This ASG video tip is brought to you by an educational grant from Braintree, a part of Cibela Pharmaceuticals, makers of SUTAB. The title of this video is Radiofrequency Ablation for Treatment of an Introductal Visible Vessel. The authors report no disclosures. This case involves an 81-year-old female with unresectable hyaluronic carcinoma, status post-hepatic artery infusion pump, who required repeated biliary stenting and presented as an outpatient for routine stent exchange. As seen on the scalp film, she had a previously placed stent in the left hepatic duct. Upon intubating the duodenum, active oozing was seen from the major papilla with a large clot overlying the papilla and the previously placed biliary stent as marked by the arrow. Upon removal of the clot and stent with a snare, active hemobilia was immediately visible. In an attempt to control the bleeding, biliary cannulation was performed using a balloon catheter and a guide wire, which was advanced into the left hepatic duct as seen here on fluoroscopy. With great difficulty due to the enlarging blood clot forming over the papilla that prevented the duodenoscope from getting close to the papilla, a 10-french biliary stent was placed into the common bioduct to attempt tamponade of the bleeding. Upon placement of the stent, an attempt was made to remove the large blood clot by suctioning it into the duodenoscope, which resulted in the blood clot breaking off from the major papilla, thus improving visualization. This allowed for significantly improved scope position as seen on fluoroscopy, facilitating repeat biliary cannulation and placement of an additional 8.5-french stent. The patient was subsequently admitted, and interventional radiology was consulted for consideration of embolization. Due to cessation of bleeding, hemodynamic stability, and risk of biliary and hepatic necrosis, interventional radiology deferred empiric embolization, and the patient was discharged after being observed for three days. Ten days after discharge, the patient was readmitted with hematemesis and concern for recurring hemobilia. After multidisciplinary discussion, a repeat ERCP was performed to attempt localizing the bleeding source. The repeat ERCP included plans to perform the following endoscopic methods. Cholangioscopy would be performed to see if the bleeding source could be visualized. If an introductal bleeding source could be localized, consideration was also made for attempting radiofrequency ablation, or RFA, to treat the bleeding source. Local endoscopic examination found migration of the previously placed stents and no active bleeding. Cholangioscopy was then performed with the cholangioscope side-by-side the guidewire. As we approach the bifurcation, diffuse narrowing of the duct becomes apparent, and the cholangioscope encounters an area of tumor characterized by diffuse erythema and narrowing. A surgical clip on the upper right-hand side becomes apparent, which will serve as an important landmark for the vessel appearing on the left. The cholangioscope is advanced into the intrapadics and gradually withdrawn. Further withdrawal brings a visible pulsatile vessel in view at the 10 o'clock position adjacent to the guidewire. Further examination reveals that while the vessel is nodular and erythematous, there are no signs of recent or active bleeding. It occupies roughly one-third of the bioduct lumen and is distal to the bifurcation and proximal to the primary area of narrowing. We then withdraw further to approximate the location of the vessel in relation to the previously seen surgical clip, which again appears on the right side of the screen. This clip will aid in targeting the RFA probe on fluoroscopy. The bipolar RFA catheter is then introduced over the guidewire into the bioduct. Under fluoroscopy, the catheter is advanced up the duct and the surgical clip is used as a reference point with the middle of the ablation zone lined up with the clip. Radiofrequency ablation was then performed for 90 seconds with an effect setting of 8 and a power of 10 watts. After a one-minute pause, radiofrequency ablation was then repeated for 90 seconds using the same settings. Cholangioscopy was then repeated with circumferential ablation clearly seen within the bioduct. Using the surgical clip as a reference point, the previously seen vessel was no longer visible and appeared to have been sufficiently ablated as it now appeared completely flattened. There was no sign of bleeding and the decision was therefore made to not perform any additional radiofrequency ablation. The procedure concluded with placement of a 10 French stent into the left hepatic duct. In regards to follow-up, the patient has had two subsequent ERCPs with stent exchanges with no further bleeding noted. Intraductal radiofrequency ablation may offer a potential salvage hemostasis option for cases of bleeding within the bioduct or the pancreatic duct. While cholangiopancreatoscopy offers direct visualization of a bleeding source, intraductal RFA can currently only be performed under fluoroscopy and not under direct visualization. The RFA catheter remains a limitation given its 8 French size with an ablation zone of 25 ± 3 mm in length and 9 ± 2 mm in width. In conclusion, further studies are needed to determine the safety and efficacy of intraductal radiofrequency ablation for intraductal hemostasis. The development of cholangiopancreatoscopy guided hemostasis devices are needed to perform targeted therapy. Multidisciplinary discussion is also paramount before embarking on salvage therapies.

biliary stenting

active bleeding

radiofrequency ablation (RFA)

cholangioscopy

intraductal RFA