Embolization Coil Migration into Duodenum

Abstract

Endoscopic hemostatis is the initial treatment modality for non variceal upper gastrointestinal bleeding. 5-10% of patients require surgery or interventional endovascular embolization therapy for massive bleeding refractory to endoscopic management. Coil migration is a rare but serious complication of embolization procedure. We report a case of gastro duodenal artery (GDA) coil migration causing duodenal perforation. A 69-year old male presented to emergency department with multiple episodes of melena and hematochezia. He was tachycardic and hypotensive on initial presentation, laboratory workup showed drop in hemoglobin from baseline of 12 gm/dl to 5.5 gm/dl. Emergent upper endoscopy showed a 2 cm ulcer in the duodenal bulb covered with fresh clot. The clot was removed with roth net. Active spurting was noticed from the artery in the ulcer base. It was injected with epinephrine and 2 hemo-clips were applied without achieving hemostasis. The continued bleeding obscured any further visualization. Thereafter emergent super selective catheterization of gastro-duodenal artery (GDA) was performed by intervention radiology. It showed pseudo aneurysm of GDA with active extravasation of contrast into duodenum. Multiple micro coils were introduced resulting in complete occlusion of GDA and pseudo aneurysm. Repeat endoscopy was performed after 4 weeks. It showed GDA coil protruding through the duodenal wall into the duodenal bulb (Panel A). CT scan of abdomen showed coil present in the GDA partially protruding into duodenal lumen without peritoneal perforation (Panel B). Patient is currently asymptomatic. Arterial embolization is considered as the gold standard for acute non variceal upper gastrointestinal bleeding refractory to endoscopy. There are no absolute contraindications to embolization because it may be needed as lifesaving procedure. It is generally considered safe because of rich collateral supply to the stomach and duodenum, however there is increased risk of infarction in patients with previous surgeries in these areas. Access site hematoma, pseudo aneurysms, arterial dissection, perforation, contrast allergy and nephrotoxicity can occur as in other endovascular procedures. Coil migration is a rare and remote complication of endovascular embolization. It can be potentially fatal due to formation of aorto-enteric fistulas.Figure: (Panel A) Embolization coil in the duodenum bulb.Figure: CT scan showing embolization coil in GDA and duodenum.