Red-out cannulation. Through the scope, vascular coiling as a novel and immediate approach to stop high-grade bleeding due to portal vein cannulation during ERCP. A 64-year-old woman with a history of a duodenal ulcer complicated by perforation, status posts, exploratory laparotomy, and grand patch repair presented to this hospital's endoscopy center for endoscopic ultrasound evaluation in anticipation of possible chemoablation of a large mucinous pancreatic cyst. Upon initial assessment in the endoscopy unit, it was noted the patient was jaundiced with a total bilirubin of 6.4 milligrams per deciliter, and an ERCP was added to the care plan. EUS revealed common hepatic and bile duct dilation to 8 millimeters without stone or mass lesion, and ERCP was then performed for evaluation and treatment. The endoscopist encounters difficult cannulation due to ampullary stenosis and apparent atypical distal common bile duct pancreatic duct ductile anatomy. The pancreatic duct is first cannulated, followed by a twin-wire technique to facilitate biliary cannulation. Here, a pancreatic duct stent has since been advanced over the pancreatic duct guide wire, and the sphincterotome is being used for wire-only biliary cannulation. Contrast is injected, and fluoroscopy immediately shows contrast extravasation with flow in a vascular-like pattern and consistent with the portal vein and portal confluence, and the endoscopist elects to abort the procedure and instead pursue further imaging including CT angiogram and possible consultation with interventional radiology for further investigation. Upon withdrawal of the sphincterotome, the endoscopist encounters bleeding, of which decreases without need for additional intervention. The patient is admitted to the hospital observation unit for close monitoring where the patient remains hemodynamically stable without a need for transfusion of blood products. The patient undergoes CT angiography of the abdomen and pelvis for further evaluation, which is essentially unrevealing with no clear biliary vascular fistula or connection. The following day, the decision is made for the patient to undergo repeat ERCP. The endoscopist experiences challenging biliary cannulation once again. Upon more aggressive efforts for biliary cannulation, a tubular structure is visualized. In contrast, illuminated what appeared to be a vascular structure communicating with the portal system. Upon further attempts to achieve biliary cannulation, the guide wire and sphincter tome were advanced to try to visualize biliary structures, but now clear demonstration of the portal system is noted. The endoscopist is unable to access the biliary system without inadvertent cannulation in the portal venous system. On any attempts of removal of the sphincter tome, the endoscopist encounters high-grade bleeding. Interventional radiology consultation was obtained from the audoscopy suite, and the decision is made to attempt to use pushable embolization coils through the endoscope to occlude the anomalous vascular connection leading to high-grade bleeding. The 0.035-inch wire was exchanged for a 0.018-inch wire and a 5-french cannula sphincteratome. The embolization coil-loading cannula was placed onto the 5-french ERCP cannula. Then, three 2-mm to 3-mm pushable coils were deployed by a brisk, high-pressure saline flush from a 3-cc syringe to advance the coils through the ERCP cannula to the targeted ectopic vessel. After coil insertion and placement, injection of contrast shows complete cessation of flow through the vasculature and non-visualization of the portal venous structures, indicating complete hemostasis following vascular coil deployment. Following the procedure, the patient was continued to be monitored in the hospital where subsequent MR angiography with venography and MRCP showed no further vascular abnormalities and, interestingly, the extrahepatic ductal dilation seemed to improve. Due to persistently elevated liver function tests, the patient then underwent liver biopsy which showed steatitosis and changes consistent with early cirrhosis and acute alcohol-associated hepatitis. The patient was discharged and outpatient clinic follow-up showed resolution of the hyperbilirubinemia with cessation of alcohol consumption. Managing bleeding during ERCP is an important skill and can be done in a variety of ways. Although most bleeding etiologies are due to sphincterotomy or intrabiliary pathology and can be best managed with tamponade using a fully covered metal wall stent, in this case, portal venous bleeding was discovered likely secondary to guidewire passage into an ectopic portal vein branch at the level of the ampulla or just proximal to it. Unusual cases, such as this, present a unique opportunity to think of novel and multidisciplinary solutions. In this case, we demonstrated the use of embolization coils as a tool that can be used through the endoscope by deploying a pushable coil with a brisk saline flush through the ERCP cannula to the desired vessel identified on fluoroscopy.

ERCP

embolization coils

portal vein cannulation

cirrhosis

hemostasis