Endoscopic ultrasound (EUS)-guided choledochoduodenostomy (EUS-CDS) is a safe alternative
to transhepatic cholangiography when endoscopic retrograde cholangiopancreatography
(ERCP) has failed or in patients with altered anatomy [1]. There are however several adverse events that can be life-threatening in some circumstances
[1]
[2].
A 66-year-old woman presented with obstructive jaundice secondary to advanced pancreatic
cancer. A gastrojejunal anastomosis had been previously performed to bypass a long
duodenal stenosis. EUS-CDS was attempted because of difficulties in reaching the papilla.
Temporary duodenal stenting as a bridge to ERCP was not considered given its high
failure rate in the presence of tumor infiltration [3].
Under carbon dioxide insufflation, the dilated common bile duct (CBD) was punctured
and bile was subsequently aspirated. The biliary tree was opacified and a 0.0025-inch
angled guidewire was inserted quite easily. A fistulotomy was performed with some
temporary bleeding, which was controlled, at the puncture site. Shockingly, at the
re-opacification check, the vascular portal system was recognized ([Fig. 1]), indicating that it had been catheterized, probably secondarily to erroneous guidewire
manipulation. Given the absence of bleeding and the patient’s stable vital parameters,
the procedure was started again, and this time was successfully performed ([Video 1]). The patient’s recovery was uneventful and she left hospital 48 hours later.
Fig. 1 Images of the re-opacification check during endoscopic ultrasound-guided choledochoduodenostomy
(EUS-CDS) showing opacification of the vascular portal system with medium contrast
wash-out, following accidental catheterization of the portal vein due, probably, to
erroneous guidewire manipulation.
Video 1: A 19-G needle was used to puncture the common bile duct, which was then opacified,
followed by deep insertion of 0.0025-inch angled guidewire and fistulotomy. The re-opacification
check showed the procedure had been complicated by portography. The procedure was
restarted and this time endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDS)
was successfully completed with delivery of a 6-cm fully covered biliary metal stent.
Opacification and/or deep cannulation of the portal vein is a rare complication of
ERCP [4], which occurs mainly in patients with biliopancreatic cancer during difficult cannulation
or pre-cut, and may lead to potentially fatal air embolism. Balloon tamponade, covered
stenting, or surgical repair is necessary in case of large defects. Being able to
recognize an erroneous catheterization during secondary opacification is mandatory
and should result in the procedure being stopped immediately, not wrongly considering
that it is the CBD.
This is the first report of portography as a complication during EUS-CDS. Certain
technical steps are important to minimize the effects of this complication: gentle
manipulation during deep insertion of the guidewire, followed by a check for biliary
tree opacification, and carbon dioxide insufflation in order to minimize the risk
of air embolism in case of vascular complications.
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