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Endovascular management of arterio-ureteral fistula in a patient with a challenging hematuria
Abstract
Arterio-ureteral fistula (AUF) is a rare, but life-threatening disease that causes massive hematuria. We present a case of a 43-year-old female with AUF successfully treated with coil embolization and deployment of endovascular stents, along with a literature review. AUF symptoms most commonly occur with intermittent hematuria. AUF can occur in association with ureteral stenting, radiation, and prior pelvic or vascular surgery. Arteriography or ureteral pyelography are recommended as the most effective diagnostic strategies. Recent treatment efforts have focused on the use of endovascular stenting techniques as an alternative to open surgery.
... *Correspondence: mustafa.abdulselam@mail.utoronto.ca 2 Diagnostic and Interventional Radiology Resident, Joint Department of Medical Imaging, University of Toronto, 1 Dunsmore Gdns., Toronto, ON M3H 3M1, Canada Full list of author information is available at the end of the article Since the early 2000s, endovascular treatment has become the preferred management method, reserving open surgery to cases of enteric contamination, abscess formation, and infected stents/failed endovascular treatment [2,[6][7][8][9]. ...
... Moreover, in a systematic review, Jose et al. reported a total of 94 cases of UAFs, none of which involved the inferior mesenteric artery [2]. UAFs predominantly develop at the crossing common iliac or branch iliac arteries [9,18]. UAFs involving the aorta, renal artery, bilateral iliac arteries (double fistulae), or other pelvic arteries are exceedingly rare but can occur [2,18,19]. ...
... We avoided the use of high viscosity liquid embolic agents because they pose higher risk of non-target embolization, including distal embolization with bowel ischemia. An alternative method of endovascular treatment of UAF is with endovascular covered stent placement, which has shown good results especially in patients with arterial-ileal-conduit fistula, however, is limited to larger vessels [2,[6][7][8][9]. Following endovascular UAF embolization, our patient demonstrated resolution of hydronephrosis and hematuria and experienced a slow but steady clinical improvement within the 45-day follow up period, including improvement in hemoglobin, creatinine, and white blood cell count. ...
Background
Uretero-arterial fistulas (UAFs) are uncommon and pose a diagnostic dilemma, making them life threatening if not recognized and treated expediently. UAFs to small arteries such as a branch of the inferior mesenteric artery (IMA) are very uncommon and present a further diagnostic and treatment challenge. There should be a high index of suspicion for UAFs when intervening on patients with history of treated pelvic cancers and long-standing ureteric stents experiencing hematuria not attributable to another cause.
Case presentation
We present a case of a fistula formed between a distal branch of the IMA—superior rectal artery—and an ileal-conduit in a patient with a long-standing reverse nephroureterostomy (Hobbs) catheter presenting with abdominal pain and hematuria through the conduit. During a tube exchange, contrast injection demonstrated a fistula with the superior rectal artery, multiple ileal intraluminal blood clots, and active extravasation. The patient became tachycardic and hypotensive, actively bleeding through the ileal-conduit, prompting a massive transfusion protocol. Successful endovascular coiling of the superior rectal artery was performed with resolution of active extravasation and stabilization of the patient. The patient recovered and was discharged in stable condition 10 days later.
Conclusions
Although UAFs are uncommon, our case demonstrated key predisposing risk factors to fistula development; pelvic cancer surgery, pelvic radiation, and a prolonged ureteric stent through the ileal-conduit. Typically, UAFs arise from communication with the iliac arterial system, however in this instance we have demonstrated that fistulization to other arterial vessels is also possible. Endovascular management has become the preferred method of therapy, typically involving the placement of covered stents when involving the iliac arterial system. In this instance stent grafting was not possible due to the small caliber vessel and therefore had to be embolized.
... As stated by Lee and Lee (1), the AUF is a rare condition and misdiagnosis can cause dire consequences. Intermittent bleeding natures and subtle abnormal image findings make it difficult to diagnose and to treat earlier (2). Endovascular treatment would be A. The axial CT image of a 65-year-old female shows small pseudoaneurysm (arrow) in the left common iliac artery adjacent to the double-J ureteral catheter (arrowhead). ...
