Clin Endosc.  2022 May;55(3):458-462. 10.5946/ce.2021.114.

Endoscopic ultrasound-guided portal vein coiling: troubleshooting interventional endoscopic ultrasonography

• Haba S
• Hara K
• Mizuno N
• Kuwahara T
• Okuno N
• Miyano A
• Fumihara D
• Elshair M

• KMID: 2529970
• DOI: http://doi.org/10.5946/ce.2021.114

Abstract

Endoscopic ultrasound (EUS)-guided hepaticogastrostomy (HGS) is widely performed not only as an alternative to transpapillary biliary drainage, but also as primary drainage for malignant biliary obstruction. For anatomical reasons, this technique carries an unavoidable risk of mispuncturing intrahepatic vessels. We report a technique for troubleshooting EUS-guided portal vein coiling to prevent bleeding from the intrahepatic portal vein after mispuncture during interventional EUS. EUS-HGS was planned for a 59-year-old male patient with unresectable pancreatic cancer. The dilated bile duct (lumen diameter, 2.8 mm) was punctured with a 19-gauge needle, and a guidewire was inserted. After bougie dilation, the guidewire was found to be inside the intrahepatic portal vein. Embolizing coils were placed to prevent bleeding. Embolization coils were successfully inserted under stabilization of the catheter using a double-lumen cannula with a guidewire. Following these procedures, the patient was asymptomatic. Computed tomography performed the next day revealed no complications.

Keyword

Biliary system; Endoscopic ultrasound; Obstructive jaundice; Pancreatic ductal carcinoma; Therapeutic embolization

Figure

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  Fig. 1. (A) Computed tomography before the procedure reveals dilatation of the intrahepatic bile duct. (B) Color doppler endoscopic ultrasound image before procedure. Slightly dilated intrahepatic bile duct (arrow) and intrahepatic portal vein (arrowhead).

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  Fig. 2. (A) Image of double-lumen cannula. Main port (opening at the tip; arrow) is available for a 0.025-inch guide wire, and side port (opening at the side hole; arrowhead) is available for a 0.035-inch guide wire. (B) The guidewire (arrow) is inserted into the portal vein through the main port of the cannula and coils (arrowhead) were placed through the side port. (C) The first coil remains peripherally in the portal vein, while the second coil is placed along the puncture route.

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  Fig. 3. (A) The final image of the procedure shows placed coils (arrows) and an inserted transpapillary stent. (B) Computed tomography the day after the procedure. The peripheral area of the intrahepatic portal vein is embolized.

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