Anatomic locations of ureterovascular fistulae: a review of 532 patients in the literature and a new series of 8 patients

Abstract

Introduction
Ureterovascular fistula (UVF) is a rare but potentially life-threatening condition. Since its primary description by Moschkowitz in 1908, many case reports, studies and reviews have been written about this condition with the suggestive symptoms and risk factors repeatedly discussed. This study will be focusing on the different locations of 532 out of 605 fistulae published from 1908 up to 2022 besides eight new patients of our own.

Material and methods
A systematic review of the literature started using PubMed database searching for “ureteroarterial fistula”, “arteriovascular fistula” and “uretero vascular fistula” was performed yielding 122, 62 and 188 results respectively. Those studies and the cited literature in each study were examined to include studies, which did not appear in the primary search. A total of 605 patients in 315 publications were gathered. Only studies mentioning new patients, a clear indication of the location of the UVF, the presence/absence of urinary diversion (UD) as well as the type of UD if present were included. Ten duplicates as well as studies lacking information regarding the UVF and/or the UD (seven publications with 63 patients) were excluded, with 298 publications including 532 external patients remaining. Eight internal cases were included with a total of 540 cases.

Results
From the 540 included cases, 384 patients (71.1%) had no UD compared to 156 patients (28.9%) with UD. Due to the anatomical ureteral course, the common iliac artery (CIA) was the most common vascular component of UVF, irrespective of the presence or absence of UD. Any dispute to whether the crossing point is the common or the external iliac artery (EIA) was settled for the CIA. Further common vascular components besides CIA include the aorta, EIA, internal iliac artery (IIA) including its branches and vascular bypasses including the anastomosis sites. Other unusual arterial localizations were stated under the “others” category.

Conclusion
Identifying the location of the bleeding artery in UVF is critical and represents the most important step for successful management. We present the largest summary of described locations up to date including our own.

Graphical Abstract

Full text

Shamseldinetal. CVIR Endovascular (2024) 7:63
https://doi.org/10.1186/s42155-024-00475-1
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CVIR Endovascular
Anatomic locations ofureterovascular
stulae: areview of532 patients intheliterature
andanew series of8 patients
Mohammed Shamseldin1* , Hendrik Heers2, Thomas Steiner3 and Ralf Puls1
Abstract
Introduction Ureterovascular fistula (UVF) is a rare but potentially life-threatening condition. Since its primary
description by Moschkowitz in 1908, many case reports, studies and reviews have been written about this condition
with the suggestive symptoms and risk factors repeatedly discussed. This study will be focusing on the different loca-
tions of 532 out of 605 fistulae published from 1908 up to 2022 besides eight new patients of our own.
Material andmethods A systematic review of the literature started using PubMed database searching for “ureter-
oarterial fistula”, “arteriovascular fistula” and “uretero vascular fistula” was performed yielding 122, 62 and 188 results
respectively. Those studies and the cited literature in each study were examined to include studies, which did
not appear in the primary search. A total of 605 patients in 315 publications were gathered. Only studies mention-
ing new patients, a clear indication of the location of the UVF, the presence/absence of urinary diversion (UD) as well
as the type of UD if present were included. Ten duplicates as well as studies lacking information regarding the UVF
and/or the UD (seven publications with 63 patients) were excluded, with 298 publications including 532 external
patients remaining. Eight internal cases were included with a total of 540 cases.
Results From the 540 included cases, 384 patients (71.1%) had no UD compared to 156 patients (28.9%) with UD.
Due to the anatomical ureteral course, the common iliac artery (CIA) was the most common vascular component
of UVF, irrespective of the presence or absence of UD. Any dispute to whether the crossing point is the common
or the external iliac artery (EIA) was settled for the CIA. Further common vascular components besides CIA include
the aorta, EIA, internal iliac artery (IIA) including its branches and vascular bypasses including the anastomosis sites.
Other unusual arterial localizations were stated under the “others” category.
Conclusion Identifying the location of the bleeding artery in UVF is critical and represents the most important step
for successful management. We present the largest summary of described locations up to date including our own.
*Correspondence:
Mohammed Shamseldin
Mohammed.Shamseldin@helios-gesundheit.de
Full list of author information is available at the end of the article

