Article published online: 2023-03-17
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Removal of an impacted migrated biliary stent with cholangioscopy:
lights, camera, action
▶ Fig. 1 Fluoroscopic image showing an
internally migrated biliary stent, with
cholecystectomy (CCX) clips in situ.
▶ Fig. 3 Cholangioscopic image showing
the impacted plastic stent in the biliary
radicle.
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
▶ 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.
▶ 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.
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).
Chavan Radhika et al. Removal of an … Endoscopy 2023; 55: E545–E546 | © 2023. The Author(s).
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
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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.
Endoscopy_UCTN_Code_CPL_1AK_2AD
Competing interests
The authors declare that they have no conflict of interest.
The authors
▶ 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.
Radhika Chavan1 , Chaiti Gandhi1, Vatsal
Bachkaniwala 1 , Milan Jolapara 2, Sanjay
Rajput 1
1
Department of Medical Gastroenterology,
Ansh Clinic Hospital, Ahmedabad, Gujarat,
India
2
Department of Interventional Radiology,
Ansh Clinic Hospital, Ahmedabad, Gujarat,
India
Corresponding author
Radhika Chavan, MD
Department of Medical Gastroenterology,
Ansh Clinic, Maninagar, Near Hirabhai tower,
Ahmedabad, Gujarat, India
drradhikachavan@gmail.com
Bibliography
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.
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
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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.
Endoscopy 2023; 55: E545–E546
DOI 10.1055/a-2037-5854
ISSN 0013-726X
© 2023. The Author(s).
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Chavan Radhika et al. Removal of an … Endoscopy 2023; 55: E545–E546 | © 2023. The Author(s).