Endoscopic Removal of a Migrated Coil after Embolization of a Splenic Pseudoaneurysm: A Case Report
A 63-year-old man was found to have advanced gastric cancer on a routine cancer screening examination. Preoperative abdominal computed tomography (CT) was performed, and there was no specific finding besides advanced gastric cancer. He underwent total gastrectomy. The tumor was located at the posterior wall of the high body. The gross type of the tumor was Bormann type II. The size of the tumor was 4.5×3.8×0.8 cm, and the depth of invasion was at the subserosal level (pT2b). Sixty-six lymph nodes were dissected, and no metastases were observed (pN0). Lymphatic, venous, and perineural invasions were present.\nOne month after the surgery, he came to the emergency department with complaints of a febrile sense and abdominal pain. An abdominal CT scan was carried out, and a pseudoaneurysm of the splenic artery and a small amount of hemoperitoneum were detected (). The total gastrectomy performed 1 month ago was thought to be the cause of the pseudoaneurysm. The size of the pseudoaneurysm was 2.7×1.9×3.6 cm. On the day after admission, a celiac angiography was performed. A large pseudoaneurysm of the splenic artery was observed on angiography (). Extravasation of the contrast agent was not observed, and there was no evidence of ongoing bleeding or rupture of the pseudoaneurysm. However, the risk of rupture seemed high, and we decided to perform embolization. The splenic artery was selected by using a microcatheter, and coils (Tornado embolization microcoil; Cook, Bloomington, IN, USA) were inserted to obliterate the pseudoaneurysm. The large size of the pseudoaneurysm and the fast blood flow required the use of 22 coils. After the coils were placed, splenic angiography was done and successful embolization of the pseudoaneurysm was confirmed (). He was discharged without any complication. As a routine surveillance, an abdominal CT scan was taken 5 months after the embolization, and it showed no evidence of cancer recurrence or any complication associated with embolization.\nNine months after the embolization of the pseudoaneurysm, the patient presented to the emergency department with epigastric pain. On upper gastrointestinal endoscopy, several strands of wire were noted at the inferolateral side of the esophagojejunal anastomosis (). A simple abdominal radiograph showed that the wires protruding through the jejunal wall were part of a coil used for pseudoaneurysm embolization (). We tried to cut the wires by using endoscissors (FS-5L-1; Olympus, Tokyo, Japan); however, it was difficult because the wires were thick and stiff. Thus, we tried to use hot biopsy forceps (Radial Jaw 3; Boston Scientific, Natick, MA, USA) for cutting the wires, which proved to be easy and effective. The hot biopsy forceps were used with an electrosurgical generator (VIO-300D; ERBE Elektromedizin, Tübingen, Germany) in the Endocut Q mode (effect 2, cut duration 2, and cut interval 2) (). It took about 1 to 2 seconds to cut each wire, and five wires were cut in total. Residual thin strands of wires were removed with endoscissors. There was no immediate complication during and after the procedure.\nThe patient was discharged from the hospital without epigastric pain and remained asymptomatic. He was followed up with upper gastrointestinal endoscopy 3 months after the endoscopic coil removal, and annually thereafter. Abdominal CT scans were performed every 6 months. There had been no symptom or complication related to the coil during the 2-year follow-up period.