Objective
Uretero-arterial fistula (UAF) is lethal condition. However, there is no consensus regarding diagnosis and treatment of UAF owing to its rarity. The aim of this paper was to present an actual case of UAF and to systematically review the symptoms, risk factors, diagnosis, and treatment of this condition.
Methods
The case study included a 52-year-old woman who showed a massive hemorrhage during urinary stent replacement. For the systematic review of articles on UAF, those written in English and published from 1939 to 2020 were searched on PubMed using the keywords “uretero-arterial fistula,” “arterio-ureteral fistula,” and “hematuria”.
Results
We included 121 articles and 235 patients (mean age, 66.0 years; women, 139 [59.1%]) in this review. UAF occurred most frequently in the common iliac artery (112 patients [47.7%]). Almost all patients (232 patients [98.7 %]) complained of hematuria. The risk factors for UAF were pelvic surgery (205 patients [87.2%]), long-term use of urinary stents (170 patients [72.3%]), oncologic radiotherapy (107 patients [45.5%]), and malignancy (159 patients [67.7%]). Although computed tomography (CT) can detect various useful findings such as extravasation, pseudoaneurysm, hydronephrosis, and opacification of ureters, it was diagnostically useful in only one-third of the cases. Angiography was useful in diagnosing UAF in 124 (66.3%) of the 187 patients (80.0%) who underwent this procedure. With regard to treatment, endovascular approaches have been widely used in recent years because their invasiveness is lesser than that of open surgical repair. In the era of endovascular therapy, the indications for open surgical repair include ureteral-intestinal fistula, abscess formation, and graft infection after endovascular therapy.
Conclusions
CT was recommended as the first examination in patients with risk factors for UAF because of its usefulness. Subsequently, angiography should be considered because UAF can be treated using an endovascular approach following diagnostic angiography. Diagnosis and treatment of UAF can often be difficult; therefore, the important first step of diagnosis is suspecting UAF and employing a multidisciplinary approach.
Aim
Secondary uretero-arterial fistulas (SUAF) are uncommon, underrated and threatening for any patient. Gross hematuria is a clinical symptom of this pathology for patients with history of pelvic radiotherapy, complex pelvic surgery or long-term ureteral stenting. The purpose of this work is to assess risk factors, diagnosis and treatment of SUAF.
Methods
Monocentric and retrospective series of 6 new cases illustrated by a literature review through MedLine and Pubmed using the keywords “arterio-ureteral fistula”, “arterio iliac fistula” and “ilio-ureteral fistula”. We excluded uretero-arterial fistula following vascular surgery.
Results
Our series included 4 men and 2 women. All patients had a history of complex pelvic surgery and long-term ureteral stenting. Three patients had history of pelvic radiotherapy. They all had inaugural macroscopic haematuria episode. Two fistula cases were diagnosed on 5 repeated CT-scans. In 2 out of 5 cases, arteriography highlighted the fistula. Fistulas were generally located at the left common iliac artery. An endovascular stent was placed in 5 out of 6 cases. One patient needed open surgery. After treatment, 3 patients remained alive, 3 patients died either by a fistula relapse or by complications late in the treatment.
Conclusion
SUAF are uncommon, but serious. Today, there is no specific recommendation regarding complex treatment of these fistulas. Endovascular stents seem to be a good therapeutic option.
Level of proof
3.
Abstract
Objective
To report and analyze the indications and results of endovascular and open surgical treatment for uretero-arterial fistula.
Methods
We retrospectively reviewed the clinical data of 25 consecutive patients with uretero-arterial fistulas admitted to our hospital from 2011 to 2020. Endpoints were technical success, freedom from open conversion, stent-graft/graft-related complications, and 30-day and one-year mortality.
