Incomplete hemostasis of high-risk adverse outcome bleeding lesions after placement of the over-the-scope clip: causes and solutions

High-risk adverse outcome (HR-AO) bleeding lesions—large-caliber (2 mm) vessel or high-risk stigmata within deep penetrating and fibrotic ulcers located in the distribution of major arteries where endoscopic therapy can cause adverse events—are at significant risk of treatment failure. Although over-the-scope clips (OTSCs) are effective in such lesions, they can sometimes fail to achieve hemostasis. We describe the causes of incomplete hemostasis and provide solutions to mitigate such OTSC failures.

We present 4 cases of incomplete hemostasis after OTSC application in HR-AO bleeding (Video 1, available online at www.VideoGIE.org). The first case demonstrates bleeding from a gastric Dieulafoy’s artery. Despite ideal placement, the medium-sized OTSC only partially occluded the artery, causing continued bleeding. We applied additional thermal coagulation and achieved complete hemostasis.

The second case describes the technical challenge with OTSC application in a deep fibrotic ulcer (Fig. 1). We identified a large vessel within a deep excavated fibrotic duodenal ulcer (Fig. 1A) and placed the OTSC using the suction technique (Figs. 1B and C). The ulcer failed to invert completely with suction alone, and the OTSC captured only the surface (Fig. 1D), causing persistent bleeding (Fig. 1E). We slowed the bleeding with epinephrine injection (Figs. 1F and G) and sprayed hemostatic powder to acquire hemostasis (Fig. 1H). We recommend using the OTSC anchor to invert the fibrotic ulcer to achieve secure clipping. The OTSC, once deployed, can be removed only with difficulty; hence, high precision is required while treating HR-AO bleeding.

Figure 1.

Incomplete hemostasis after placement of OTSC in high-risk adverse outcome bleeding. A, A large vessel within a fibrotic ulcer seen in the duodenal bulb. B, Use of medium-sized (17.5-mm) OTSC to capture the visible vessel. C, Active bleeding after suction, resulting in poor visualization of the bleeding site. D, Ulcer was suctioned but failed to invert completely; OTSC deployed. E, OTSC was deployed superficially, with failure to compress the bleeding vessel, causing continued bleeding (arrow). F, Epinephrine injected around the OTSC site. G, Bleeding slowed after epinephrine injection. H, Hemostatic powder was sprayed, and bleeding stopped completely. OTSC, over-the-scope clip.

The third case shows the removal of a superficially placed OTSC using rat-tooth forceps and applying a second OTSC to stop the bleeding. The last case illustrates the adverse outcome after OTSC misplacement. A chronic ulcer with a pulsating vessel was seen in the narrowed duodenal bulb. We pulled the ulcer using an OTSC anchor, but bleeding occurred during this maneuver, obscuring visualization. We misplaced the OTSC proximal to the bleeding vessel, and massive bleeding occurred. We used a second OTSC, crossed the narrow lumen beyond the first clip, and captured the bleeding vessel, achieving secure hemostasis.

Incomplete hemostasis after OTSC placement may be caused by a large bleeding artery, a fibrotic ulcer base, or shallow placement or misplacement of the OTSC. Any of several techniques can be used to mitigate incomplete hemostasis.

Disclosure

All authors disclosed no financial relationships relevant to this publication.

Supplementary data

Video 1

Incomplete hemostasis after placement of over-the-scope clip in high-risk adverse outcome bleeding.