Page 2 of 15
Shamseldinetal. CVIR Endovascular (2024) 7:63
Graphical Abstract
Introduction
In the literature usually referred to as ureteroarterial fis-
tula or arterioureteral fistula (UAF/AUF) is a potentially
life-threatening condition which should be abruptly and
correctly diagnosed and treated. e term ureterovas-
cular fistula (UVF) would be used in this article instead
of the more commonly used ureteroarterial fistula to
emphasise the possiblity of venous participation in ure-
teral fistulae. e condition was primarily described
by Moschkowitz in 1908 [1], UVF could be classified
into primary and secondary UVF based on the underly-
ing pathology. e most common and serious symptom
is macrohematuria [2–4]. e majority of the cases are
secondary (85%) due to previous pelvic interventions
including pelvic surgery to remove pelvic tumors (89%)
with combined radiation (67%) being an additional risk
factor. e most common risk factor is the presence of
a chronic ureteral stent in 73.7% of the cases [3]. Pri-
mary UVF are rare (15%) and involve primarily a vascu-
lar pathology such as aneurysms, vascular malformations
and aberrant vessels [5, 6]. In the case of uretero-caval
fistula in which the inferior vena cava was involved as the
vascular (venous) component, the risk factors are quite
similar, however without hematuria present, but rather
nonspecific clinical signs such as fever with pulmonary
microembolism due to formation of a thrombus at the
vascular point of the fistula [7].
erapeutic options include historically surgical treat-
ment with or without transarterial embolization [8–10].
With the rapid advancement of the minimally invasive
endovascular therapy especially of stent grafts (SG) and
embolic materials, this became quickly the primary
option in many centers, both favored by both patients
and medical staff, taking into consideration that the
majority are cancer patients suffering from multi-mor-
bidities, which make surgery quite difficult.
Irrespective of the underlying pathology, the single
most important key to a successful treatment of UVF is
to accurately identify the vascular component sharing in
the fistula. To reach that goal, an accurate patient´s his-
tory should be documented. Important is get a detailed
history of previous operations in the abdominopelvic
region, whether the patient was subjected to radio- and/
or chemotherapy, the presence of a urinary diversion
(UD) and the type of diversion which was performed.
Urinary diversion is a surgical procedure performed
when the bladder is not functioning properly or has
been removed due to disease or injury that reroutes the
normal flow of urine from the kidneys and ureters to an
alternative exit route. e two main categories of UD are

Page 3 of 15
Shamseldinetal. CVIR Endovascular (2024) 7:63
urostomy (eg. Ileal conduit and cutaneous ureterostomy)
and continent urinary diversion (eg. Neobladder). is is
specifically critical due to the anatomical changes regard-
ing the course of the ureter(s) leading to a high risk of
unexpected unusual locations of the UVF involving vas-
cular components, which are not normally in direct prox-
imity to the ureters.
In our review, we will be presenting a detailed descrip-
tion of all published UVF locations in the literature
through reviewing 315 published articles. We added
eight cases from our institute with important teaching
points included in the discussion section. e novelty of
this article is to indicate all published atypical locations
of UVF, especially in cases with UD, which were mainly
scattered in the literature in form of case reports due to
the rarity of the condition.
Material andmethods
Our systematic review of the literature started using
PubMed database searching for “ureteroarterial fistula”
“arteriovascular fistula” and “uretero vascular fistula”
was performed yielding 122, 62 and 188 results respec-
tively from 1908 up to 2022. All the studies found were
examined and then all the literature references cited in
each study were separately examined to gather the larg-
est possible number of published articles including stud-
ies, which did not appear in the primary search in the
PubMed database. A total of 605 patients were found in
