Lumen-apposing-metal stent misdeployment in endoscopic ultrasound-guided drainages: A systematic review focusing on issues and rescue management

Table 1 Characteristics of studies reporting lumen-apposing metal stents misdeployment during endoscopic ultrasound-guided choledochoduodenostomy

Ref.	Study design	Study population (n)	Clinical indication	Technical success (%)	LAMS misdeployment (n)	LAMS type	Size of LAMS (mm)	Use of guidewire	LAMS flange misdeployed	Rescue therapy
Anderloni et al[20], 2019	Retrospective single center	46	MBO	93.5	3	Hot Axios	-	No	Distal (1/3), not specified (2/3)	Rendezvous technique with transpapillary placement of 10 mm × 40 mm FCSEMS after advancing a guidewire through the existing fistula into the bile duct and then across the papilla (1/3); 10 mm × 10 mm LAMS placement through the existing fistula (1/3); double-pigtail plastic stent placement across the LAMS (1/3)
Di Mitri R et al[21], 2022	Retrospective single center	31	MBO	80.6	7	Hot Axios	8 mm × 8 mm (6/7) 10 mm × 10 mm (1/7)	Yes	Distal	Over-the-wire FCSEMS placement (5/7); transpapillary percutaneous-transhepatic-endoscopic rendezvous (1/7); transpapillary laparoscopic-endoscopic rendezvous (1/7)
Rajadurai et al[22], 2022	Retrospective multicenter	66	MBO	90.9	6	Hot Axios	-	No (4/6). Yes (2/6)	Distal	Over-the-wire FCSEMS placement (2/6); laparotomy (2/6); EUS-GBD (1/6); palliation due to rapid deterioration (1/6)
Jacques et al[23], 2019	Retrospective multicenter	52	MBO	88.5	4	Hot Axios	-	-	Distal (1/4), proximal (1/4 intraperitoneal, 2/4 intraparietal)	Stent-in-stent strategy with SEMS (1/4); ERCP rendezvous (1/4); repeat classic EUS-CDS with SEMS (2/4)
Jacques et al[24], 2020	Retrospective multicenter	70	MBO	98.6	1	Hot Axios	-	-	No evidence of bile flow even if stent was correctly in situ	Stent-in-stent strategy
El Chafic et al[25], 2019	Retrospective multicenter	67	MBO	95.5	2	Hot Axios	-	Yes	-	Over the same guidewire FCSEMS placement (all)
Fugazza et al[26], 2022	Retrospective multicenter	256	MBO	93.3	17	Hot Axios	-	-	-	Over the guidewire SEMS placement (10/17); deployment of a second LAMS (4/17); EUS-guided rendezvous with subsequent placement of a transpapillary stent (3/17)
Hindryckx and Degroote[27], 2021	Retrospective single center	13	-	92.3	1	Hot Axios	8 mm × 6 mm	Yes	Distal	Clip closure of duodenal defect and new EUS-CDS with 8 mm × 6 mm LAMS
Armellini et al[28], 2023	Case report	1	Difficult biliary lithiasis	-	1	Hot Axios	8 mm × 8 mm	Yes	Distal	Rendezvous technique with transpapillary placement of FCSEMS after advancing a guidewire directly through the LAMS and choledochal breach into the bile duct and then across the papilla
Teoh et al[29], 2021	Prospective multicenter	26	MBO	88.5	3	Cold spaxus	-	Yes	Entirely into the bile duct	Over the guidewire SEMS placement
Fugazza et al[30], 2020	Case report	1	Pancreatic adenocarcinoma	-	1	Axios	6 mm × 8 mm	Yes	Proximal	Stent-in-stent strategy using SEMS
Brückner et al[31], 2015	Case series	5	MBO	80	1	Cold Axios	6 mm × 8 mm	Yes	Distal	Over the guidewire stent placement
Vanella et al[32], 2023	Retrospective study of prospectively maintained databases	93	MBO	97.8	4	Hot Axios	-	No	Distal (2/4); misdeployments after both flanges release (2/4)	Repeat EUS-CDS (1/4); inserting a guidewire through the LAMS catheter followed by over the guidewire LAMS placement (1/4) (the effective rescue therapies were counted as technical success); PTBD (2/4)
de Benito Sanz et al[33], 2021	Retrospective single center	37	MBO	100	4	-	-	-	Distal (2/4); not specified (2/4)	Stent-in-stent strategy (the effective rescue therapies were counted as technical success)
Garcia-Sumalla et al[34], 2021	Retrospective multicenter	41	MBO	95.1	2	Hot Axios	-	-	No evidence of bile flow even if stent was correctly in situ; distal flange	Stent-in-stent strategy using SEMS; rendezvous technique with placement of a transpapillary FCSEMS
Sanchez-Ocana et al[35], 2022	Case report	1	Pancreatic adenocarcinoma	-	1	Axios	8 mm × 8 mm	Yes	Distal	EUS-guided gallbladder drainage as a portal for antegrade transcystic guidewire passage, followed by rendezvous ERCP with placement of a biliary metal stent and clips to seal the perforation
Graves et al[36], 2021	Case report	1	Pancreatic metastasis of renal cell carcinoma	-	1	Axios	10 mm × 10 mm	No	Distal	A bridging 10 mm × 8 mm FCSEMS was deployed over the guidewire and through theccessing LAMS
Chin et al[37], 2020	Retrospective analysis of a prospectively maintained database	56	MBO	100	1	Axios	-	-	-	Over the guidewire tubular biliary stent placement (the effective rescue therapy was counted as technical success)
On et al[38], 2022	Retrospective multicenter	120	MBO	90.8	7	Hot Axios	-	No (4/7). Yes (3/7)	-	Bridging stents (5/7), PTBD (1/7), conservative management (1/7)
Ligresti et al[39], 2018	Case report	1	Pancreatic adenocarcinoma	-	1	Axios	8 mm × 8 mm	Yes	Distal	Reinsertion of the delivery system over the guide wire and second deployment of distal flange into common bile duct under EUS guidance

