Salvage Endoscopic Management for Basket Impaction Using Cholangioscopy and Electrohydraulic Lithotripsy

Basket impaction is a serious complication of mechanical lithotripsy during endoscopic retrograde cholangiopancreatography, often necessitating surgical intervention. Risk factors include stones > 1.5 cm, multiple stones, extremely hard stones, or inadequate dilatation of the bile duct.

We describe a 64-year-old woman with recurrent cholangitis and choledocholithiasis who underwent endoscopic retrograde cholangiopancreatography for a 1.6-cm common bile duct stone. Initial balloon lithotripsy was unsuccessful, and subsequent mechanical lithotripsy resulted in basket impaction. Attempts with a rescue lithotripter handle were ineffective due to challenging ampullary angulation. Peroral cholangioscopy with the Boston Scientific SpyGlass DSII system was utilized, and electrohydraulic lithotripsy successfully fragmented the stone. The basket and stone fragments were subsequently removed without complications.

This case underscores the value of cholangioscopy-assisted electrohydraulic lithotripsy as a salvage strategy for basket impaction, offering direct visualization and precise targeting to reduce the risk of tissue injury associated with blind or forceful interventions, thereby preventing the need for surgery. While cost and limited availability remain barriers, this minimally invasive technique provides a timely and effective alternative to surgical intervention, offering a critical salvage option for managing basket impaction.