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Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) was first described in 2007 [1] and is considered the treatment of choice for acute cholecystitis in patients unsuitable for surgery [2, 3]. EUS-GBD was recently demonstrated to be safe and effective even in patients with cirrhosis [4, 5]. A 72-year-old man with cirrhosis was admitted to intensive care for biliary sepsis and hepatic encephalopathy. Computed tomography showed hydropic gallbladder, with thickened wall and multiple stones within the lumen. After multidisciplinary evaluation, the patient was considered unfit for surgery and EUSGBD was undertaken (▶Video 1). Upon insertion of a lumen-apposing metal stent (LAMS; Hot Axios 10×10mm; Boston Scientific, Marlborough, Massachusetts, USA), torrential bleeding occurred due to inadvertent puncture of an arteriole in the gallbladder wall, as confirmed by color Doppler (▶Fig. 1 a). The gallbladder lumen quickly filled with hyperechoic material and the LAMS tip became invisible with EUS, resulting in misdeployment of the distal flange outside the gallbladder (▶Fig. 1b). The proximal flange was not released and the stent was removed. A second LAMS (Hot Axios 8×8mm) was inserted as close as possible to the bleeding point; after successful deployment, a large amount of fresh blood and bile drained into the stomach. Contrast-enhanced harmonic EUS (CH-EUS) identified the feeding vessel (▶Fig. 2, ▶Fig. 3). As no contrast spreading was seen, we hypothesized that the bleeding source was being compressed by the stent. After washing away blood clots, clear bile was observed. Nonclinically relevant hemoglobin drop was observed and biliary sepsis resolved following the procedure. Unfortunately, the patient’s condition deteriorated due to progressive renal failure and he died 25 days after admission. Immediate LAMS replacement with its tamponade action could be an effective rescue strategy for periprocedural bleeding; color Doppler and CH-EUS were E-Videos

Failed endoscopic ultrasound-guided gallbladder drainage due to severe bleeding immediately rescued by redo-drainage under contrast-harmonic guidance