Rare Complication of Interventional Radiology-guided Arterial Embolization of the Gastroduodenal Artery in the Setting of Acute Gastrointestinal Bleed: Migrated Coils in the Duodenum

Abstract

A 91-year-old male presented to the emergency room with hemodynamically significant upper gastrointestinal bleeding. The patient underwent an esophagogastroduodenoscopy (EGD), which showed frank blood in the duodenum interfering with the visualization. Hence, the patient underwent urgent interventional radiology (IR)-guided arteriogram and embolization. An EGD done 48 hours later showed a giant, non-bleeding, cratered duodenal ulcer with a visible vessel and vascular coils partially protruding into the duodenal bulb lumen. The patient had no evidence of bleeding post embolization. The patient presented three months later with abdominal pain. Computed tomography (CT) abdomen showed multiple liver abscesses. IRguided drainage of abscesses was performed, and the culture grew Streptococcus intermedius. Magnetic resonance cholangiopancreatography (MRCP), endoscopic retrograde cholangiopancreatography (ERCP), and barium enema were unremarkable. The patient was treated with a prolonged course of intravenous (IV) antibiotics and recovered without any further issues. IR guided arterial embolization can be lifesaving in cases where GI bleeding cannot be controlled endoscopically, however, it can lead to serious complications, including endovascular coil migration into the gastrointestinal (GI) lumen causing infection and rebleeding. Endovascular coil migration can occur immediately or several years later, which can result in fatal bleeding and infection. The best approach to prevent and manage migrated endovascular coils in the GI lumen remains unclear.

Pulsation of visible vessel or adherent clot in duodenal ulcer may indicate pseudoaneurysm: Case series

“…A possible reason is that the coil can partially or completely migrate into the duodenal lumen through the pseudoaneurysm as the bowel moves, which indirectly confirms that the visible vessel or adherent clot is a break of the pseudoaneurysm by which the pseudoaneurysm communicates with the duodenum, and pulsation caused by the GDA pseudoaneurysm is more likely to occur at the junction of D1 and D2. [12][13][14][15][16]…”

Two Cases of Duodenal Ulcers That Developed after Transcatheter Procedures for Unruptured Visceral Artery Aneurysms

“…In addition to aneurysm treatment, transcatheter embolization has been used for the management of gastrointestinal bleeding refractory to endoscopic hemostasis and transarterial chemoembolization of hepatocellular carcinoma. Adverse events related to endovascular treatment include bleeding, arterial dissection, intestinal ischemia, intestinal stenosis, coil migration [ 3 , 13 ], pancreatitis [ 14 ], and access-site hematomas. Major ischemic complications of the gastrointestinal tract reportedly range from 0% to 16% [ 14 , 15 ].…”

Intraluminal Endovascular Coil Migration: A Rare Complication Post-Embolization of the Gastroduodenal Artery for a Previously Bleeding Duodenal Ulcer

“…Therefore, TAE is considered the first-line therapy for non-variceal UGIB refractory to endoscopic intervention. Several potential complications can arise from TAE, including access site hematomas (3%-17%), pseudoaneurysm, and coil migration (3%) [15][16][17].…”

“…Intraluminal coil migration is a rare but notable complication of TAE that can occur immediately or several years later [ 16 ]. It is hypothesized that embolization of the feeding artery leads to ischemia, which allows for coil migration through the bowel wall [ 16 ]. In our patient, a displaced coil was seen on endoscopy at the time of intervention.…”

“…In most cases, coil migration is a self-limiting process without significant complications. However, it can lead to severe complications, including fatal rebleeding and bowel obstruction [ 16 - 18 ]. It is unclear whether our patient had rebleeding from coil migration itself or a separate ulcer invading the left gastric artery branches, but the onset of the bleed shortly after the TAE procedure and the finding of an embolization coil in the lumen within close proximity of the active bleeding suggests that migration of the coil was the precipitating event.…”