S4683 Coil Migration into Duodenum: Uncommon Cause of Recurrent Gastrointestinal Bleeding

Introduction: Endoscopic hemostatic intervention is the first-line treatment for upper gastrointestinal (GI) bleeding, but patients often require transarterial angiographic embolization (TAE) for refractory bleeding. TAE has high success rates; however, it is important to acknowledge its complications such as bowel perforation, recurrent bleeding, vessel perforation, ischemia, and rarely, coil migration. Coil migration has been noted to occur in up to 3% of all cases that undergo TAE for GI bleeding. Timely recognition and coordination of interventions are critical to improving outcomes. We present a case of recurrent bleeding duodenal ulcer secondary to a TAE coil migration through the duodenal wall. Case Description/Methods: A 76-year-old man with a history of hypertension, chronic kidney disease, and right femur fracture status post repair presented with complaints of right leg pain and was found to have a dehiscence of his right leg wound. He was incidentally found to have a subacute pulmonary embolism. After initiation of heparin, he developed melena and became hemodynamically unstable requiring vasopressor support. Imaging revealed a duodenal ulcer, and extravasation from the gastroduodenal artery (GA) prompting emergent angiography. A moderate size pseudoaneurysm in the GA was noted and he underwent successful coil embolization. After stabilization, he underwent debridement of his right femur, and an IVC filter was placed instead of anticoagulation. The patient again began to experience melena with decreasing hemoglobin despite multiple transfusions. Given persistent melena and needing frequent blood transfusions, the patient underwent esophagogastroduodenoscopy that showed a 4 cm duodenal bulb ulcer with a clean ulcer base (Forrest Class III) with surrounding erythema. Multiple loops of coil from recent TAE were seen protruding adjacent to the clean-based ulcer from the duodenal wall. After transfer to the intensive care unit, general surgery was consulted for urgent surgical evaluation. Unfortunately, due to extensive comorbidities, the patient was not deemed as a surgical candidate, subsequently was switched to comfort care, and passed away shortly thereafter. Discussion: Coil migration is an uncommon serious complication after TAE. A retrospective case review of 10 cases showed multidisciplinary management is key and often requires surgical intervention. Although rare, Coil migration should be considered in differential in patients presenting with recurrent upper GI bleeding despite TAE.