Removal of an impacted migrated biliary stent with cholangioscopy: lights, camera, action

A 50-year-old woman was referred for removal of an internally migrated biliary stent. Fluoroscopy showed the migrated biliary stent and cholecystectomy clips ([Fig. 1]). She underwent endoscopic retrograde cholangiopancreatography (ERCP) and a biliary balloon was passed over the guidewire. Balloon sweeping was done; however, on sweeping, fresh blood was noticed emerging through the papilla. The procedure was therefore abandoned and a 7-Fr, 10-cm double-pigtail plastic stent (DPPS) was placed alongside the migrated stent. On day 3, the patient presented with severe anemia and hypotension. Contrast-enhanced computed tomography angiography (CTA) showed a right hepatic artery pseudoaneurysm, with an adjacent hematoma. She underwent conventional angiography and angioembolization with cyanoacrylate ([Fig. 2]).

Fig. 1 Fluoroscopic image showing an internally migrated biliary stent, with cholecystectomy (CCX) clips in situ.

Fig. 2 Fluoroscopic images during conventional angiography with angioembolization showing: a a right hepatic artery (RHA) pseudoaneurysm; b angioembolization being performed with glue; c no refilling of the pseudoaneurysm on contrast injection, suggesting complete obliteration of the pseudoaneurysm.

On day 14, a further ERCP was performed for abdominal pain. Because of the past history of bleeding, blind cannulation was avoided and a digital single-operator cholangioscope (SpyGlass DS; Boston Scientific, Marlborough, Massachusetts, USA) was passed into the common bile duct. Cholangioscopy showed common hepatic duct narrowing, through which a part of the migrated stent could be visualized. A guidewire was inserted deep into intrahepatic biliary radicle and the cholangioscope was advanced over the guidewire. A long piece of stent was seen to be impacted with its proximal end in the right posterior intrahepatic biliary radicle and its distal end at the bifurcation ([Fig. 3]). The cholangioscope could not be advanced alongside the impacted stent, so removal was attempted by grasping the shaft of the stent with a small biopsy forceps; however, this failed as the large size of the stent shaft precluded it being successfully grasped. A holmium laser was therefore used and the stent was fragmented into two pieces ([Fig. 4]). After stent fragmentation, the distal end of a fragmented piece was grasped with a forceps (SpyBite; Boston Scientific) and successfully extracted. During removal of the larger stent fragment, the smaller piece also passed naturally into duodenum ([Fig. 5]). Under cholangioscopic guidance, a 10-Fr, 10-cm DPPS was placed across the common hepatic duct narrowing ([Video 1]). After the procedure, the patient’s condition was stable.

Fig. 3 Cholangioscopic image showing the impacted plastic stent in the biliary radicle.

Fig. 4 Cholangioscopic images showing: a the laser being used to fragment the plastic stent under direct visualization; b complete fragmentation of the impacted plastic stent into two pieces.

Fig. 5 Endoscopic images showing: a removal of the larger fragment of the plastic stent with forceps under cholangioscopic guidance; b the second fragment of the stent, which was naturally extracted during removal of the larger piece.

Video 1 An internally migrated impacted biliary stent is visualized with cholangioscopy, before being fragmented using a laser, allowing the two pieces to be successfully extracted.

In conclusion, cholangioscopy-guided removal of an internally migrated biliary stent is safe and feasible. Laser lithotripsy can be used to fragment an impacted stent if required in particular situations.

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Publication History

Article published online:
17 March 2023