Arterial bleeding during endoscopic ultrasound-guided pancreatic pseudocyst drainage using a novel ultrasound processor

Bleeding during endoscopic ultrasound-guided pancreatic pseudocyst drainage (EUS-PPD) is most often associated with electrocautery puncture or tract dilation [ 1 ] [ 2 ] [ 3 ] [ 4 ] [ 5 ]. Conversely, bleeding caused solely by fine-needle puncture is rare. We report a case of arterial bleeding induced by fine-needle puncture performed using a novel ultrasound processor ([ Video 1 ]). Download Video Arterial bleeding induced by fine-needle puncture performed using a novel ultrasound processor, followed by endoscopic hemostasis.Video 1 A 61-year-old man with a 9-cm pseudocyst in the pancreatic head underwent EUS-PPD ([ Fig. 1 ]). After Doppler evaluation confirmed no intervening vessels, the pseudocyst was punctured from the duodenum with a 22-gauge needle (EZ Shot 3 Plus, Olympus) under the guidance of a novel ultrasound processor (EU-ME3, Olympus, Japan) and an ultrasound endoscope (GF-UCT260, Olympus). We inserted a 0.018-inch guidewire and subsequently removed the needle. We then immediately observed marked arterial spurting into the cyst cavity on gray-scale imaging ([ Fig. 2 ] a ). Color Doppler confirmed pulsatile flow from the puncture site into the cyst cavity ([ Fig. 2 ] b ). Despite inserting a 7-Fr dilator (ES Dilator, Zeon Medical Co., Japan) for compression hemostasis, bleeding recurred upon its withdrawal. Therefore, a 10-mm fully covered self-expandable metal stent (FCSEMS; HILZO biliary stent, ABIS Inc., Japan) was deployed across the EUS-guided created route, resulting in complete hemostasis. Then, a nasal catheter was placed through the FCSEMS ([ Fig. 3 ]). Postprocedural computed tomography showed no extravasation; however, injury to the posterior superior pancreaticoduodenal artery was suspected ([ Fig. 4 ]). The patient experienced no further bleeding, and 1 month later, the FCSEMS was removed without complications. Fig. 1 Computed tomography showing a 9-cm pseudocyst in the pancreatic head. Fig. 2 a Gray-scale ultrasound showing marked arterial spurting from the puncture site into the cyst cavity immediately after the withdrawal of the needle. b Color Doppler imaging confirming the presence of pulsatile arterial flow. Fig. 3 a Placement of a fully covered self-expandable metal stent deployed across the bleeding site resulting in complete hemostasis. b A nasal catheter inserted through the stent. Fig. 4 a Postprocedural computed tomography (CT) showing no extravasation. b The reconstructed CT image suggesting injury to the posterior superior pancreaticoduodenal artery (arrow). This case highlights the possibility of bleeding during EUS-PPD even when Doppler imaging reveals no visible vessels and a thin needle is used. Compared with its predecessor (EU-ME2 model), the EU-ME3 processor detected certain small areas near the gastrointestinal wall lacking blood-flow signals ([ Fig. 5 ]). Thus, caution must be exercised to avoid inadvertent vessel injury near the gastrointestinal wall. Fig. 5 Color Doppler imaging comparison between the ( a ) EU-ME3 and ( b ) EU-ME2 ultrasound processors. The EU-ME3 processor displays a slightly reduced color Doppler imaging area (yellow highlight) near the gastrointestinal wall compared with the EU-ME2. Endoscopy_UCTN_Code_CPL_1AL_2AD Publication History Article published online: 30 January 2026 © 2026. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/). Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany