Delayed, life-threatening hemorrhage after self-expandable metallic biliary stent placement: clinical manifestations and endovascular treatment

Background: Life-threatening, delayed hemorrhage after self-expandable metallic stent (SEMS) insertion for malignant biliary obstruction is very rare. Clinical manifestations, radiologic characteristics, treatment, and prognosis of this complication are not well-known.

Purpose: To present the clinical manifestations, radiologic findings, and endovascular treatment of life-threatening, delayed hemorrhage secondary to SEMS placement.

Material and methods: A total of six patients (five men and one woman; mean age, 65.5 years) with life-threatening, delayed arterial bleeding after SEMS placement for malignant bile duct obstruction were recruited between 2000 and 2011 from three different hospitals in Korea. The original SEMS placement in all patients utilized either percutaneous (n = 3) or endoscopic approaches (n = 3). We retrospectively reviewed the clinical presentations, computed tomography (CT) and angiographic findings, endovascular treatments, and prognoses of these patients.

Results: All patients presented with life-threatening gastrointestinal bleeding such as melena (n = 4), hematochezia (n = 1), and hematemesis (n = 1). Mean time period between biliary metallic stent insertion and presentation with bleeding was 75 days (range, 15-152 days). All stents were encased by primary or metastatic cancer along with nearby arteries on CT images. Digital subtraction angiogram (DSA) revealed pseudoaneurysm close to the stent (n = 2), in-stent pseudoaneurysm (n = 2), arteriobiliary fistula (n = 1), or pseudoaneurysm with arteriobiliary fistula (n = 1). The origins of hemorrhage were the gastroduodenal artery (n = 3), the aberrant right posterior hepatic artery from the gastroduodenal artery (n = 2), and the right hepatic artery (n = 1). Hemorrhages were successfully controlled after intra-arterial coil embolization in five patients followed by placement of a stent graft and direct puncture N-butyl-2-cyanoacrylate (NBCA) embolization in one patient.

Conclusion: Life-threatening, delayed hemorrhage within a metallic biliary stent may occur if a stent is placed across the bulky bile duct tumor or tumor encases the stent. Bleeding can be successfully treated with endovascular treatment. However, the overall prognosis was poor.