Abdominal Radiology (2021) 46:776–791

https://doi.org/10.1007/s00261-020-02696-z

REVIEW

Lumen‑apposing metals stents in advanced endoscopic

ultrasound‑guided interventions: novel applications, potential
complications and radiologic assessment
Jessica Li1 · Hamed Basseri1 · Fergal Donnellan2 · Alison Harris1

Received: 28 April 2020 / Revised: 20 July 2020 / Accepted: 25 July 2020 / Published online: 6 August 2020
© Springer Science+Business Media, LLC, part of Springer Nature 2020

Abstract
Endoscopic ultrasound (EUS)-guided drainage procedures are an increasingly utilized minimally invasive alternative to
percutaneous or surgical management strategies, having been shown to decrease recovery time, cost, and duration of hospital
stay. The current mainstay of EUS-guided drainage procedures is in pancreatic and peripancreatic collections in pancreatitis.
Recent technological advancements and the development of specialized stents have allowed for novel applications in a grow-
ing variety of clinical scenarios, including biliary obstruction, cholecystitis and gastrointestinal obstruction. An overview
is provided of standard EUS-guided lumen-apposing metal stent (LAMS) management in pancreatic collections, including
the expected radiologic findings and appropriate post-treatment sequelae. Relevant parameters to report include presence
of a walled-off collection, collection contents, proximity of the target collection to the gastrointestinal lumen, intervening
vascular structures or vascular malformations, and presence of regional cystic structures. Novel stent applications in biliary
and gastrointestinal drainage are summarized and examples are provided, including choledochoduodenostomy in biliary
obstruction, cholecystogastrostomy in cholecystitis, and jejunogastrostomy in focal gastrointestinal obstruction. Finally, a
pictorial review of imaging findings of complications including perforation, hemorrhage, displacement, occlusion, migra-
tion and mistargeting is provided. Minimally invasive EUS-guided endoluminal stenting is utilized in a growing variety of
clinical applications. Radiologist familiarity with common and novel applications of EUS-guided stenting is invaluable in
determining suitability for endoscopic management, evaluating treatment response and identifying potential complications.

Keywords Endoscopic ultrasound (EUS) · Lumen-apposing metal stent (LAMS) · Pancreatitis · Biliary drainage ·
Pancreatic fluid collections · Interventional EUS

Introduction drainage and necrosectomy [3–5]. Furthermore, internal

Endoscopic ultrasound (EUS)-guided stent drainage first
emerged as an alternative to percutaneous drainage and sur-
gical debridement in the management of collections in com-
plicated pancreatitis [1, 2]. In multiple randomized control
trials, endoscopic management has been shown to result in
lower patient morbidity, shorter hospital stays and decreased
costs with equivalent efficacy when compared to surgical
* Jessica Li
j.li.8@alumni.ubc.ca
1
Department of Radiology, Faculty of Medicine, University
of British Columbia, Vancouver, Canada
2
Division of Gastroenterology, Faculty of Medicine,
University of British Columbia, Vancouver, Canada
stenting of pancreatic and peripancreatic collections has
been shown to decrease the risk of displacement, infection,
and fistula formation compared to percutaneous drainage [5].
Technological advancements have accompanied the more
widespread adoption of endoscopic stenting techniques,
resulting in the development of specialized lumen-apposing
metal stents (LAMS). These stents are specially shaped in
a dumbbell configuration with metal flanges at either end
and a larger caliber lumen. This decreases the risk of stent
blockage and migration and provides an access point for
endoscopic intervention when compared to standard plastic
double pigtail or self-expanding metal stents [6]. However,
LAMS endoscopic drainage is not without risks, as proce-
dural and post-procedural complications including delayed
bleeding, buried stent syndrome and stricture formation have
been reported in the gastroenterology literature [7].