MBO: Malignant biliary obstruction; FCSEMS: Fully covered self-expanding metal stent; SEMS: Self-expanding metal stent; LAMS: Lumen-apposing metal stent; EUS-GBD: Endoscopic ultrasound-guided gallbladder drainage; ERCP: Endoscopic retrograde cholangiopancreatography; EUS-CDS: Endoscopic ultrasound-guided choledochoduodenostomy; PTBD: Percutaneous transhepatic biliary drainage.

Table 2 Summary of rescue strategies for lumen-apposing metal stent misdeployment

EUS-CDS
Deployment of a new stent through the created fistula tract	44.1%
Stent-in-stent strategy	23.5%
Endoscopic rendezvous	11.8%
Non-endoscopic rescue strategies	10.3%
EUS-GBD
Stent-in-stent strategy	60%
Clip closure of gastrointestinal wall defect	13%
Deployment of a new stent through the created fistula tract	8%
Non-endoscopic rescue strategies	16%
EUS-PFC
Deployment of a new stent through the created fistula tract	64.5%
Repeated EUS-guided drainage	16.1%
Stent-in-stent strategy	12.9%
Non-endoscopic rescue strategies	3.2%

LAMS: Lumen-apposing metal stent; EUS-CDS: Endoscopic ultrasound-guided choledochoduodenostomy; EUS-GBD: Endoscopic ultrasound-guided gallbladder drainage; EUS-PFC: Endoscopic ultrasound-guided pancreatic fluid collections drainage.

Table 3 Characteristics of studies reporting lumen-apposing metal stents misdeployment during endoscopic ultrasound-guided gallbladder drainage

Ref.	Study design	Study population (n)	Clinical indication	Access to GB	Technical success (%)	LAMS maldeployment (n)	LAMS type	Size of LAMS (mm)	LAMS flange misdeployed	Rescue therapy
Ngamruengphong et al[50], 2015	Case report	1	Cholecysto-choledocal lithiasis	Duodenum	-	1	Hot Axios	-	Proximal	Stent-in-stent strategy using SEMS
Rajadurai et al[22], 2022	Retrospective multicenter	49	-	Duodenum	95.7	2	Hot Axios	10 mm × 10 mm; 15 mm × 10 mm	Distal	Closure of the defect with clip; palliation (no further endoscopic treatment)
Cho et al[51], 2019	Prospective single center	22	Acute cholecystitis unfit for surgery	-	95.5	1	Spaxus	10 mm × 20 mm	Proximal	Stent-in-stent strategy using SEMS
Walter et al[52], 2016	Prospective multicenter	30	Acute cholecystitis unfit for surgery	Stomach	90	3	Hot Axios			Stent-in-stent strategy using SEMS
Irani et al[53], 2015	Retrospective multicenter	15	Acute cholecystitis unfit for surgery	Duodenum	93	1	Axios	10 mm × 10 mm	Distal	Stent-in-stent strategy using SEMS
de la Serna-Higuera et al[54], 2013	Prospective single center	13	Acute cholecystitis unfit for surgery	Stomach	84.6	1	Axios	10 mm × 10 mm	Distal	Closure of the defect with clip (no further endoscopic treatment)
Dollhopf et al[55], 2017	Retrospective multicenter	75	Acute cholecystitis unfit for surgery	Stomach	98.7	1	Hot-Axios	10 mm × 10 mm	Proximal	Surgery
Teoh et al[56], 2017	Retrospective multicenter	59	Acute cholecystitis unfit for surgery	-	96.6	1	Axios	10 mm × 10 mm	Distal	Surgery
Mangiavillano et al[57], 2021	Retrospective multicenter	18	Acute cholecystitis unfit for surgery	-	83.3	1	Spaxus		Distal	Closure of the defect with clip followed by transpapillary stent placment
Teoh et al[29], 2021	Retrospective multicenter	27	Acute cholecystitis unfit for surgery	-	88.9	2	Spaxus	10 mm × 10 mm; 16	Proximal	Stent-in-stent strategy using SEMS
Higa et al[58], 2019	Retrospective single center	40	Acute cholecystitis unfit for surgery	-	97.5	2	Hot Axios	10 mm × 10 mm; 15 mm × 10 mm	Distal	Redeployment of a new LAMS
Garg et al[59], 2018	Case report	1	Acute cholecystitis unfit for surgery	Stomach	-	1	Hot Axios	10 mm × 10 mm	Distal	Stent-in-stent strategy using SEMS
Torres Yuste et al[60], 2020	Retrospective single center	34	Acute cholecystitis unfit for surgery	-	97.1	3	Axios	10 mm × 10 mm; 15 mm × 10 mm	Distal	Stent-in-stent strategy using SEMS (2/3); double pig-tail plastic stent in LAMS (1/3)
		37		-	97.3	1	Axios	10 mm × 10 mm; 15 mm × 10 mm	Proximal	Stent-in-stent strategy using SEMS
James et al[61], 2019	Retrospective multicenter	15	Acute cholecystitis unfit for surgery	Stomach	93.3	1	Axios	10 mm × 10 mm; 15 mm × 10 mm	Proximal	Surgery
Irani et al[62],2017	Retrospective multicenter	45	Acute cholecystitis unfit for surgery	-	97.8	1	Axios	-	Distal	Stent-in-stent strategy using SEMS
Cho et al[63], 2020	Retrospective multicenter	36	Acute cholecystitis, advanced malignancy unfit for surgery	-	94.4	2	Spaxus	-	Proximal	Stent-in-stent strategy using SEMS, emergent PTC