Results
The study included 25 patients (68% female, n = 17) with 27 uretero-arterial fistulas by bilateral pathologies in two patients. The mean age was 61 ± 11 years (range 35–80). The most common predisposing factors for uretero-arterial fistula were history of pelvic operations for malignancy in 21 patients (84%), radiotherapy in 21 patients (84%), previous pelvic vascular bypass in 2 patients (8%), and iliac aneurysms in 2 patients (8%). On average, the period between the primary pelvic surgery and the diagnosis of uretero-arterial fistulas was 46 months (range 7–255). Twenty patients (80%) underwent endovascular treatment of the uretero-arterial fistulas. The primary technical success of the endovascular treatment was 95%, and the freedom from open conversion was 40% at six months and 30% at one year. Thirteen uretero-arterial fistulas (48%) underwent delayed open conversion due to recurrent bleeding in six cases (46%), stent-graft infection in three cases (23%), or pelvic abscess in four cases (31%). Primary open surgery was applied for five (20%) patients. After a mean follow-up of 34 months, early (<30 days) mortality was 8% (2/25), one-year mortality 16% (4/25), and overall mortality was 24% (6/25).
Conclusions
Uretero-arterial fistula is a late complication of prior pelvic surgery, radiation, and indwelling ureteral stents. Endovascular treatment remains an effective and less invasive modality in controlling the related life-threatening arterial bleeding of the uretero-arterial fistula. Open surgical treatment is still required for patients with local sepsis, previously failed endovascular treatment or infected stent-grafts.
Background
Arterioureteral fistula (AUF) is a condition resulting from the pathologic connection between the ureter and the artery. Despite the low incidence, it can lead to devastating clinical consequences due to massive hematuria with a considerable mortality rate.
Material and methods
From January 2009 to December 2018, eight patients with AUF from two tertiary referral centers were included. Clinical data including presenting symptoms, previous pelvic surgery or radiotherapy, indwelling ureteral stents, primary vascular pathology, angiographic findings, type of treatment, survival, and recurrence were analyzed.
Results
All eight patients (six women, mean age 62.4 ± 14.5 years) presented with macroscopic hematuria and were successfully treated by endovascular management. One patient developed AUF due to an underlying iliac artery aneurysm, and the rest were due to secondary causes. Six patients had a history of an indwelling ureteral stent for a median of 5.5 months (1–84 months). All of the patients were successfully treated by endovascular management. For the median follow up of 987 days, three patients had recurrence of hematuria in a mean of 6.3 months, two patients were treated by surgery, while one was treated by endovascular treatment.
Conclusion
AUF should be confirmed through a purposeful iliac angiogram or ureterography when suspected based on a relevant history or CT findings. AUF can be successfully treated by endovascular management. The surgical option should be considered in cases of recurrence.
Abbreviations: AUF: arterioureteral fistula; CIA: common iliac artery; DJ: double J; EIA: external iliac artery; IIA: internal iliac artery; NBCA: N-butyl cyanoacrylate; PCN: percutaneous nephrostomy
We describe a case of successful surgical treatment for spontaneous rupture of an iliac artery aneurysm into a ureter. An 80-year-old man was admitted with massive hematuria. Immediate enhanced abdominal computed tomography scan and cystoscopy were suspicious for a uretero-arterial fistula caused by aneurysmal rupture. Emergent surgical intervention was performed because of the high mortality rate of this condition. Intraoperative findings revealed the fistula between the true aneurysm of the right common iliac artery and the ureter. Repair of the aneurysm and ligation of the ureter was performed, with an uneventful postoperative course.
Active extravasation via an arterioureteral fistula (AUF) is a rare and life-threatening emergency that requires efficient algorithms to save a patient’s life. Unfortunately, physicians may not be aware of its presence until the patient is in extremis. An AUF typically develops in a patient with multiple pelvic and aortoiliac vascular surgeries, prior radiation therapy for pelvic tumors, and chronic indwelling ureteral stents. We present a patient with a left internal iliac arterial-ureteral fistula and describe the evolution of management and treatment algorithms based on review of the literature.
Highlights
•
Ureteroarterial fistula (UAF) is a rare cause of massive hematuria.
•
Percutaneous retrograde ureteral stents via DBWC can be done safely in the compliant patient for improved comfort.
•
Understanding the anatomy, risks, and minimally invasive treatment options for UAF is important for prompt patient care.
