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). 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. 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. EndoscopyUCTNCodeCPL₁AL₂AD 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
Sato et al. (Fri,) studied this question.