Severe hemobilia due to arterio-biliary fistula. diagnosis and treatment by endoscopic ultrasound

75-year-old man with locally advanced cholangiocarcinoma. Uncovered self-expandable metal stent for biliary drainage was placed by ERCP. The patient was admitted to the hospital because of hematemesis. ERCP demonstrated direct visualization of oozing blood through the papilla. The patient presented hemodynamic instability following balloon catheter removal. Fully covered self-expandable metal stent (10x60 mm) was delivered blindly. EUS revealed anomalous artery adjacent to the stent with active bleeding into the common bile duct. Embolization of the anomalous blood vessel was attempted using 22-gauge needle and five 0.0018-inch coils (Tornado Embolizations Coils). Bleeding cessation and hemodynamic stabilization were achieved after the procedure.