Ureteral-arterial fistula (UAF) is an exceedingly rare but life-threatening condition warranting emergent intervention. Prompt recognition and management of UAF in suspect patients presenting with gross hematuria are required for a successful outcome. We report a rare subset of UAF involving the bilateral common iliac arteries. The patient underwent successful endovascular stent-grafting to correct the arterial defect and delayed open repair of the ureteral strictures. Timely management has benefited from the collaboration of the involved medical teams, which included emergency medicine, urology, and interventional radiology.
Introduction:
Primary arterial-ureteral fistula is a rare and diagnostically challenging condition which may present with massive hematuria.
Presentation of case:
A case of primary arterial-ureteral fistula (AUF) is presented in a patient with a previous prosthetic aortic-bifemoral bypass. The AUF treated with arterial and ureteral resection, arterial ligation and ureteral reconstruction.
Discussion:
Primary AUF are more frequently associated with aneurysmal degeneration of the arterial wall. The development of a primary fistula due to an iliac artery aneurysm many years after an aortic-bifemoral bypass performed due to atherosclerotic obstructive disease is a very unusual presentation of this entity. Multiple surgical strategies can be employed in achieving hemorrhage and infection control, urinary tract continuity, and vascular reconstruction.
Conclusion:
A multidisciplinary approach and the achievement of a pre-operative diagnosis are essential for an effective management of this condition with prognostic implications.
A 74-year-old woman presenting with bilateral ureteral stricture was referred to our hospital. She had undergone radical hysterectomy and adjuvant irradiation therapy for cervical cancer in 2000. Double-J stents were inserted in both the ureters and replaced at regular intervals. Eighteen months after ureteral stenting, she complained of gross hematuria and was managed with hemostatic agents. During a routine replacement of the right double-J stent, massive bleeding was observed from the urethra which continued intermittently. The source of bleeding was not identified on computed tomography and angiography. We kept her at rest, which reduced the bleeding. However, she required intermittent transfusions. Angiography was performed at the time of bleeding on March 5, 2011. A uretero-internal pudendal artery fistula was found, and coil embolization was performed. Thereafter, hematuria did not recur up to the last followup in July 2011.
We describe an 80-year-old female with a left ureteroileal fistula and simultaneously a right ureteroiliac fistula. Her history highlights the predisposing factors of radiation, major surgery in the region, and presence of bilateral double-J-stents. She was successfully treated with an endovascular approach after being initially misdiagnosed. There seems to be an increase in reporting ureteral fistulas, however this entity remains a rare clinical condition that can lead to life-threatening situations. A fast and accurate diagnosis of an ureteroarterial fistula remains a challenge.
Uretero-Iliac artery fistulas (UAFs) are very uncommon in urological practice. The rarity of this clinical entity may lead to a delayed or missed diagnosis which can result in life-threatening consequences. We present a case of a right ureteric and right external iliac artery fistula, its presentation, diagnosis, and management along with the review of the literature.
Ureteral-iliac artery fistula (UIAF) is a rare life threatening cause of hematuria. The increasing frequency is attributed to increasing use of ureteral stents. A 68-year-old female presented with gross hematuria. She had prior low anterior resection for rectal cancer and a retained ureteral stent. CT abdomen and pelvis showed a large recurrent pelvic mass and a retained stent. The patient underwent cystoscopy which showed a normal bladder. Upon removal of the stent, brisk bleeding was noted coming from the ureteral orifice. Antegrade pyelogram was done which revealed a UIAF. Angiography was done and a covered stent was placed. Multiple treatment options are available. All must consider management of the arterial and ureteral side. The arterial side may be addressed by primary open repair, embolization with extra-anatomic vascular reconstruction, or endovascular stenting. The ureter can be managed with nephroureterectomy, ureteral reconstruction, placement of a nephrostomy tube, or ureteral stenting. Being minimally invasive, we believe that endovascular stenting should be the preferred therapeutic option as it also corrects the source of bleeding while preserving distal blood flow.
An arterioureteral fistula (AUF) is a rare but life-threatening condition bordering on the expertise of the urologist, vascular surgeon, and interventional radiologist. We reviewed published cases in order to better recognize and treat patients with an AUF. Of all 139 patients, 13% died of an AUF-related cause; in this group, only 22% of the fistulas were recognized before treatment. The diagnosis AUF should be considered in patients with unexplained hematuria who have a history of pelvic cancer or vascular surgery. Angiography and ureteral contrast studies most often confirmed AUFs. Patients treated with endovascular technique had the most favorable outcome.