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Abdominal Radiology (2021) 46:776–791
Table 1  Revised Atlanta classification of pancreatic and peripancreatic collections
Collection Acuity Pancreatitis subcategory
Acute peripancreatic fluid col- ≤ 4 weeks Interstitial edematous pancrea-
lection titis
Acute necrotic collection ≤ 4 weeks Necrotizing pancreatitis
Pseudocyst > 4 weeks Interstitial edematous pancrea-
titis
Walled-off pancreatic necrosis > 4 weeks Necrotizing pancreatitis
Although the conventional use of EUS-guided LAMS in
acute pancreatitis has been well-described, no comprehen-
sive overview currently exists outlining the novel applica-
tions of LAMS in biliary and gastrointestinal drainage as
well as the potential complications [8].
The purpose of this article is to serve as a pictorial over-
view of standard and novel applications of EUS-guided
LAMS placement for pancreatic, biliary and gastrointes-
tinal drainage and familiarize the radiologist with proce-
dural eligibility parameters and appropriate post-treatment
sequelae. Additionally, examples of the common complica-
tions including perforation, hemorrhage, stent displacement,
occlusion, migration and mistargeting are presented.
LAMS in pancreatic and peripancreatic
collections
As outlined in the revised Atlanta classification, pancreatic
and peripancreatic collections in complicated pancreatitis
are divided into four distinct categories (Table 1) [9]. The
categories are stratified by collection acuity and the presence
of necrosis. Non-necrotic collections are defined as acute
pancreatic fluid collections (APFC) at less than four weeks
and pseudocysts at 4 weeks, while necrotic collections are
termed acute necrotic collections (ANC) in the acute phase
and walled-off necrosis (WON) at 4 weeks. The most impor-
tant distinction for the purposes of endoscopic intervention
is the presence of an established capsule, found in pseu-
docysts and walled-off necrosis. Intervention is generally
limited to well-demarcated collections with a capsule as they
facilitate drainage and debridement while reducing the rate
of complication [3].
In the absence of infection and necrosis, 70% of APFCs
resolve without progressing to pseudocysts and up to 90% of
pseudocysts resolve without endoscopic intervention [10].
In contrast, up to 80% of ANCs will develop into WON,
with mortality rates as high as 30% reported in cases of
infected necrosis [9]. Therefore, indications for pancreatic
or peripancreatic collection drainage include suspected or
777
Location Appearance
Extrapancreatic Homogeneous, fluid attenuation,
no wall
Intra- and/or extrapancreatic Inhomogeneous, non-liquid
components, no wall
Extrapancreatic Homogeneous, fluid attenuation,
encapsulated with wall
Intra- and/or extrapancreatic Inhomogeneous, non-liquid
components, encapsulated with
wall
confirmed infection, sepsis, enlarging collections, clinical
symptoms such as pain, jaundice, biliary or gastric outlet
obstruction, or clinical deterioration or failure to improve
on conservative management [11].
Endoscopic drainage and necrosectomy is based on the
creation of a controlled fistulous tract between the collec-
tion and the gastric or duodenal lumen (cystogastrostomy
or cystoduodenostomy) via echoendoscope. Once endo-
scopic access is established, a drain or stent can be placed
for continuous drainage of fluid and debridement of necrotic
contents [12]. Traditionally, double pigtail plastic stents
were placed to facilitate collection drainage. While gener-
ally sufficient for pancreatic pseudocysts, which contain
homogeneous fluid contents, the solid and inhomogeneous
contents in walled-off necrosis may occlude smaller caliber
stents [13]. Thus, specialized fully covered, self-expanding
lumen-apposing metal stents (LAMS) were developed; the
large lumen diameter allows for direct endoscope passage for
cystoscopy, irrigation and necrosectomy, while the dumb-
bell configuration with flanges at either end minimizes stent
migration (Fig. 1).
A meta-analysis assessing the efficacy of LAMS in pan-
creatic collection drainage demonstrated estimate-pooled
technical and clinical success rates of 97% and 98% in
Fig. 1  Lumen-apposing Hot AXIOS metal stent and introducer sys-
tem (Boston Scientific Corporation, Natick, MA, USA)
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778 Abdominal Radiology (2021) 46:776–791

Fig. 2  Intraprocedural fluoroscopic images from a cystogastrostomy showing; needle knife (a), guidewire passage (b), balloon tract dilatation
(c), LAMS stent passage over the guidewire and partial expansion (d), and LAMS in situ (e)

pseudocyst drainage and 99% and 90% in WON drainage, clinical success rates (90–97.7% compared to 73.7–92.6%)
with an adverse event rate of 10% [14]. Retrospective stud- and decreased mean procedure time for WON drain-
ies comparing the use of LAMS against plastic stents in age. Clinical success rates for pseudocyst drainage are
pancreatic collection drainage have demonstrated higher

