Successful management of arterial bleeding complicating endoscopic ultrasound-guided cystogastrostomy using a covered metallic stent.

A 56-year-old woman with a symptomatic pancreatic pseudocyst refractory to conservative treatment was referred to us for endoscopic ultrasound-guided pancreatic pseudocyst drainage (EUSPPD). EUS showed a 12-cm cyst near the pancreatic body and tail. The cyst was punctured using a 19-gauge fine needle aspiration (FNA) needle from the stomach under EUS imaging, after careful examination of the intervening vessels with Doppler function (●" Fig.1). A guide wire was coiled within the cyst, followed by dilation of the fistula with needleknife cautery and a 10-mm balloon. However, on deflation of the balloon, arterial blood was seen spurting from the fistula (●" Fig.2). The balloon was reinflated to tamponade the fistula for another 5 minutes to achieve temporary hemostasis. Deflation of the balloon again resulted in arterial bleeding. Attempts to locate the exact bleeding point failed due to the brisk bleeding as well as cystic fluid gushing from the fistula. Therefore, we placed an esophageal, fully covered self-expandable metallic stent (FCMS; 18mm×60mm, Bonastent, Standard Sci-Tech, Seoul, Korea) across the cystogastrostomy to tamponade the bleeding vessel, which led to successful hemostasis (●" Fig.3 and ●" Fig.4). Inspection of the cyst cavity Fig.1 A pancreatic pseudocyst in a 56-yearold woman, resistant to conservative management, punctured from the stomach under realtime endoscopic ultrasound (EUS) imaging.