S3639 Vascular Coil Migration: A Rare Cause of Post-Embolization Biliary Obstruction and Cholangitis

Introduction: Migration of embolization coils to the biliary tree is a rare complication following interventional radiology (IR) embolization of the hepatic arteries. The pathophysiology often involves fistulation of the coil into the adjacent biliary ducts, likely facilitated by local tissue necrosis, infection, or persistent inflammation at the coil placement site. We report a case of cholangitis secondary to migration of embolization coils from the hepatic artery into the common bile duct. Case Description/Methods: A 71-year-old woman with a history of cholecystectomy initially presented with haemobilia and biliary obstruction secondary to a pseudoaneurysm of the right and common hepatic arteries with fistulous connection to the biliary tree. Coil embolization of the common and right hepatic arteries was performed by interventional radiology. Endoscopic retrograde cholangiopancreatography (ERCP) the next day revealed extrinsic compression of the common hepatic duct and a fully covered self-expanding metal stent (FCSEMS) was placed. The stent was removed 2 months later. No apparent stricture was seen on cholangiogram and stent placement was deferred. Two months later, she was readmitted with ascending cholangitis. Computed tomography angiographyrevealed migration of the embolization coils into the distal common bile duct (CBD). ERCP revealed a mild stricture of the upper third of the CBD adjacent to the embolization coils likely secondary to external compression and/or local ischemic changes. The bile duct was swept with an extraction balloon revealing an unraveled embolization coil which was successfully removed. A plasticstent was placed across the CBD stricture. Two months later a follow-up ERCP demonstrated persistent CBD stricture adjacent to the embolization coils. Two additional embolization coils were swept from the CBD and a plastic stent was placed. One month later, repeat ERCP was performed following stent migration into the small bowel. Cholanigogram demonstrated a persistent CBD stricture. No coils were found in the biliary tree and a FCSEMS was placed across the stricture. No further complications have occurred 2 months later. Discussion: Although rare, clinicians should maintain a high level of suspicion for coil migration in patients with a history of hepatic artery embolization who present with cholangitis or biliary obstruction. FCSEMS placement across the fistulous tract may decrease the risk of recurrence.