Clin J Gastroenterol (2013) 6:395–397 DOI 10.1007/s12328-013-0415-9
CASE REPORT
Portogastric fistula complicating remote gastric variceal coil embolization Monish Merchant • Disha Mahendra • John Martin Richard Chen • Scott Resnick
•
Received: 3 July 2013 / Accepted: 11 August 2013 / Published online: 7 September 2013 Ó Springer Japan 2013
Abstract We present a case of a patient who suffered a rare complication of gastroesophageal varix coil embolization. During a follow up esophagogastroduodenoscopy, 4 years after transjugular intrahepatic portosystemic shunt placement and variceal coil embolization, the coil pack was endoscopically visualized to be eroding into the gastric lumen. Keywords Portal hypertension and variceal bleeding Endoscopy upper GI tract Transjugular intrahepatic portosystemic shunt
Introduction Initial coil embolizations were performed with metallic wool coils first described by Gianturco in 1975. They were initially used for renal artery embolization prior to tumor resection [1]. Since then there have been significant advances in coil material and the therapeutic use of coil embolization. Treatment with coil embolization has been described in numerous applications throughout the body, including cessation of active hemorrhage, aneurysm exclusion, and as a component of various transcatheter
M. Merchant (&) Advocate Illinois Masonic Medical Center, Chicago, IL, USA e-mail: [email protected] D. Mahendra Barnes-Jewish Hospital, Washington University School of Medicine, St. Louis, MO, USA J. Martin R. Chen S. Resnick Northwestern Memorial Hospital, Feinberg School of Medicine, Chicago, IL, USA
tumor therapies. Specifically in the gastrointestinal area, tract coils have been used for gastroesophageal variceal bleeding, arterial gastrointestinal tract bleeding [2], and visceral artery aneurysm exclusion [3]. Complications described with the early Gianturco’s metallic wool coils included difficulty in accurate placement, failure of permanent occlusion, and reflux of coils outside of the target vessel [4]. Although complications occur with modern embolic technology, they are significantly less common with new coil types and protocols [5, 6]. A very rare complication of gastroesophageal varix coil embolization is the formation of a portogastric fistula from erosion of the endovascular coil pack through the gastric varix wall and subsequently into the gastric lumen. Our literature search via PubMed revealed only two similar cases [7, 8]. Additionally, erosion of endovascular coils has been described in other procedures as well. It is an important complication to consider in cases of recurrent bleeding following previously successful coil embolization.
Case report A 55-year-old female with hepatitis C cirrhosis (ChildPugh grade C), listed for liver transplantation, was admitted to our institution for hematemesis and hemodynamic instability. The patient was transferred to the ICU and treated with IV fluids, pressors, and blood products. Subsequently an EGD was performed which revealed gastric varices without evidence of esophageal varices. There was layering of blood in the stomach and the gastric varices could not be visualized. Given the concern for portal vein thrombosis, the clinical decision to proceed with a TIPS and coil embolization of the gastric varices was made.
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During TIPS creation, antegrade splenic venography demonstrated a large varix arising from the splenic vein which passed through the region of the gastric wall and filled a large splenorenal shunt. Additionally, there was also a large varix arising from the splenoportal confluence which perfused the previously noted splenorenal shunt as well as a large network of gastroesophageal varices. The patient underwent successful placement of a 12 mm diameter TIPS between the right hepatic vein and right portal vein. Following TIPS, the above noted varices were embolized using a number of 4, 6, 8, and 12 mm platinum embolization coils (NesterCook, Bloomington,IN) until
Clin J Gastroenterol (2013) 6:395–397
flow stasis was achieved. (Fig. 1) The final post-TIPS and varix embolization portosystemic gradient was 3 mmHg. The patient had an uneventful post procedure hospital course and was discharged home without further bleeding. Four weeks later the patient underwent a successful orthotopic liver transplant. Approximately 3 years later the patient was readmitted for shortness of breath secondary to hepatic hydrothorax from recurrent cirrhosis. The patient underwent an EGD for staging of portal hypertension given the known history of gastric varices. The EGD demonstrated moderate portal hypertensive gastropathy and in retroflexion view, large fundic varices were visualized. Additionally, multiple metallic embolization coils were visualized eroding through a gastric varix into the gastric lumen without evidence of active bleeding from the involved varix (Fig. 2). The vessels containing the coils in question appeared thrombosed. The interventional radiology staff was called to confirm that the visualized metallic objects were indeed embolization coils. Since we did not know what sequelae could result from removal of these asymptomatic coils, they were left in situ. During her hospital course, the patient required intubation for progressive dyspnea and subsequently developed polymicrobial sepsis. Despite extensive intensive care resources and treatment, the patient expired.
