345 Caught Between a Rock and a Hard Place: EUS-Guided Drainage of a Vascular Configuration

Abstract

INTRODUCTION: Vascular configuration in the portal confluence are rarely reported. Therefore there are currently no guidelines on how to manage bloody collection in the portal venous system. CASE DESCRIPTION/METHODS: A 36 yo M with a Hx of antiphospholipid syndrome & CVA on coumadin, presented for epigastric pain & vomiting. An US was negative for stones and reveled normal CBD. A CT showed edema around the portal confluence. A week later, a repeat CT showed a bloody collection at the SMV. An angiogram by IR ruled out an arterial source of bleeding, however the GDA was coiled empirically. A few days later a 3rd CT revealed an increase in size of the collection, severe SMV stenosis and the emergence of varices. The bleeding had stabilized however the emerging findings on CT raised 2 concerns: 1- A risk of bleeding from the formed varicose in a patient who is dependent on anticoagulation. 2- A risk of of thrombus formation in the portal system due to a compromise in the portal venous flowery the stenosing effect of the collection. A multidisciplinary approach was planned with with IR to drain the bloody configuration endoscopically. In the IR suite, the portal venous system was accessed percutaneously. The IMV was eventually accessed however the SMV was completely occluded. Through a collateral between the IMV and SMV, the SMV was accessed retrogradely. The catheter was then advanced to the splenic vein. With this setup, the portal vasculature was under visualization of IR who were ready to embolize in case of bleeding. EUS revealed a 4.6 cm heterogenous collection suggesting different consistencies of blood. 19 gage needle was introduced into the collection through a trans gastric access. A guide wire was then introduced and with wire guidance a 10 x 10 mm lumen apposing metallic stent was deployed between the configuration and the stomach. Blood drained spontaneously to the gastric lumen. Using a CRE balloon dilation to 12 mm was performed. Further evacuation of clots was performed to a point where the stenosis in the SMV decreased to allow anterograde access of the IR catheter. Clinically, the patient’s is doing well, is pain free and resumed his full anticoagulation. DISCUSSION: Our patient had complicated autoimmune disease predisposing him to clot formation. The etiology of his SMV injury is unclear. Possible etiologies include ideopathic pancreatitis or autoimmune vasculitis. Regardless of the etiology, prompt evacuation of the bleed was crucial. IR / GI coordination made this procedure safe and possible. Watch the video: http://bit.ly/2JWRdfs