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Abdominal Radiology (2021) 46:776–791
Fig. 3  Endoscopic ultrasound images demonstrate a large hypo-
echoic peripancreatic collection abutting the gastric wall (a). A
lumen-apposing metal stent (LAMS) (arrow) has been inserted with
complete decompression of the collection (b). Direct visualization
confirms the proximal flange of the stent is well-situated within the
gastric wall (c). C* = collection
comparable across both stent types, although mean proce-
dure time remains lower with LAMS [12].
Standard LAMS stenting technique is performed under
fluoroscopic guidance. To be technically feasible, the
779
collection must be less than 1 cm from the gastrointestinal
wall. A therapeutic linear array echoendoscope is advanced
into the stomach or duodenum. The adjacent pancreatic or
peripancreatic collection is identified under ultrasound, and
Doppler is used to assess for interposed vessels. The collec-
tion is punctured with a 19 gauge needle and an aspirate is
taken for analysis. A guidewire is passed through the needle
and a tract is created with a needle knife. The tract is then
balloon dilated and the LAMS is inserted (Figs. 2 and 3)
[12].
There are several eligibility criteria for endoscopic stent
placement which should be mentioned in the pre-proce-
dural report. The most salient points include the presence
or absence of a well-defined collection wall, proximity of
the collection to the stomach or duodenum, and presence of
intervening vessels between the collection and the stomach
or duodenum (Fig. 4). Furthermore, it is prudent to report
the presence of any regional cystic structures that could be
inadvertently targeted under EUS (i.e., a large or atypically
located gallbladder, renal cysts) (Table 2).
Once access has been established during the initial
LAMS insertion session, the patient may return for repeat
cystoscopy, irrigation, instillation with hydrogen peroxide
and necrosectomy at two to five day intervals depending
on the patient’s clinical status. As the collection decreases
in size and complexity, the patient may be downstaged to
double pigtail plastic stents, which are eventually retrieved
once the collection resolves (Fig. 5).
Relevant post-procedural findings to include in the radi-
ology report include the collection size, the presence and
location of residual necrotic debris, appropriate stent posi-
tioning and patency, and the presence of surrounding fluid,
gas locules or hemorrhage (Table 2).
Imaging technique
Standard intravenous contrast-enhanced portal venous phase
abdominal CT is generally sufficient for delineating the col-
lection and relevant anatomical structures pre-intervention.
A dedicated arterial phase is not essential in routine pre-pro-
cedural imaging, as endoscopists are able to assess for inter-
vening vessels using intraprocedural Doppler ultrasound,
but would be appropriate in evaluation of post-procedural
complications where bleeding is suspected. While no studies
exist examining the use of oral contrast in LAMS imaging,
our institutional experience has been that it has not offered
significant additional value in pre-procedural assessment.
Potential applications of oral contrast include assessing for
stent patency or leakage; however, in the event of suspected
leakage one must weigh the risk of oral contrast obscur-
ing detection of concomitant hemorrhage. Often, secondary
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780 Abdominal Radiology (2021) 46:776–791

Fig. 4  Pre-procedural assessment—61 y.o. with alcoholic pancreatitis
complicated by an ANC without a defined wall (a) who is ineligible
for LAMS stenting, vs. a 56 y.o. with an infected pancreatic pseudo-
cyst with a well-defined wall (white arrow) adjacent to the stomach
who is a good candidate (b). 65 y.o. with chronic pancreatitis and an
infected pseudocyst, note the presence of extensive gastric varices
(white arrowheads) interposed between the collection and stomach (c,
d). Echoendoscopy with Doppler US was performed to assess for a
safe puncture tract. C* = collection, P* = pancreas, G* = stomach

Table 2  Imaging features to report in LAMS candidates

Findings to report before intervention

Target collection size and location

Presence of a well-defined wall
Collection contents (simple fluid, inhomogeneous debris) and evidence of infection—i.e., gas locules
Proximity of target collection to the stomach or duodenum (< 1 cm mandatory)
interposed vessels between the target and gastrointestinal tract
Adjacent vascular malformations, varices, pseudoaneurysms and aneurysms
Adjacent large cystic structures—i.e., renal cysts, abnormally positioned gallbladder
Findings to report post-intervention

