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.