SEMS: Self-expanding metal stent; LAMS: Lumen-apposing metal stent; PTC: Percutaneous cholecystostomy; GB: Gallbladder.

Table 4 Characteristics of studies reporting lumen-apposing metal stent misdeployment during endoscopic ultrasound-guided pancreatic fluid collections drainage

Ref.	Study design	Study population (n)	Clinical indication	Technical success (%)	LAMS misdeployment (n)	LAMS type	Size of LAMS (mm)	Use of guidewire	LAMS flange misdeployed	Rescue therapy
Venkatachalapathy et al[77], 2018	Retrospective multicenter	116	WON, PFC	99	1	Hot Axios	-	No	Distal	LAMS removal followed by over-the-wire deployment of a new LAMS
Khan et al[78], 2021	Retrospective multicenter	208	PFC	97.1	7	-	-	-	Distal	LAMS re-insertion (not counted as technical failure) (1/7); immediate repeat drainage (5/7); procedure abandoned (1/7)
Law et al[79], 2018	Retrospective single center	46	WON	93.5	5	Cold Axios/hot Axios	-	-	-	LAMS removal followed by over-the-wire deployment of a new LAMS (4/5; 2 LAMS re-insertion, not counted as technical failure) and of a FCSEMS 10 × 60 mm (1/5)
Walter et al[10], 2015	Prospective multicenter	61	PFC	98	1	Axios	-	Yes	Entirely inside the PFC	Placement of double pigtail stents
Siddiqui et al[80], 2016	Retrospective multicenter	82	PFC	97.5	2	Cold Axios	-	Yes	Distal	LAMS removal followed by over-the-wire deployment of a SEMS; surgical cystogastrostomy (difficulty to re-advance the guidewire into the PFC to perform an endoscopic rescue therapy)
Mendoza et al[81], 2020	Retrospective single center	21	WON	95	1	Hot Axios	-	Yes	Entirely inside the PFC	LAMS misdeployed was left inside the collection and a new one was then successfully placed through the original puncture site (both stents were removed 4 wk later)
Shah et al[82], 2015	Prospective multicenter	33	PFC	91	3	Cold Axios	-	Yes	-	Placement of double pigtail stents
Despott et al[83], 2020	Case report	1	WON	-	1	Hot Axios	20x10	-	Deployment in a non-target organ (colon)	LAMS removal and closure of both colonic and gastric defects with over-the-scope-clips
Rinninella et al[84], 2015	Retrospective multicenter	93	PFC	98.9	1	Hot Axios	-	Yes	Distal	Placement of double pigtail stents
Song et al[85], 2019	Prospective multicenter	34	PFC	97.1	1	Hot spaxus	-	Yes	Distal	LAMS in LAMS technique
Fugazza et al[86], 2020	Retrospective multicenter	328	PFC, WON	97.9	7	Hot Axios	-	-	-	New LAMS placement (4/7); placement of plastic stents (3/7)
Zhang et al[12], 2022	Retrospective multicenter	35	PFC	97	1	Hot Axios	15 mm × 15 mm	Yes	-	SEMS in LAMS technique
Yang et al[87], 2019	Retrospective multicenter	80	PFC	97.5	3	Cold Axios/hot Axios	-	-	-	-
Adler et al[70], 2018	Retrospective multicenter	80	WON	98.7	1	Cold Axios	-	-	-	-
Curieses Luengo et al[88], 2019	Case report	1	WON	-	1	Hot Axios	10 mm × 10 mm	-	Distal	LAMS in LAMS technique

WON: Walled of necrosis; PFC: Pancreatic fluid collections; FCSEMS: Fully covered self-expanding metal stent; SEMS: Self-expanding metal stent; LAMS: Lumen-apposing metal stent.