Discussion Fig. 1 Post TIPS and Post splenorenal shunt coil embolization (92) splenoportogram demonstrates patent TIPS and occluded splenorenal shunts (92) with embolization coils in place (subtracted)
Fig. 2 Erosion of vascular coil pack. Coil had been placed remotely for hemostasis of acute gastric variceal bleeding. At subsequent esophagogastroduodenoscopy undertaken for staging of portal hypertension, eroded vascular coil pack was visualized incidentally. Note persistent portal hypertensive stigmata including gastric varices and portal hypertensive gastropathy
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Transjugular intrahepatic portosystemic shunt (TIPS) placement combined with embolization of gastroesophageal varices is recognized as an effective way of treating uncontrolled actively bleeding varices. A number of different techniques to achieve endovascular varix occlusion exist, including embolization with coils or plugs as well as the use of liquid embolic agents such as sclerosants or glues. Coil embolization is the most common and has been described to have a 90 % success rate in controlling hemorrhage [9]. A rare potential complication of varix coil embolization is erosion of the coils into the gastric lumen. In the two patients identified in our literature search, both had undergone emergent TIPS placement for uncontrolled variceal bleeding. In the first patient, repeat EGD 4 weeks after TIPS and coil embolization identified partially eroded coils [7]. Subsequent EGD at 11 months demonstrated absence of the coils, which were presumed to have passed spontaneously through the GI tract, with scar formation at the original varix site. In the second patient, eroded coils were seen on repeat EGD 2 weeks after the procedure [8]. The major difference in our patient was that she underwent orthotopic liver transplant 4 weeks after TIPS and embolization, and the eroded metallic coils were not visualized
Clin J Gastroenterol (2013) 6:395–397
until 3 years after the initial TIPS and coiling. It cannot be concluded if the orthotopic liver transplant played a role in causing erosion of the coils into the gastric lumen. Management of eroded coils into the gastric lumen has been neither developed nor standardized. In all three reported cases, including our own, the patients were asymptomatic and the coils were not removed. Theoretical complications of intentional removal of the coils could result in rebleeding and gastric perforation. Conversely there is also a possibilty of spontaneous dropout of the coils which may result in subsequent bleeding from the gastric varices. Close followup is probably prudent in these cases to ensure the coils are not eroding further into the gastric lumen. Extravascular erosion of embolic coils has been reported with clinically significant complications. Embolic coils used to exclude splenic, gastroduodenal, and hepatic artery aneurysms or pseudoaneurysms have been visualized in various luminal locations including the GI tract [10], biliary tree [11, 12], and pseudocysts [13], as well as in patients’ stool [14]. Some of the complications described from the migrated coils include partial gastric outlet obstruction [10] and ascending cholangitis [11]. In a patient who underwent coil embolization of a renal artery branch secondary to hemorrhage, the coil was visualized eroding into the collecting system [15]. Dinter et al. [16] identified a case of coil erosion resulting in an arteriogastric fistula after treatment of a celiac trunk aneurysm, resulting in fatal gastric hemorrhage. Although the reason for extravascular erosion of embolization coils is unknown, a potential etiology may include pressure erosion through the relatively thin vessel wall secondary to expansion from thrombus formation. Another potential factor is the well described immunologic response to a foreign body which is intended to eliminate and isolate the foreign material. The foreign body reaction takes place at the interface between the tissue and the foreign body for the lifetime of the device. This immunologic response consists of adhesion of macrophages and giant cells at the surface of biomaterials and formation of a fibrous capsule with the release of degradation mediators [17]. When evaluating patients who have received previous embolization therapy for a new symptomatic complaint, the possibility of extravascular erosion of the embolization coils should be considered given the potential complications. Disclosures Conflict of Interest: The authors declare that they have no conflict of interest. Human/Animal Rights: All procedures followed were in accordance with the ethical standards of the responsible committee on human
397 experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2008(5). Informed Consent: Informed consent was obtained from all patients for being included in the study.