Ureteroarterial fistulas are rare, erosive defects that occur between the distal segments of the ureter and the adjacent blood vessels in individuals with urologic and vascular comorbidities. Characterized by diffuse, pulsatile bleeding into the urinary tract, this condition carries a significant mortality rate in the absence of early recognition. Recent treatment efforts have focused on use of endovascular stenting techniques as an alternative to open surgical closure of the underlying defects in hemodynamically stable patients. We provide a literature review detailing the characteristics, mechanism, and management of ureteroarterial fistulas.
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Ureteroarterial fistula is a rare, potentially life-threatening cause of hematuria characterized by an abnormal channel between a ureter and artery. The rarity of this condition, complexity of predisposing risk factors and intermittence of symptoms may delay or obscure its diagnosis. With a high index of suspicion and careful angiographic evaluation, embarking on this condition is not only possible but sets the stage for curative intervention. We report a case of a ureteroarterial fistula presenting with intermittent hematuria, successfully diagnosed at angiography and managed with endovascular stent graft placement.
A neobladder-arterial fistula is a very rare complication following cystectomy, with only 1 previously reported case. Delay in diagnosis can be rapidly fatal and requires prompt intervention. We report the case of a 63-year-old male who developed massive hematuria, and was found to have a fistula between the right external iliac artery and Studer neobladder during emergent exploratory laparotomy. Treatment success relies on a high index of suspicion and may include open operative intervention.
To review the indications and results of open surgical and endovascular treatment for ureteral-iliac artery fistula (UIAF).
We reviewed the clinical data of 20 consecutive patients treated for 21 UIAFs between 1996 and 2010. Since 2004, iliac artery stent grafts were the primary treatment except for complex fistulas with enteric contamination or abscess. Endpoints were early morbidity and mortality, patient survival, vessel or graft patency, freedom from vascular or stent graft/graft infection, and freedom from recurrent bleeding.
There were 20 patients, 15 females, and five males, with mean age of 63 ±13 years. Predisposing factors for UIAF were prior tumor resection in 18 patients, radiation in 15, ureteral stents in 15, ileal conduits in four, and ileofemoral grafts in three. All patients presented with hematuria, which was massive in 10. Treatment included iliac stent grafts in 11 patients/12 fistulas (55%), with internal iliac artery (IAA) exclusion in nine, femoral crossover graft with IAA exclusion in five, direct arterial repair in three, and ureteral exclusion with percutaneous nephrostomy and no arterial repair in one. There were no early deaths. Five of eight patients treated by open surgical repair developed complications, which included enterocutaneous fistula in three and superficial wound infection in two. Four patients (36%) treated by iliac stent grafts had complications, including pneumonia, non-ST segment elevation myocardial infarction, buttock claudication, and early stent occlusion in one each. After a median follow-up of 26 months, no one had recurrent massive hematuria, but minor bleeding was reported in three. Patient survival at 5 years was 42% compared with 93% for the general population (P < .001). Freedom from any recurrent bleeding at 3 years was 76%. In the stent graft group, primary and secondary patency rates and freedom from stent graft infection at 3 years were 81%, 92%, and 100%.
UIAF is a rare complication associated with prior tumor resection, radiation, and indwelling ureteral stents. In select patients without enteric communication or abscess, iliac artery stent grafts are safe and effective treatment, and carry a low risk of recurrent massive hematuria or stent graft infection on early follow-up. Direct surgical repair carries a high risk of enterocutaneous fistula.
Ureteroarterial fistulas can be treated with open vascular or percutaneous arterial stent placement. We compared the long-term outcomes of each treatment.
A single center, retrospective review of ureteroarterial fistulas (1996 to 2008) was performed.