Stent position (ensure both flanges are well-situated) and evidence of migration
Change in collection size
Presence of residual necrotic or solid debris
Evidence of stent obstruction
Adjacent fluid or gas locules at the access site to suggest perforation or leak
Active hemorrhage at the access site

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Abdominal Radiology (2021) 46:776–791
Fig. 5  85 y.o. with acute pancreatitis complicated by infected pan-
creatic pseudocyst (a). CT images demonstrate cystogastrostomy
with insertion of a lumen-apposing metal stent (LAMS) (arrow) (b),
signs of leakage including adjacent gas locules and free fluid
are sufficient to make the diagnosis.
Existing LAMS, including the Hot AXIOS, NAGI and
SPAXUS stents, have been labeled as MR conditional,
allowing the patient to be safely scanned if certain technical
parameters are fulfilled [15]. Maximum artifact size seen on
the gradient-echo pulse sequence extends approximately 10
mm, thus necessitating optimization of MR technique. Given
the relatively short duration of stent placement and improved
accessibility, CT remains the modality of choice in post-
procedural assessment. While MRI offers better ability to
characterize the degree of pancreatic necrosis, CT is robust
in providing relevant information regarding collection size,
stent patency and potential complications [16].
Novel applications in biliary drainage
Given the increasing utilization and success of LAMS in
pancreatic collection drainage, off-label applications have
expanded to include biliary tract and gallbladder drainage.
Traditionally, the mainstay of biliary drainage in the setting
of obstructive jaundice is performed through endoscopic
transpapillary drainage or through a percutaneous transhe-
patic approach if transpapillary drainage is unsuccessful
781
decrease in collection size with downsizing to double pigtail plastic
stents (c) and complete collection resolution (d). G* = stomach, C*
= collection
[17]. More recently, EUS-guided biliary drainage has
emerged as an alternative to percutaneous drainage and
has been shown in multiple meta-analyses and randomized
controlled trials to have comparable technical and clinical
success rates, fewer adverse events, and lower reinterven-
tion rates [18–20]. Similar to EUS-guided interventions in
pancreatic collection drainage, EUS-guided biliary drain-
age involves creating a controlled fistula between the biliary
system and gastrointestinal tract with subsequent stent inser-
tion. Current applications with plastic or covered metallic
stents include choledochoduodenostomy, hepaticogastros-
tomy, hepaticoduodenostomy, and hepaticojejunostomy [21].
While the use of plastic or covered metallic stents is the
current standard, LAMS have been demonstrated as a viable
alternative, with a recent retrospective review of choledo-
choduodenostomy LAMS finding technical and clinical suc-
cess rates of 93.5% and 97.7%, respectively [22]. As techni-
cal factors require the biliary and gastrointestinal tracts to be
< 1 cm apart with no intervening vessels or hepatic paren-
chyma, LAMS are most appropriate for choledochogastros-
tomy or choledochoduodenostomy (Fig. 6), usually in the
setting of bile duct stricture or malignant obstruction.
Another emerging application for LAMS is endoscopic
transmural gallbladder drainage in the setting of acute
cholecystitis (Fig. 7). This represents an alternative to
13
782
Fig. 6  75 y.o. with CBD and duodenal stricturing from metastatic
pancreatic cancer (a). Covered metal duodenal stent placement
resulted in obstruction at the ampulla and biliary distension despite
presence of a CBD drain (black arrowhead) (b). Choledochoduoden-
percutaneous drainage for patients with acute cholecystitis
who are unable to tolerate surgical resection. The endoscopic
approach eliminates the need for an external drain, reducing
the risk of premature tube dislodgement and infection. A
meta-analysis of LAMS use in gallbladder drainage showed
a pooled technical success rate of 95% and clinical success
rate of 93% [14]. When compared to both percutaneous chol-
ecystostomy and endoscopic transpapillary drainage, endo-
scopic transmural drainage resulted in higher technical and
clinical success rates, fewer complications, and decreased
mean hospital stay and need for additional surgical inter-
vention [23].
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Abdominal Radiology (2021) 46:776–791
ostomy LAMS placed for decompression (arrows) (c, d). Note pneu-
mobilia in keeping with stent patency. M* = stricturing mass, S* =
metal stent
Novel Applications in Gastrointestinal
Decompression
The bulk of LAMS use in the gastrointestinal tract has been
in the management of gastrointestinal strictures, with recent
meta-analyses demonstrating favorable technical and clinical
success rates (97.6% and 78.8%) compared to covered self-
expanding metal stents and biodegradable stents [24–26].
Transmural gastrointestinal tract decompression is still
limited to isolated case reports [27–29], usually in patients
with obstruction and altered post-surgical anatomy or malig-
nancy which precludes conventional management. In these
complex patients, LAMS can be considered as a salvage
Abdominal Radiology (2021) 46:776–791 783