References 1. Gianturco C, Anderson JH, Wallace S. Mechanical devices for arterial occlusion. Am J Roentgenol Radium Ther Nucl Med. 1975;124:428–35. 2. Kramer SC, Gorich J, Rilinger N, et al. Embolization for gastrointestinal hemorrhages. Eur Radiol. 2000;10:802–5. 3. Sachdev-Ost Ulka. Visceral artery aneurysms: review of current management options. Mt Sinai J Med. 2010;77:296–303. 4. Tisnado J, Beachley MC, Cho SR, et al. Peripheral embolization of a stainless steel coil. Am J Roentgenol. 1979;133:324–6. 5. Chuang VP, Wallace S, Gianturco C, Soo CS. Complications of coil embolization: prevention and management. Am J Roentgenol. 1981;137:809–13. 6. Loffroy R, Guiu B, Cercueil JP, et al. Transcatheter arterial embolization of splenic artery aneurysms and pseudoaneurysms: short- and long-term results. Ann Vasc Surg. 2008;22:618–26. 7. Kupkova B, Fejfar T, Krajina A, et al. Porto-gastric fistula due to penetration of metallic coil into the stomach: a rare complication of endovascular treatment of gastric varices. A case report. Folia Gastroenterology Hepatol. 2006;4:107–11. 8. Syed H, Rony G. Porto-gastric fistula from penetration of coil from gastric varix after TIPS procedure for bleeding varices. J Interv Gastroenterol. 2011;1:33. 9. Sanyal AJ, Freedman AM, Luketic VA, et al. Transjugular intrahepatic portosystemic shunts for patients with active variceal hemorrhage unresponsive to sclerotherapy. Gastroenterology. 1996;111:138–46. 10. Skipworth J, Morkane C, Raptis D, et al. Coil migration—a rare complication of endovascular exclusion of visceral artery pseudoaneurysms and aneurysms. Ann R Coll Surg Engl. 2011;93:19–23. 11. Turaga KK, Amirlak B, Davis RE, et al. Cholangitis after coil embolization of an iatrogenic hepatic artery pseudoaneurysm: an unusual case report. Surg Laparosc Endosc. 2006;16:36–8. 12. Ozkan OS, Walser EM, Akinci D, et al. Guglielmi detachable coil erosion into the common bile duct after embolization of iatrogenic hepatic artery pseudoaneurysm. J Vasc Interv Radiol. 2002;13:935–8. 13. Takahashi T, Shimada K, Kobayashi N, et al. Migration of steelwire coils into the stomach after transcatheter arterial embolization for a bleeding splenic artery pseudoaneurysm: report of a case. Surg Today. 2001;31:458–62. 14. Shah NA, Akingboye A, Haldipur N, et al. Embolization coils migrating and being passed per rectum after embolization of a splenic artery pseudoaneurysm, ‘the migrating coil’: a case report. Cardiovasc Intervent Radiol. 2007;30:1259–62. 15. Phan J, Lall C, Moskowitz C, Clayman R, et al. Erosion of embolization coils into the renal collecting system causing hematuria and mimicking stone disease. West J Emerg Med. 2012;13:127–30. 16. Dinter DJ, Rexin M, Kaehler G, et al. Fatal coil migration into the stomach 10 years after endovascular celiac aneurysm repair. J Vasc Interv Radiol. 2007;18:117–20. 17. Anderson JM, Rodriguez A, Chang DT. Foreign body reaction to biomaterials. Semin Immunol. 2008;20:86–100.
