Y patient. Dig Endosc 2011; 23: 51-53
• 2 Iwashita T, Lee JG, Nakai Y. et al. Successful management of arterial bleeding complicating endoscopic ultrasound-guided cystogastrostomy using a covered metallic stent. Endoscopy 2012; 44: E370-E371
• 3 Săftoiu A, Ciobanu L, Seicean A. et al. Arterial bleeding during EUS-guided pseudocyst drainage stopped by placement of a covered self-expandable metal stent. BMC Gastroenterol 2013; 13: 93
• 4 Matsumori T, Katanuma A, Maguchi H. et al. A case of delayed bleeding 9 days after endoscopic ultrasound-guided pancreatic pseudocyst drainage. Endoscopy 2014; 46: E245-E246
• 5 Li Y, Zhang L, Yu T. et al. Endoscopic management of bleeding after endoscopic ultrasound-guided drainage of a pancreatic pseudocyst. Endoscopy 2023; 55: E310-E311

Publication History

Article published online:
30 January 2026