a total of 315 publications. Each study was then exam-
ined to determine whether new patients were included,
a clear indication of the location of the UVF, the pres-
ence/absence of UD as well as the type of UD if present.
Ten duplicates not including new patients were excluded
including only original articles with newly mentioned
cases. e lack of sufficient information regarding the
UVF and/or the UD as mentioned above was used to
exclude seven further publications including 63 patients,
with 298 publications including 532 external patients
remaining. After the addition of eight cases of our own,
a total of 540 patients were included in this study (Fig.1).
e patients from our institute were referred to us from
the department of urology with a suspected UVF for
endovascular therapy between February 2017 and March
2021 (Table1). A detailed overview of all the publications
considered as well as the vascular and ureteral compo-
nents of UVF in each study were gathered and supplied as
supplementary files. In our hospital, the side of the bleed-
ing was always identified using endoscopy, usually dur-
ing an exchange of ureteral stents. A biphasic Computer
tomography (CT) scan with arterial and portal venous
phases was perfomed in all patients which did not have
any CT scans in our system prior to the onset of symp-
toms and had no UD (six out of eight patients). Older CT
scans of the remaining two patients were used to identify
the possible vascular component of the fistula. e aim of
the CT scan was mainly to identify the suspected vessel
involved in the fistula whether through vascular changes
such as pseudoaneuryms and vascular irregularities
or through proximity to the ureter on the bleeding side
identified during endoscopy. A digital subtraction angi-
ography (DSA) was then routinely performed to treat the
patient. A standard right femoral access using a 5-French
(F) Destination guiding sheath (Terumo, Tokyo, Japan)
and a 4F-UF-flush catheter (Cordis, California, USA) or
4F-Sidewinder Simmons 1 catheter (Cordis, California,
USA) in the case of the IMA were performed. A trial to
disclose the UVF with and without applying a provoca-
tive maneuver through temporarily removing the ure-
teric catheter and applying contrast medium at the point
of ureteral crossing was attempted in all cases. In some
cases, the only way to visualize the UVF was a selective
injection of contrast medium in the direct proximity of
the suspected crossing point after temporary removal of
the ureteral stent through the urologist in the angiogra-
phy suite as a provocation.
In all cases, therapy was performed either through
embolization of the vessel in question whenever pos-
sible, for example the internal iliac artery (IIA) or the
inferior mesenteric artery (IMA) using coils or a vascu-
lar plug or by using particle embolization in the case of
inferior vesical artery (IVA) or glue embolization in the
case of superior vesical artery (SVA). In cases where the
common iliac artery (CIA), external iliac artery (EIA)
or IIA were involved, a slightly oversized stent graft (1
mm) was used to cover the UVF from the arterial side
or covering the origin of the IIA. As long as the origin
of the IIA was expected to be covered by the stent graft,
an additional proximal embolization of the IIA using
coils or a vascular plug was routinely performed to dis-
allow any possible collateralization.
Results
In this study, we were able to collect the largest number of
published UVF based on their location. e localization
of the UVF was the single most important step in manag-
ing the condition. We thereby present all the published
locations of UVF in the literature up to date (Table2).
From the 540 included cases, 384 patients (71.1%) had no
UD compared to 156 patients (28.9%) with UD (Table2).
Since the ureters anatomically cross the pelvic arteries
over the distal CIA directly above the iliac bifurcation,
the CIA was the most common vascular component of
UVF, irrespective of the presence or absence of UD. Any
dispute to whether the crossing point is the CIA or the
EIA was settled for the CIA. Further common vascu-
lar components besides CIA include the aorta, EIA, IIA