Fig. 7  81 y.o. with cholangiocarcinoma obstructing the common right upper quadrant pain (c, d). Note the close proximity of the gall-
bile duct (CBD), appearing as a focal stricture on ERCP (arrow) (a). bladder and gastric antrum. Cholecystogastrostomy LAMS inserted
Metal CBD stent insertion (b) resulted in cystic duct obstruction and for decompression (e). G* = stomach, GB* = gallbladder

13
784
Fig. 8  68 y.o. with Roux-en-Y hepaticojejunostomy for metastatic
gallbladder carcinoma. A large mass obstructs the jejunostomy with
massive dilatation of the proximal Roux limb (a, b). Subsequent
procedure for endoscopic decompression of gastrointestinal
obstruction (Fig. 8).
Complications
Potential procedural and post-procedural complications with
LAMS insertion include bleeding, perforation, mistarget-
ing, stent displacement and leakage, stent occlusion, buried
stents under the GI tract mucosa and collection re-accumu-
lation post-stenting [7, 21, 30]. The rate of adverse events
varies with technique and operator experience. Recent stud-
ies of complication rates in EUS-guided drainage in pancrea-
titis found a range of 5–30%, with higher rates in infected
compared to sterile collection drainage [5]. Biliary drain-
age complication rates are reported at 4–26% for gallbladder
drainage [14] and 11–23% for biliary tract drainage [21, 22].
13
Abdominal Radiology (2021) 46:776–791
decompression following insertion of a jejunogastrostomy LAMS (c,
d). M* = mass, J* = jejunal Roux limb, G* = stomach
Patients may develop symptoms such as peritonitis, sep-
sis, hypotension or hemorrhage immediately or several days
post-procedure. The presence of such symptoms should raise
suspicion for procedural or stent complications and consid-
eration of imaging evaluation.
Perforation and leak
On immediate post-procedural imaging, extraluminal gas
locules or fluid should raise suspicion for perforation and
leakage (Fig. 9). Necrotic collection contents or bile can
leak into the peritoneal cavity via the puncture site and cause
peritonitis, or form an organized collection necessitating
drainage.
Abdominal Radiology (2021) 46:776–791
Fig. 9  Perforation—62 y.o. treated with cystogastrostomy for infected
pancreatic pseudocyst. Fluoroscopic images show guidewire advance-
ment through the gastric wall and opacification of a blind-ending cyst
with tract dilation (a). The patient developed acute peritonitis and
Hemorrhage
Hemorrhage can occur intra-procedurally due to mucosal
puncture or unintentional injury to intervening vessels, or on
a delayed basis due to friction of the stent against regional
vasculature. Dedicated CT angiographic imaging should be
performed if active hemorrhage is suspected (Fig. 10).
Stent displacement and migration
It is critical to ensure both flanges of the stent are well-
positioned on post-procedural imaging. Initial stent dis-
placement may occur if the transmural tract is excessively
dilated, deployment of the flanges is not well-visualized, or
785
hypotension post-procedure. CT demonstrates ascites and locules of
free air adjacent to the stent (arrows) in keeping with perforation (b,
c). G* = stomach, C* = collection
the stent becomes dislodged during endoscopic access [30].
As in leak or perforation, the patient is at significant risk of
peritonitis and abscess formation due to bile or digestive
content leakage (Fig. 11). Delayed stent migration into the
GI tract may occur; however, as long as the fistulous tract
has matured no intraperitoneal leak is expected (Fig. 12).
Stent occlusion
A stent can become obstructed by debris or food impaction,
often heralded by clinical signs of obstruction or sepsis. CT
may be helpful in showing dense impacted material within
the stent lumen (Fig. 13). Often the obstructing material
can be removed endoscopically, allowing the stent to remain
in situ.
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786 Abdominal Radiology (2021) 46:776–791