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CASE REPORT
Portogastric fistula complicating remote gastric variceal coil embolization Monish Merchant • Disha Mahendra • John Martin Richard Chen • Scott Resnick
•
Received: 3 July 2013 / Accepted: 11 August 2013 / Published online: 7 September 2013 Ó Springer Japan 2013
Abstract We present a case of a patient who suffered a rare complication of gastroesophageal varix coil embolization. During a follow up esophagogastroduodenoscopy, 4 years after transjugular intrahepatic portosystemic shunt placement and variceal coil embolization, the coil pack was endoscopically visualized to be eroding into the gastric lumen. Keywords Portal hypertension and variceal bleeding Endoscopy upper GI tract Transjugular intrahepatic portosystemic shunt
Introduction Initial coil embolizations were performed with metallic wool coils first described by Gianturco in 1975. They were initially used for renal artery embolization prior to tumor resection [1]. Since then there have been significant advances in coil material and the therapeutic use of coil embolization. Treatment with coil embolization has been described in numerous applications throughout the body, including cessation of active hemorrhage, aneurysm exclusion, and as a component of various transcatheter
M. Merchant (&) Advocate Illinois Masonic Medical Center, Chicago, IL, USA e-mail: [email protected] D. Mahendra Barnes-Jewish Hospital, Washington University School of Medicine, St. Louis, MO, USA J. Martin R. Chen S. Resnick Northwestern Memorial Hospital, Feinberg School of Medicine, Chicago, IL, USA
tumor therapies. Specifically in the gastrointestinal area, tract coils have been used for gastroesophageal variceal bleeding, arterial gastrointestinal tract bleeding [2], and visceral artery aneurysm exclusion [3]. Complications described with the early Gianturco’s metallic wool coils included difficulty in accurate placement, failure of permanent occlusion, and reflux of coils outside of the target vessel [4]. Although complications occur with modern embolic technology, they are significantly less common with new coil types and protocols [5, 6]. A very rare complication of gastroesophageal varix coil embolization is the formation of a portogastric fistula from erosion of the endovascular coil pack through the gastric varix wall and subsequently into the gastric lumen. Our literature search via PubMed revealed only two similar cases [7, 8]. Additionally, erosion of endovascular coils has been described in other procedures as well. It is an important complication to consider in cases of recurrent bleeding following previously successful coil embolization.
Case report A 55-year-old female with hepatitis C cirrhosis (ChildPugh grade C), listed for liver transplantation, was admitted to our institution for hematemesis and hemodynamic instability. The patient was transferred to the ICU and treated with IV fluids, pressors, and blood products. Subsequently an EGD was performed which revealed gastric varices without evidence of esophageal varices. There was layering of blood in the stomach and the gastric varices could not be visualized. Given the concern for portal vein thrombosis, the clinical decision to proceed with a TIPS and coil embolization of the gastric varices was made.
123
396
During TIPS creation, antegrade splenic venography demonstrated a large varix arising from the splenic vein which passed through the region of the gastric wall and filled a large splenorenal shunt. Additionally, there was also a large varix arising from the splenoportal confluence which perfused the previously noted splenorenal shunt as well as a large network of gastroesophageal varices. The patient underwent successful placement of a 12 mm diameter TIPS between the right hepatic vein and right portal vein. Following TIPS, the above noted varices were embolized using a number of 4, 6, 8, and 12 mm platinum embolization coils (NesterCook, Bloomington,IN) until
Clin J Gastroenterol (2013) 6:395–397
flow stasis was achieved. (Fig. 1) The final post-TIPS and varix embolization portosystemic gradient was 3 mmHg. The patient had an uneventful post procedure hospital course and was discharged home without further bleeding. Four weeks later the patient underwent a successful orthotopic liver transplant. Approximately 3 years later the patient was readmitted for shortness of breath secondary to hepatic hydrothorax from recurrent cirrhosis. The patient underwent an EGD for staging of portal hypertension given the known history of gastric varices. The EGD demonstrated moderate portal hypertensive gastropathy and in retroflexion view, large fundic varices were visualized. Additionally, multiple metallic embolization coils were visualized eroding through a gastric varix into the gastric lumen without evidence of active bleeding from the involved varix (Fig. 2). The vessels containing the coils in question appeared thrombosed. The interventional radiology staff was called to confirm that the visualized metallic objects were indeed embolization coils. Since we did not know what sequelae could result from removal of these asymptomatic coils, they were left in situ. During her hospital course, the patient required intubation for progressive dyspnea and subsequently developed polymicrobial sepsis. Despite extensive intensive care resources and treatment, the patient expired.
