Beyond severe iodinated contrast allergy: a contrast-free endoscopic ultrasound-guided rendezvous approach

Abstract

Figures

Puncture of the dilated bile duct at the cystic confluence under endoscopic ultrasound guidance.

Fluoroscopic visualization of the restricted portion of the prosthesis within the stenotic area.

Full text

Endoscopic retrograde cholangiopancreatography (ERCP) is a standard technique for managing various pancreatobiliary conditions. When ERCP fails or is not feasible, endoscopic ultrasound-guided (EUS) biliary drainage has emerged as a valuable alternative 1 . Both procedures typically rely on fluoroscopic guidance using iodinated contrast media to visualize the biliary and pancreatic ducts, essential for diagnosis and intervention.

Although rare, allergies to iodinated contrast can be severe. Reactions are mostly mild to moderate, with life-threatening events occurring in only 0.01%–0.02% of cases. In most situations, premedication with steroids and antihistamines is sufficient 2 3 4 .

We report the case of a 45-year-old woman with pancreatic neoplasia and jaundice, referred for biliary drainage. She had a confirmed history of severe anaphylactic shock to iodinated contrast media, with a formal contraindication confirmed by the hospital’s allergy unit ( Video 1 ).

Contrast-free endoscopic ultrasound-guided rendezvous approach.Video 1

Due to the impossibility of performing ERCP, an EUS-guided rendezvous approach was adopted. After identifying the pancreatic lesion and confirming absence of cystic duct invasion, an opaque iron wire was fixed on the skin to mark the optimal biliary access point. Under EUS guidance, the dilated bile duct was punctured at the cystic confluence ( Fig. 1 ), and a guidewire was advanced toward the duodenum and retrieved with forceps using a duodenoscope.

Puncture of the dilated bile duct at the cystic confluence under endoscopic ultrasound guidance.

A second guidewire was placed retrogradely in the bile duct. Positioning of a fully covered metal stent was assisted by the radio-opaque marker of the first scope wire placed in the cystic duct. Good biliary flow was confirmed, with clear visualization of the restricted section of the prothesis within the stenotic area at fluoroscopy ( Fig. 2 ). No adverse events occurred. Biochemical improvement was evident by Day 2.

Fluoroscopic visualization of the restricted portion of the prosthesis within the stenotic area.

This case highlights the feasibility and safety of EUS-guided rendezvous as an alternative when ERCP is contraindicated. The procedure enabled successful biliary drainage without iodinated contrast, demonstrating its potential role in managing pancreatobiliary obstructions in high-risk patients.

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