A 42-year-old woman at 13 weeks of pregnancy with a history of severe alcoholic pancreatitis 9 months earlier was admitted to an outside institution for recurrent abdominal pain. She was found to have a pancreatic walled-off necrosis (WON) abutting the body and tail of the pancreas, measuring 17.2 cm on MRI ([Figs. 1](#fig1){ref-type="fig"} and [2](#fig2){ref-type="fig"}). The patient underwent EUS-guided transgastric drainage of the WON with placement of a 20-mm × 10-mm cautery-enhanced lumen-apposing metal stent (\[LAMS\] AXIOS; Boston Scientific, Marlborough, Mass, USA) and was discharged home.Figure 1T2-weighted MRI coronal view of walled-off necrosis before EUS-guided lumen-apposing metal stent deployment.Figure 2T2-weighted MRI axial view of walled-off necrosis and stomach with a measured distance of 10.73 mm between them.

The following day, the patient presented to our institution with abdominal pain, nausea, vomiting, and fever because of the unavailability of therapeutic endoscopy at the original facility. She was found to have sepsis and hypotension with a body temperature of 38°C, heart rate of 134 beats per minute, and blood pressure of 80/50 mm Hg. Her laboratory values were significant for leukocytosis of 15,000/uL but were otherwise normal. MRI demonstrated a moderate amount of fluid outside of the WON extending down the left paracolic gutter/retroperitoneum, which was concerning for a leak ([Fig. 3](#fig3){ref-type="fig"}). No free air was seen. CT revealed misdeployment of the WON with the distal flange within the wall of the WON ([Fig. 4](#fig4){ref-type="fig"}).Figure 3T2-weighted MRI coronal view of walled-off necrosis after EUS-guided lumen-apposing metal stent misdeployment with left paracolic gutter fluid leak.Figure 4CT axial view after EUS-guided lumen-apposing metal misdeployment into the wall of the walled-off necrosis.

EGD with a 16F gastroscope (GIF-XP190N; Olympus America, Center Valley, Pa, USA) showed the proximal flange of the LAMS in appropriate position within the stomach. The gastroscope was advanced into the WON, where solid debris and turbid fluid were seen. A retroflexion was performed within the WON to visualize the distal flange of the LAMS. The distal flange appeared to be misdeployed, with a portion of it deployed within the wall of the WON ([Fig. 5](#fig5){ref-type="fig"}). Under fluoroscopic guidance, pediatric biopsy forceps were used to adjust the distal flange of the LAMS further into the cavity of the WON ([Fig. 6](#fig6){ref-type="fig"}).Figure 5Endoscopic view of the distal flange of the lumen-apposing metal stent (LAMS) on retroflexion within the cavity of the walled-off necrosis.Figure 6Fluoroscopic view of the 16F gastroscope retroflexed within the walled-off necrosis cavity repositioning the lumen-apposing metal stent (LAMS).

Upon review of MRI, the distance between the gastric wall and the WON appeared to be greater than the 10-mm channel length of the LAMS. We therefore switched to a 34F adult gastroscope (GIF-1TH190; Olympus America) to bridge the gastric wall and WON with another stent. The WON was accessed with the gastroscope, and a 20-mm × 60-mm through-the-scope fully covered metal esophageal stent (TaeWoong Medical, Gyeonggi-do, South Korea) was placed through the LAMS into the WON ([Fig. 7](#fig7){ref-type="fig"}). Radiation was minimized, and the patient received a total of 11 seconds of radiation. The WON was lavaged with 100 mL sterile water.Figure 7Fluoroscopic view of the through-the-scope (TTS) fully covered metal esophageal stent deployed through the lumen-apposing metal stent (LAMS).

The patient's sepsis resolved, and the fetus was healthy without diffficulties for the remainder of the hospital course. The patient was discharged home with antibiotics a few days after the procedure. The patient and fetus continued to do well at home, and a follow-up MRI 1 month after the procedure demonstrated significant improvement of the WON, with stents in the appropriate position ([Fig. 8](#fig8){ref-type="fig"}). EGD demonstrated the appropriate position of the esophageal stent in the stomach. However, the LAMS was noted to have migrated into the cavity of the WON ([Fig. 9](#fig9){ref-type="fig"}). The esophageal stent and the LAMS were removed with rat-tooth forceps. Examination of the pancreatic bed was performed, and the WON appeared to be decompressed. At the 20-week follow-up visit, the patient and fetus remained healthy without issues.Figure 8T2-weighted MRI coronal view of resolved walled-off necrosis and stents at 1-month follow-up visit.Figure 9Endoscopic view at 5-week follow-up visit demonstrating complete migration of the lumen-apposing metal stent (LAMS) into the walled-off necrosis.

With increasing use of the 20-mm LAMS and the potential for adverse events such as misdeployment, it is important for therapeutic endoscopists to have several solutions available. We demonstrate the salvage therapy of a misdeployed 20-mm LAMS by use of a combination of repositioning with a 16F gastroscope and through-the-scope covered esophageal stent. ([Video 1](#appsec1){ref-type="sec"}, available online at [www.VideoGIE.org](http://www.videogie.org){#intref0010}).

Disclosure {#sec1}
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*Dr Nasr is a consultant for Boston Scientific. The other authors disclosed no financial relationships relevant to this publication.*

Supplementary data {#appsec1}
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Video 1Demonstration of salvage therapy of a misdeployed 20-mm lumen-apposing metal stent by use of a 20-mm through-the-scope fully covered metal esophageal stent in a pregnant patient.
