INTRODUCTION: Perforation is a devastating complication. The solution has always been surgical. At the Minneapolis, we have encountered a case of complicated duodenal ulcer which failed both surgical and radiology interventions. The EVT finally achieved the closure. CASE DESCRIPTION/METHODS: A 65 y/o veteran presented with persistent vomiting and weight loss. Initial CT revealed a large stomach and a duodenal wall thickening. EGD showed a large amount of bezoar, reflux esophagitis, and ulcerated duodenal stricture that only 6mm endoscope could pass. A 15 mm Axio stent was placed in the stricture. The patient’s symptoms improved and the stent was removed after 3 weeks. Two weeks later, the symptoms recurred. NPO and TPN were initiated. Repeat EGD revealed a pin point pylorus that could not be traversed. Liquid contrast was injected. A duodenal fistula between the duodenal bulb and sub-hepatic space was identified. A surgical procedure was then performed consisting of pylorus exclusion, gastro-jejunostomy (GJ), and sub-hepatic drain, Continuous bilious material via the sub-hepatic drain continued. The patient was unable to tolerate any oral intake. A PEG-J tube then was inserted by the Interventional radiology. Afterwards, the patient’s abdominal pain and drainage increased. Another EGD was performed. This time, a wide-open GJ was seen. The tube was found to pass through the suture line of the “excluded pylorus”. There were 2 additional disruptions at suture line. The PEG-J tube was repositioned into the GJ. The 3 open disruptions at the suture lines were cauterized using argon plasma and then closed using two 8mm and one 12mm Ovasco clips. Within a week, the percutaneous drain from the fistula decreased by 80%. But abdominal pain continued. A fifth EGD was performed to initiate EVT. A new PEG-J tube was inserted through the GJ into the duodenum loop. The distal tip loop string of the tube was secured onto the duodenal wall using 3 small endo-clips. High vacuum suction was applied to the J-port. Within a few days, all drainage from the fistula had ceased. A sixth EGD showed that 1 of the 3 Ovasco clips had fallen off so that standard 9mm endoscope could pass. The duodenal bulb was narrowed. The fistula resolved. The PEG-J was removed. DISCUSSION: EVT is a very effective treatment for perforation and fistula. The fundamental basis is to evacuate gastric, bile, and pancreatic secretions near the internal wound. This therapy should be considered as first-line rather than last resort.