Mistarget

It is critical to report any additional regional cystic struc-

tures adjacent to the target collection as they can be difficult
to distinguish endoscopically from a walled-off collection,
thus presenting a risk of inadvertent cannulation. Cannulat-
ing the wrong target—in this example, a large renal cyst—
functionally creates an open gastrointestinal tract perforation
(Fig. 14).

Conclusion

Minimally invasive EUS-guided LAMS drainage is being

utilized in an expanding variety of clinical scenarios beyond
its standard application in pancreatic and peripancreatic col-
lections, where studies have already demonstrated compa-
rable efficacy and decreased morbidity and costs compared
to percutaneous drainage. While application of LAMS in
biliary and gastrointestinal drainage is still evolving, initial
studies have been promising in demonstrating comparable to
superior technical and clinical success rates and decreased
complication rates. This increasing scope of utilization
obligates the radiologist to familiarize themselves with the
relevant pre- and post-procedural imaging parameters to
determine suitability for endoscopic management and evalu-
ate treatment response. Furthermore, in presenting a com-
prehensive review of the potential complications of LAMS
insertion, we have highlighted the crucial role radiologists
may play in identifying complications and improving patient
outcomes.
Fig. 10  Hemorrhage—56 y.o. with severe necrotizing gallstone pan-
creatitis and salvage cystogastrostomy performed via plastic pigtail
stent for disconnected duct syndrome. The patient developed hemate-
mesis several days post-procedure. CT angiogram shows active con-
trast extravasation from a left gastric artery branch near the site of
stent insertion (arrows) (a, b). G* = stomach, C* = collection

13
Abdominal Radiology (2021) 46:776–791 787

Fig. 11  Stent displacement—84 y.o. with emphysematous cholecys- internal drainage (c). Shortly afterward, the patient became perito-
titis (a), treated initially with percutaneous cholecystostomy (black nitic and repeat CT demonstrated stent migration out of the gallblad-
arrowheads) as he was not an operative candidate (b). Cholecysto- der lumen and free fluid representing bile in the right upper quadrant
gastrostomy LAMS (arrow) inserted under fluoroscopic guidance for (white arrowhead) (d). GB* = gallbladder, G* = stomach

13
788 Abdominal Radiology (2021) 46:776–791

Fig. 12  Stent migration—42 y.o. with cystogastrostomy LAMS symptoms and repeat CT showed stent migration to the distal jeju-
(arrow) for infected walled-off pancreatic necrosis secondary to alco- num (arrow) (b). Follow-up radiographs show further stent migration
holic pancreatitis (a). The patient developed increasing infectious through the small bowel (c) and complete passage (d)

13
Abdominal Radiology (2021) 46:776–791
Fig. 13  Stent occlusion—78 y.o. with infected walled-off pancreatic
necrosis (a) treated with cystogastrostomy who developed worsening
infectious symptoms one week post-procedure. Repeat CT demon-
strated adequately positioned stent with high density material in the
stent lumen (arrow) (b) and repeat endoscopy confirmed the pres-
789
ence of necrotic material occluding the stent (asterisk). Fluoroscopic
image from the subsequent wash-out and necrosectomy delineates
the residual collection cavity (c). Follow-up CT 3 months later shows
collection resolution. Note air locules denoting a patent stent (d). G*
= stomach, C* = collection
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790 Abdominal Radiology (2021) 46:776–791

Fig. 14  Mistarget—94 y.o. presenting with acute acalculous chol- denostomy LAMS insertion attempted (arrows); however, the renal
ecystitis (a) who was initially not an operative candidate. Note the cyst was mistakenly targeted, leading to retroperitoneal duodenal per-
gallbladder wall thickening (black arrow). Several inches below the foration requiring open laparotomy repair (c, d). GB* = stomach, C*
gallbladder is an 8 cm right lower pole renal cyst (b). Cholecystoduo- = cyst

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