Endoscopic Removal of Migrated Vascular Embolic Material from the Common Bile Duct: A Multimodality Approach

Abstract

Figure: No Caption available.Purpose: A 74-year-old man underwent percutaneous trans-hepatic cholangiography (PTC) for a distal non-malignant common bile duct (CBD) stricture with internal and external drain placement in 2009. At a subsequent drain exchange, he developed significant bleeding from the drain, which necessitated coil embolization of the hepatic artery. He did well afterwards and drains were removed. Three years later, he developed jaundice and cholangitis. ERCP done at an outside facility revealed a foreign body, which was assumed to be jag wires from a prior ERCP. A plastic stent was placed for biliary drainage, and he was referred to us for further management. A CT scan noted hardware within the porta-hepatis that caused streak artifact, along with dilation of intra-hepatic bile ducts. Review of the case suggested endovascular coils in the bile duct. It was assumed that some of the embolic material from the hepatic artery had eroded into CBD. It was decided to remove this embolic material by ERCP. Due to concern of hepatic artery rupture during retrieval, a catheter was positioned in the hepatic artery by interventional radiology (IR) to facilitate rapid re-embolization, should uncontrolled bleeding occur. During ERCP balloon extraction of a vascular plug with sludge was performed, followed by removal of filamentous wires in distal CBD with rat-tooth forceps. The duct was then accessed with spyglass to extract the more proximal wires using spybite. A fluoroscopic video obtained at the end of the procedure demonstrated remaining coils in a different plane from the biliary system, most likely in the hepatic artery. There was a thin sliver of embolic material remaining in the CBD that will probably epithelialize. There was no GI bleeding during the procedure. The patient has been event-free for over seven months now. Post-cholecystectomy clips, suture material and displaced stents are commonly discussed foreign bodies in CBD. There are limited reports on migration of vascular embolic material into duodenum; however, erosion of vascular coils into CBD is an extremely rare situation. Our case demonstrates successful use of various endoscopic techniques to manage this otherwise high-risk and presumably surgical condition. Adopting a multi-modality approach with IR backup may prevent need for surgical exploration of CBD in such intricate cases. Our method of management may serve as a teaching tool for endoscopists who may encounter a similar situation.