We identified 20 ureteroarterial fistulas in 19 patients. All patients had undergone extirpative surgery with pelvic radiation in 74% and long-term ureteral stents in 84%. At a mean followup of 15.5 months (range 1 to 99) survival was 53%. Of the 70% (14 of 20) treated with percutaneous endovascular iliac artery stenting or embolization, 2 patients later required open vascular graft and 12 were treated with long-term ureteral stenting. Of the 30% (6 of 20) of patients treated with open surgical repair or bypass 2 required bypass revision and/or thrombectomy, and 4 had concomitant ureteral ligation or nephrectomy. Despite undergoing anticoagulation 10 patients (53%) experienced lower extremity morbidity including ulceration, ischemia and amputation. In each treatment group 2 patients had recurrent hemorrhage requiring a secondary procedure, leading to death in 2 for an overall 10% acute mortality rate. Overall noncause specific mortality of ureteroarterial fistulas was 47% and 10% to 20% was related to the fistula or treatment complications.
Endovascular stenting is increasingly used in lieu of open techniques due to the high operative risk and comorbidities in patients with ureteroarterial fistulas. This retrospective review fails to identify a clear advantage for endovascular or open vascular surgical management. Thus, endovascular stenting is preferred in most cases. Regardless of therapy, patients are at risk for recurrent bleeding, lower extremity complications and stent/graft complications. The use of antibiotics and long-term anticoagulant therapy appear prudent but not proved.
Ureteroarterial fistula is a rare condition with life-threatening hematuria that should be diagnosed and treated immediately. We reported two patients of ureteroarterial fistula who underwent successful endovascular treatment by stent-grafts. They had undergone pelvic surgery followed by placement of an indwelling ureteral stent for stricture of the ureter before sudden hematuria occurred. Routine contrast-enhanced computed tomography did not reveal extravasation or a pseudo-aneurysm. Angiograms with multiple oblique views demonstrated small pseudoaneurysms of the iliac artery overriding the ipsilateral ureter. The endovascular treatment of ureteroarterial fistula using stent-grafts was successful, and the hematuria disappeared immediately after stent-graft deployment. The hematuria did not recur up to the last follow-up visits of 3 and 19 months, respectively.
Ureteroarterial fistulas are rare, with less than 20 well documented cases reported. We report a case of a fistula between the left external iliac artery and the left ureter in a patient who underwent a previous operation for bladder cancer. The diagnostic and therapeutic approaches in these rare but high risk patients are discussed.
A fistula formed between the common iliac artery and the ureter following balloon dilatation of the distal ureter and stent placement in the presence of an ileal conduit. Possible causes are discussed.
Ureteroarterial fistulae (UAF) are a rare complication of prolonged ureteral stenting. To date only three patients have been reported who have developed UAF after pelvic exenteration. This report presents two additional patients with UAF following exenteration and prolonged ureteral stenting. Rapid diagnosis with pelvic arteriography and retrograde ureteral angioplasty balloon catheter placement is discussed, and successful management with femoral artery embolization and bypass surgery is reviewed.
Ureteroarterial fistulae are rare. We report 2 cases of this clinical problem. Ureteroarterial fistulae can occur in association with prolonged ureteral stenting, radiation therapy, vascular pathology, and prior pelvic or vascular surgery. Identification of a fistula is often difficult and requires the physician to be highly alert and vigilant. Diagnostic and therapeutic options for a ureteroarterial fistula are discussed.
Ureteroarterial fistula (UAF) is a rare occurrence. It can be difficult to diagnose with a high mortality. We report a case of a recurrent UAF.
A 38-year-old women diagnosed with cervical cancer had undergone pelvic exenteration for severe radiation-induced necrosis with a vesicovaginal and rectovaginal fistula after primary radiation therapy. Hemorrhage into the urinary tract necessitated surgical intervention and vascular repair with a femoral-femoral bypass. Although these measures were effective, the patient died 6 months later following an acute hemorrhage into her conduit. Arteriogram revealed a second UAF.
When urinary tract bleeding occurs in patients previously diagnosed with a gynecologic malignancy and treated with radiation therapy and extensive surgery with urinary diversion, UAF should be considered in the differential diagnoses.
To review published reports on arterio-ureteral fistula.
Literature search.