Discussion Fig. 1 Post TIPS and Post splenorenal shunt coil embolization (92) splenoportogram demonstrates patent TIPS and occluded splenorenal shunts (92) with embolization coils in place (subtracted)
Fig. 2 Erosion of vascular coil pack. Coil had been placed remotely for hemostasis of acute gastric variceal bleeding. At subsequent esophagogastroduodenoscopy undertaken for staging of portal hypertension, eroded vascular coil pack was visualized incidentally. Note persistent portal hypertensive stigmata including gastric varices and portal hypertensive gastropathy
123
Transjugular intrahepatic portosystemic shunt (TIPS) placement combined with embolization of gastroesophageal varices is recognized as an effective way of treating uncontrolled actively bleeding varices. A number of different techniques to achieve endovascular varix occlusion exist, including embolization with coils or plugs as well as the use of liquid embolic agents such as sclerosants or glues. Coil embolization is the most common and has been described to have a 90 % success rate in controlling hemorrhage [9]. A rare potential complication of varix coil embolization is erosion of the coils into the gastric lumen. In the two patients identified in our literature search, both had undergone emergent TIPS placement for uncontrolled variceal bleeding. In the first patient, repeat EGD 4 weeks after TIPS and coil embolization identified partially eroded coils [7]. Subsequent EGD at 11 months demonstrated absence of the coils, which were presumed to have passed spontaneously through the GI tract, with scar formation at the original varix site. In the second patient, eroded coils were seen on repeat EGD 2 weeks after the procedure [8]. The major difference in our patient was that she underwent orthotopic liver transplant 4 weeks after TIPS and embolization, and the eroded metallic coils were not visualized
Clin J Gastroenterol (2013) 6:395–397
until 3 years after the initial TIPS and coiling. It cannot be concluded if the orthotopic liver transplant played a role in causing erosion of the coils into the gastric lumen. Management of eroded coils into the gastric lumen has been neither developed nor standardized. In all three reported cases, including our own, the patients were asymptomatic and the coils were not removed. Theoretical complications of intentional removal of the coils could result in rebleeding and gastric perforation. Conversely there is also a possibilty of spontaneous dropout of the coils which may result in subsequent bleeding from the gastric varices. Close followup is probably prudent in these cases to ensure the coils are not eroding further into the gastric lumen. Extravascular erosion of embolic coils has been reported with clinically significant complications. Embolic coils used to exclude splenic, gastroduodenal, and hepatic artery aneurysms or pseudoaneurysms have been visualized in various luminal locations including the GI tract [10], biliary tree [11, 12], and pseudocysts [13], as well as in patients’ stool [14]. Some of the complications described from the migrated coils include partial gastric outlet obstruction [10] and ascending cholangitis [11]. In a patient who underwent coil embolization of a renal artery branch secondary to hemorrhage, the coil was visualized eroding into the collecting system [15]. Dinter et al. [16] identified a case of coil erosion resulting in an arteriogastric fistula after treatment of a celiac trunk aneurysm, resulting in fatal gastric hemorrhage. Although the reason for extravascular erosion of embolization coils is unknown, a potential etiology may include pressure erosion through the relatively thin vessel wall secondary to expansion from thrombus formation. Another potential factor is the well described immunologic response to a foreign body which is intended to eliminate and isolate the foreign material. The foreign body reaction takes place at the interface between the tissue and the foreign body for the lifetime of the device. This immunologic response consists of adhesion of macrophages and giant cells at the surface of biomaterials and formation of a fibrous capsule with the release of degradation mediators [17]. When evaluating patients who have received previous embolization therapy for a new symptomatic complaint, the possibility of extravascular erosion of the embolization coils should be considered given the potential complications. Disclosures Conflict of Interest: The authors declare that they have no conflict of interest. Human/Animal Rights: All procedures followed were in accordance with the ethical standards of the responsible committee on human
397 experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2008(5). Informed Consent: Informed consent was obtained from all patients for being included in the study.
