Endoscopic Extraction of a Migrated Coil From the Duodenum 9 Years After Superior Mesenteric Artery (SMA) Aneurysm Embolization

Abstract

Although visceral artery aneurysms and pseudo-aneurysms are relatively rare entities, they carry a life threatening risk of rupture. Therefore, elective treatment is warranted to reduce this risk, and trans-catheter arterial embolization has recently emerged as a safe and effective modality. Immediate complications of this procedure include hematoma at the entry site, occlusion of an incorrect vessel, and inadvertent aneurysm rupture. Herein, we report an unusual case of late coil migration into the gastrointestinal tract that was successfully removed endoscopically. A 30 year old gentleman with a past medical history of Gardner's syndrome status post total proctocolectomy with an ileal-J-pouch-anal anastomosis was diagnosed with an extensive abdominal desmoid tumor. This was complicated by recurrent intra-abdominal abscesses, which subsequently resulted in the formation of a 2.5 cm diameter mid-SMA aneurysm. This was successfully treated with trans-catheter arterial coil embolization. The patient later on developed gastric polyposis, requiring interval screening esophagogastroduodenoscopies (EGD). During a routine EGD, 9 years after his SMA aneurysm coil embolization, a free floating coil was discovered in the duodenum. The patient was completely asymptomatic, and an EGD 5 months prior revealed no such abnormality. The duodenal wall was inspected and showed no ulceration, erosion or fistulous tract. The coil was removed from the duodenum with raptor forceps and placed into the stomach, which was then retrieved using a roth net. There were no complications during or after the procedure. CT angiogram demonstrated continued occlusion of the SMA. He was followed for 1 year after coil removal without complication. Coil migration into the gastrointestinal lumen is extremely rare, and to our knowledge, this is the second case reported of a migrated coil that had been removed endoscopically. Migration is associated with ulcers, fatal hemorrhage, or can be asymptomatic as in our case. The exact mechanism of asymptomatic coil migration is not clearly defined, and has only been speculated. Although no treatment strategy has been established in managing these migrated coils, endoscopy proves to be a safe and suitable option.1863_A Figure 1. Migrated Coil in the Duodenum1863_B Figure 2. Extraction of Coil using Roth Net