St. Elizabeth's Medical Center, Boston University School of Medicine Brighton, MA
Butros Fakhoury, MD1, Mohanad Awadalla, MD2, Michael Talanian, MD3, Leandro Sierra, MD4, Erika A. Tsuchiyose, BA5, Tanya Zeina, MD3, Erik Holzwanger, MD3, Natov Nikola, MD3 1St. Elizabeth's Medical Center, Boston University School of Medicine, Brighton, MA; 2Beth Israel Deaconess Medical Center, Boston, MA; 3Tufts Medical Center, Boston, MA; 4Cleveland Clinic Foundation, Cleveland, OH; 5Tufts University School of Medicine, Boston, MA
Introduction: Endoscopic ultrasound (EUS)-guided placement of lumen apposing metal stents (LAMS) is increasingly used for managing pancreatic fluid collections, yet intraprocedural bleeding poses a notable complication. Management strategies for significant arterial bleeding may involve interventional radiology coil embolization or surgical intervention. Topical hemostatic agents, such as gels and powders, are more recent developments that offer the benefits of broad targeted therapy. We present a case demonstrating successful application of topical hemostatic gel and powder for achieving durable endoscopic hemostasis following active arterial bleeding during LAMS placement.
Case Description/Methods: A 39-year-old male with a history of alcohol use disorder and recurrent necrotizing pancreatitis presented with multiple walled-off pancreatic necrotic collections (WOPNs). Initial treatment involved cystogastrostomy with a pigtail stent placement. However, subsequent CT angiogram revealed the emergence of two new WOPNs, one measuring 17.5cm. EUS identified the WOPN adjacent to the pancreatic body, where an electrocautery-equipped LAMS stent was deployed. Despite successful stent placement, significant arterial bleeding occurred during stent dilation, promptly managed with a combination of topical hemostatic gel and powder. Post-procedure imaging showed no active bleeding, and the patient remained stable without requiring further intervention.
Discussion:
Various topical hemostatic agents are available for managing bleeding complications. EndoClot, a starch-derived polysaccharide, accelerates the clotting cascade by concentrating platelets and clotting factors. PuraStat, a sterile gel composed of a synthetic peptide, forms a transparent hydrogel matrix barrier upon exposure to physiological fluids, preserving visibility post-application. While PuraStat was approved for managing mild to moderate bleeding, its efficacy for arterial bleeding remains debated. Studies have reported variable success rates in controlling arterial bleeding with PuraStat. Our case underscores the challenge of managing arterial bleeding during LAMS placement when targeted hemostatic therapies are not feasible. Overall, the successful management of arterial bleeding with topical hemostatic agents highlights their evolving role and their potential advantage in reducing adverse events associated with invasive procedures. Further research is needed to explore optimal management strategies and evaluate long-term outcomes.
Figure: (A) Brisk arterial bleeding beneath the LAMS stent post-dilation. (B) Gel hemostatic agent was administered at the suspected bleeding site using a specialized catheter. (C) Powder hemostatic agent was applied at the suspected bleeding site. (D) Endoscopic confirmation of hemostasis following the application of topical hemostatic agents.
Disclosures:
Butros Fakhoury indicated no relevant financial relationships.
Mohanad Awadalla indicated no relevant financial relationships.
Michael Talanian indicated no relevant financial relationships.
Leandro Sierra indicated no relevant financial relationships.
Erika Tsuchiyose indicated no relevant financial relationships.
Tanya Zeina indicated no relevant financial relationships.
Erik Holzwanger indicated no relevant financial relationships.
Natov Nikola indicated no relevant financial relationships.
Butros Fakhoury, MD1, Mohanad Awadalla, MD2, Michael Talanian, MD3, Leandro Sierra, MD4, Erika A. Tsuchiyose, BA5, Tanya Zeina, MD3, Erik Holzwanger, MD3, Natov Nikola, MD3. P2847 - Novel Hemostatic Gel and Powder as Rescue Agents for Arterial Bleeding Related to Lumen Apposing Metal Stent Placement, ACG 2024 Annual Scientific Meeting Abstracts. Philadelphia, PA: American College of Gastroenterology.
