Delayed Biliary Hemorrhage due to Pseudoaneurysm Rupture Caused by Migration of Placed Plastic Stent After Endoscopic Ultrasound-Guided Hepaticogastrostomy.

Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) is an effective method for cases where transpapillary approaches to pancreato-biliary diseases are challenging, though serious complications often occur. Here, we report an extremely rare case of delayed biliary hemorrhage due to pseudoaneurysm rupture after EUS-HGS, caused by migration of the placed plastic stent. The patient was pathologically diagnosed with unresectable advanced pancreatic cancer and presented with severe duodenal stenosis and bile duct obstruction. Before chemotherapy, EUS-HGS with a biliary plastic stent (7Fr Type IT stent) was successfully performed without early complications. However, after 46 days, the patient developed massive melena, and computed tomography revealed a biliary hemorrhage within the common bile duct. Imaging revealed that the hepatic end of the plastic stent had migrated from the hepatic hilum to the posterior segment. After 71 days, the patient experienced a recurrent biliary hemorrhage, and an 8 mm pseudoaneurysm was identified in the posterior hepatic region at a location consistent with the migrated hepatic end of the plastic stent. Hemostasis was successfully achieved by emergency transcatheter arterial embolization with N-butyl cyanoacrylate. During the 6 months after the intervention, no recurrence of the pseudoaneurysm was observed, and the patient continued systemic chemotherapy with stable disease control. We suggest that biliary hemorrhage due to pseudoaneurysm rupture, which may be caused by migration of the placed plastic stent, should be considered a life-threatening late complication of EUS-HGS, requiring thorough follow-up.