References 1. Gianturco C, Anderson JH, Wallace S. Mechanical devices for arterial occlusion. Am J Roentgenol Radium Ther Nucl Med. 1975;124:428–35. 2. Kramer SC, Gorich J, Rilinger N, et al. Embolization for gastrointestinal hemorrhages. Eur Radiol. 2000;10:802–5. 3. Sachdev-Ost Ulka. Visceral artery aneurysms: review of current management options. Mt Sinai J Med. 2010;77:296–303. 4. Tisnado J, Beachley MC, Cho SR, et al. Peripheral embolization of a stainless steel coil. Am J Roentgenol. 1979;133:324–6. 5. Chuang VP, Wallace S, Gianturco C, Soo CS. Complications of coil embolization: prevention and management. Am J Roentgenol. 1981;137:809–13. 6. Loffroy R, Guiu B, Cercueil JP, et al. Transcatheter arterial embolization of splenic artery aneurysms and pseudoaneurysms: short- and long-term results. Ann Vasc Surg. 2008;22:618–26. 7. Kupkova B, Fejfar T, Krajina A, et al. Porto-gastric fistula due to penetration of metallic coil into the stomach: a rare complication of endovascular treatment of gastric varices. A case report. Folia Gastroenterology Hepatol. 2006;4:107–11. 8. Syed H, Rony G. Porto-gastric fistula from penetration of coil from gastric varix after TIPS procedure for bleeding varices. J Interv Gastroenterol. 2011;1:33. 9. Sanyal AJ, Freedman AM, Luketic VA, et al. Transjugular intrahepatic portosystemic shunts for patients with active variceal hemorrhage unresponsive to sclerotherapy. Gastroenterology. 1996;111:138–46. 10. Skipworth J, Morkane C, Raptis D, et al. Coil migration—a rare complication of endovascular exclusion of visceral artery pseudoaneurysms and aneurysms. Ann R Coll Surg Engl. 2011;93:19–23. 11. Turaga KK, Amirlak B, Davis RE, et al. Cholangitis after coil embolization of an iatrogenic hepatic artery pseudoaneurysm: an unusual case report. Surg Laparosc Endosc. 2006;16:36–8. 12. Ozkan OS, Walser EM, Akinci D, et al. Guglielmi detachable coil erosion into the common bile duct after embolization of iatrogenic hepatic artery pseudoaneurysm. J Vasc Interv Radiol. 2002;13:935–8. 13. Takahashi T, Shimada K, Kobayashi N, et al. Migration of steelwire coils into the stomach after transcatheter arterial embolization for a bleeding splenic artery pseudoaneurysm: report of a case. Surg Today. 2001;31:458–62. 14. Shah NA, Akingboye A, Haldipur N, et al. Embolization coils migrating and being passed per rectum after embolization of a splenic artery pseudoaneurysm, ‘the migrating coil’: a case report. Cardiovasc Intervent Radiol. 2007;30:1259–62. 15. Phan J, Lall C, Moskowitz C, Clayman R, et al. Erosion of embolization coils into the renal collecting system causing hematuria and mimicking stone disease. West J Emerg Med. 2012;13:127–30. 16. Dinter DJ, Rexin M, Kaehler G, et al. Fatal coil migration into the stomach 10 years after endovascular celiac aneurysm repair. J Vasc Interv Radiol. 2007;18:117–20. 17. Anderson JM, Rodriguez A, Chang DT. Foreign body reaction to biomaterials. Semin Immunol. 2008;20:86–100.
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