Eighty cases were identified. Primary fistulas were mainly seen in combination with aortoiliac aneurysmal disease. Secondary fistulas were seen after pelvic cancer surgery, often with radiation, fibrosis and ureteral stenting or after vascular surgery with synthetic grafting. The dominating symptom is massive haematuria, often with circulatory impairment. The clue to a rapid and correct diagnosis is a high degree of suspicion. Most frequently diagnosis has been obtained through angiography or pyelography. When there is a ureteral stent manipulation it will often provoke bleeding and lead to diagnosis. The fistula must be excluded and a vascular reconstruction made. Most frequently this has been obtained through occlusion of the fistula and an extra-anatomic reconstruction (femoro-femoral crossover). Recently stent-grafting has been successfully used but follow-up is short.
Arterio-ureteral fistula is rare and should be suspected in patients with complicated pelvic surgery and massive haematuria, especially where rigid ureteral stents have been placed.
Ureteral-iliac artery fistulae are rare, yet potentially life-threatening, causes of hematuria. Treatment has traditionally been surgical, but advances in endovascular technology have led to a few recent reports of therapy with covered stents. We report two cases of patients diagnosed with ureteral-iliac artery fistulae who were treated with Wallgraft endoprostheses, a new, commercially available covered stent.
We report two patients with gynecologic malignancies who presented with massive hematuria and hypotension and were subsequently proven to have ureteral-iliac arterial fistulae. Both patients had prior pelvic surgery, radiation, and chronic indwelling ureteral stents. Once the diagnosis was established, both patients were managed with endovascular covered stent placement. The patients' conditions stabilized, hematuria ceased, and both were discharged from the hospital without additional transfusion or surgical treatment.
Endovascular therapy with covered stents is a safe, effective, and readily available method for the treatment of ureteral-iliac artery fistulae.
Ureteroarterial fistulae (UAFs) are a rare entity, often difficult to identify, and associated with a high mortality rate. This fact has been attributed to a delay in diagnosis and treatment. Five conditions that can predispose to the development of this uncommon entity have been described: prior pelvic surgery, prolonged ureteral stenting, radiation therapy, previous vascular surgery and vascular pathology.
We present 4 patients with UAFs and at least three of the above-mentioned conditions. Ureteral ischemia and subsequent necrosis promote the formation of these fistulae. The constant pulsation of the iliac artery is transmitted to an already compromised ureter containing a stiff intraluminal foreign body, resulting in pressure necrosis, most likely where the ureter crosses the iliac artery.
Cases were managed percutaneously with a combination of the deployment of a covered prosthesis and, when needed, with mechanical occlusion of the ureter. Hematuria stopped in all the patients with no evidence of immediate rebleeding. One patient presented a new episode of vaginal bleeding 13 months after endograft placement and ureteral embolization. Arteriography showed the presence of a hypogastric artery pseudoaneurysm that was occluded using coils. No new bleeding has occurred in this patient 12 months after the second embolization. At present all 4 patients are alive with follow-up periods of 5, 9, 11 and 25 months since the first procedure.
To review the diagnosis and treatment of ureteroarterial fistulas and to develop a management algorithm. Long-term ureteral stenting, along with pelvic surgery and radiotherapy, have led to an increased incidence of ureteroarterial fistulas. Experience diagnosing and treating these fistulas has been limited to case reports.
A retrospective chart review from 1975 to 2004 revealed eight ureteroarterial fistulas in 7 patients at our institution. The patient demographics, presenting symptoms, and diagnostic studies were reviewed. Also, we analyzed the treatment, hospital course, and long-term outcomes.
Ureteroarterial fistulas were more common in women (86%) than in men. All patients presented with gross hematuria, and 57% had lateralizing flank pain. Risk factors included chronic indwelling stents (87%), previous pelvic external beam radiotherapy (71%), pelvic surgery (100%), and vascular disease (87%). Provocative angiography was diagnostic in only 63% of cases. Although not sensitive, cystoscopy revealed lateralized, pulsatile hematuria in all cases when performed. Treatment ranged from endovascular stenting with nephrostomy tube to primary surgical repair with nephrectomy.
On the basis of this review, we propose a systematic diagnostic and treatment approach to a serious disease process. The use of these proposed algorithms will minimize unnecessary testing, increase the speed of diagnosis, and potentially improve overall outcomes of patients with ureteroarterial fistulas.