Uncommon complications of therapeutic endoscopic ultrasonography: What, why, and how to prevent

Table 1 Uncommon complications of endoscopic ultrasound-guided biliary drainage

Ref.	Procedure	Stent	Complications(n/total successful cases)	Postulated causes	Treatment	Prevention recommendation
Püspök et al[20]	EUS-CDS, EUS-HGS, rendezvous	Plastic stent, FCSEMS, UCSEMS	Cholangitis (1/6), cholecystitis from previous ERCP (1/6)	Cholangitis may result from previous ERCP attempt	Antibiotics, PTBD, surgery	Consider antibiotic prophylaxis
Bories et al[11]	EUS-HGS, rendezvous	FCSEMS	Biloma (1/11), cholangitis (1/11)	Stent shortening	Percutaneous drainage (biloma), second stent insertion (cholangitis)	Select a stent of appropriate length Observe stent position during deployment (both endoscopic and fluoroscopic views) Keep at least 2 cm length of stent at the mural site
Attasaranya et al[19]	EUS-CDS, EUS-HGS, cholecystoduodenostomy, transduodenal FCSEMS insertion	Plastic stent, FCSEMS	Duodenal perforation (1/31), retrogastric collection (1/31), cholangitis (1/31)	Stent shortening	Surgery (duodenal perforation), percutaneous drainage (retrogastric collection)
Martin et al[18]	EUS-HGS	PCSEMS	Stent migration and biloma	Stent migration	(Dead)
Siddiqui et al[21]	EUS-CDS	FCSEMS	Duodenal perforation (1/8)	Stent shortening	Surgery
Khashab et al[23]	EUS-HGS	Not mentioned	Wire shearing (1/1)	Injury from EUS needle	Percutaneous intervention	Avoid acute angulation of guidewire and retract it gently Change needle to a small-size cannula during guidewire manipulation
Prachayakul et al[8]	EUS-CDS, EUS-HGS	FCSEMS	Biloma (1/21)	Malpositioned stent	Percutaneous drainage[17]	Observe stent position during deployment (both endoscopic and fluoroscopic views)
Prachayakul et al[22]	EUS-HGS	FCSEMS	Bleeding from hepatic artery aneurysm (1/1)	Iatrogenic trauma during EUS-HGS	Angiographic embolization	Puncture site should be away from major vascular structure
Kawakubo et al[3]	EUS-CDS, EUS-HGS	Plastic stents, FCSEMS	Cholangitis (1/61), biloma (1/61), perforation (1/61)	Stent misplacement	Percutaneous drainage (biloma), surgery (perforation)	Observe stent position during deployment (both endoscopic and fluoroscopic views)
Saxena et al[28]	Rendezvous	FCSEMS	Guidewire knot	Guidewire formed a knot during exchanges	Untangled using forceps	Maintain constant pressure on the guidewire during exchanges

ERCP: Endoscopic retrograde cholangiopancreatography; EUS-CDS: Endoscopic ultrasound-guided choledochoduodenostomy; EUS-HGS: Endoscopic ultrasound-guided hepaticogastrostomy; FCSEMS: Fully covered self-expandable metallic stent; PCSEMS: Partially covered self-expandable metallic stent; PTBD: Percutaneous transhepatic biliary drainage; UCSEMS: Uncovered self-expandable metallic stent.

Table 2 Uncommon complications of endoscopic ultrasound-guided pancreatic drainage

Ref.	Procedure	Stent	Complication (n/total successful cases)	Postulated causes	Treatment	Prevention recommendation
Hikishi et al[41]	EUS-cystogastrostomy drainage	Plastic stent, nasobiliary drainage	Gallbladder puncture and drainage	Marked distension of gallbladder with debris, overlapping location between pseudocyst and gallbladder in fluoroscopy	Conservative with antibiotics	EUS scanning prior to initiating drainage intervention
Barkay et al[29]	EUS-PD rendezvous, dye injection	Plastic stent	Peripancreatic abscess (1/10), wire shearing (1/10)	Failed to inject PD (peripancreatic abscess), repeated to-and-fro movements of wire	Percutaneous drainage (abscess), transluminal removal (wire)	Carefully manipulate the guidewire, avoid acute angles
Jow et al[40]	EUS-cystogastrostomy drainage	Not mentioned	Air emboli	Prolonged high pressure air sufflation, inflammation, mechanical injury	(Dead)	Use CO2 inflation instead of air
Fujii et al[36]	EUS-PD stent (antegrade and retrograde)	Plastic stents	Peripancreatic abscess (1/32), wire shearing (1/32)	Balloon dilation? Multiple devices (peripancreatic abscess), injury from EUS needle (wire shearing)	EUS-guided transmural drainage (abscess)	Carefully manipulate the guidewire
Kurihara et al[38]	EUS-PD rendezvous, and PD stenting	Plastic stents, UCSEMS	Pancreatic pseudocyst with splenic artery aneurysm	Pancreatic juice leakage	Angiographic embolization	Avoid major vascular structures

EUS-PD: Endoscopic ultrasound-guided pancreatic duct drainage; PD: Pancreatic duct; UCSEMS: Uncovered self-expandable metallic stent.

Table 3 Uncommon complications of endoscopic ultrasound-guided celiac plexus neurolysis

Ref.	Composition of injection solution	Complication	Treatment and outcome	Prevention recommendation
Fujii et al[47]	0.25% bupivacaine in 99% alcohol (ganglia: 1 mL; plexus: 23 mL)	Paraplegia	Remained paraplegic until death	Use color Doppler to avoid intravascular injection Minimize the volume of absolute alcohol
Mittal et al[48]	0.25% bupivacaine and epinephrine with alcohol (1:5) (ganglia: 5 mL; around the celiac artery: 19 mL)	Paraplegia	Lumbar drainage but no improvement
Jang et al[56]	0.25% bupivacaine (5 mL), 98% ethanol (10 mL), triamcinolone (1 mL)	Hepatosplenic, stomach, and small bowel infarctions, gastroduodenal ulcers	Supportive treatment, died 27 d later
Ahmed et al[57]	0.25% bupivacaine (20 mL), 98% ethanol (20 mL)	Pancreaticosplenic infarction, gastric ischemia and stenosis	Subtotal gastrectomy with Roux-en-Y gastrojejunostomy
Gimeno-García et al[58]	0.5% bupivacaine (5 mL), absolute alcohol (10 mL) on each side of the celiac takeoff	Thrombosis of celiac artery, pneumatosis of the stomach andsmall and large intestines, and liver, kidney, and spleen infarctions	Conservative treatment, died 8 d later
Muscatiello et al[59]	Not mentioned	Peripancreatic abscess	EUS-guided aspiration of abscess and ceftazidime injection	Consider antibiotic prophylaxis
Lalueza et al[60]	Not mentioned	Brain abscess by Cladosporium macrocarpum and Streptococcus constellatus	Surgery, antibiotics, and antifungal

EUS: Endoscopic ultrasound.