Page 4 of 15
Shamseldinetal. CVIR Endovascular (2024) 7:63
including its branches and vascular bypasses including
the anastomosis sites. Other unusual arterial localiza-
tions were stated under the “others” category.
We further subcategorized the locations according to the
presence and type of UD, as a distorted course of the ureters
was the main reason for unexpected localizations of UVF.
Rare UVF including unusual vascular involvement,
unusual urinary tract involvement, double-vessel UVF
and complex UVF were recollected in separate tables
(Tables3, 4, 5 and 6).
A summary of the most common locations of UVF with
and without UD are shown in Fig.2[11]. Although the
most common sites of UVF with or without UD were the
CIA (64% and 48% respectively) and EIA (14% and 18%
respectively), the presence of UD increased the incidence
of the aortic involvement drastically up to 13% (only 1%
without UD). is is supposedly due to the medial para-
aortal course of the ureters due to the UD. If the UD
cross the midline, the IMA as a midline artery should be
considered as a possible vascular component of the UVF.
Discussion
Ureterovascular fistula (UVF) is an abnormal com-
munication between a vascular structure (artery, vas-
cular bypass or rarely a vein) and the ureter. It is a rare
Fig. 1 Publications search and investigations with exclusion criteria

Page 5 of 15
Shamseldinetal. CVIR Endovascular (2024) 7:63
Table 1 Internal patients with UVF in Helios Klinikum Erfurt
Case Age
(years) Gender Primary
disease and
therapy
Risk Factors of
UAF Symptoms Radiological
diagnosis UAF visualized UAF
location UAF
side Urinary
diversion UAF
treatment Technical
success Clinical
success Postinterventional
medication
1 71 M - Rectal
cancer resec-
tion + radia-
tion ther-
apy + chemo-
therapy
- Prostate
cancer TURPa
- Radiation
therapy
- Chemo-therapy
- ureteric catheter
(obstructive BPHb)
- recurrent
urosepsis
- Phenprocou-
mon anticoagula-
tion (absolute
tachyarrhyth-
mia + atrial fibr il-
lation)
- recurrent
Macro-
hematuria
with bladder
tamponade
- ureteroscopy bleed-
ing from left ostium
- C T negative + ureter-
oarterial crossing
- overview DSA nega-
tive (2x)
- selective DSA
positive
Yes (direct in selec-
tive DSA)
IIA L No - Coil-
ing + Glue
embilzation
IIA
- Viabahn
Stent
Yes Yes - Phenprocoumon
pause for 6 weeks
- ASAc 100 mg for 6
weeks
- LMWHd 20 mg s.c.
for 6 weeks
2 80 F - Rectal
cancer resec-
tion + radia-
tion ther-
apy + chemo-
therapy
- Radiation
therapy
- Chemo-therapy
- ureteric catheter
(post radiogenic
stricture)
- recurrent
urosepsis
- ASAc + Clopi-
dogrel dual
platelet inhibition
(TVCADe + coro-
nary stents)
- recurrent
Urosepsis
- recurrent
Macro-
hematuria
with bladder
tamponade
- acute pain
of the left
flank
- ureteroscopy bleed-
ing from left ostium
- overview DSA nega-
tive (1x)
- selective DSA
positive
Yes (direct in selec-
tive DSA)
IIA branch
(SVAf)
L No - Glue embo-
lization SVAf
- Coiling IIA
- Viabahn
Stent
Yes Yes - ASAc 100 mg lifelong
- Clopidogrel 75 mg
long term
3 84 M - Urothelial
carcinoma
of the left
ureter distally
Laser ablation
- Laser ablation
of the left ureter
- ureteric catheter
(malignant ure-
teric obstruction)
- recurrent
urosepsis
- Clopidogrel
monotherapy
(PADg + coronary
stent + ischemic
cardiomyopathy)
- recurrent
Macro-
hematuria
- ureteroscopy bleed-
ing from left ostium
- overview DSA
negative
- selective DSA
negative
No IIA branch
(IVAh)
L No - Particle
embolization
IVAh
- Coiling IIA
- Advanta
V12
Yes Yes - Clopidogrel 75 mg
lifelong
- ASAc 100 mg for 4
weeks

Page 6 of 15
Shamseldinetal. CVIR Endovascular (2024) 7:63
Table 1 (continued)
Case Age
(years) Gender Primary
disease and
therapy
Risk Factors of
UAF Symptoms Radiological
diagnosis UAF visualized UAF
location UAF
side Urinary
diversion UAF
treatment Technical
success Clinical
success Postinterventional
medication
4 79 F - Rectal
cancer resec-
tion + radia-
tion ther-
apy + chemo-
therapy
- Radiation
therapy
- Chemo-therapy
- ureteric catheter
(post radiogenic
stricture)
- ASAc mono-
therapy (ischemic
cardiomyopathy)
- recurrent
Macro-
hematuria
- ureteroscopy bleed-
ing from left ostium
- C T negative + ureter-
oarterial crossing
- overview DSA nega-
tive (2x)
- selective DSA
negative
No IIA L No - Coiling IIA
- Viabahn
Stent
Yes Yes - ASAc 100 mg lifelong
5 76 M - Prostate
cancer
TURPa + radia-
tion therapy
- Radiation
therapy
- ureteric catheter
(post radiogenic
stricture)
- recurrent
Macro-
hematuria
with bladder
tamponade
- ureteroscopy bleed-
ing from right ostium
- R-UPGi active bleed-
ing into the retroperi-
toneal space
- CT pseudoaneu-
rysm + retroperitoneal
contrast medium
from the R-UPGi + ure-
teroarterial crossing
- DSA pseudoaneu-
rysm
Yes (indirect
through pseudo-
aneurysm + active
bleeding in R-UPGi
and CT )
EIA R No - Vascular
plug IIA
- Advanta
V12 Stents
(3x)
Yes Yes - ASAc 100 mg lifelong
6 85 M - Rectal
cancer resec-
tion + radia-
tion ther-
apy + chemo-
therapy
- Radiation
therapy
- Chemo-therapy
- ureteric catheter
(post radiogenic
stricture)
- ASAc mono-
therapy (ischemic
cardiomyopathy)
- recurrent
Macro-
hematuria
- ureteroscopy bleed-
ing from left ostium
- selective DSA
negative
- C T negative + ureter-
oarterial crossing
No CIA L No - Coiling
IIA + cover-
ing IIA using
stent graft
(during
EVAR)
Yes Yes - ASAc 100 mg lifelong
First recurrence after 3
years
- Eliquis antico-
agulation (atrial
fibrillation)
- recurrent
Macro-
hematuria
with bladder
tamponade
- acute pain
of the left
flank
- CT pseudoaneurysm
(at the distal end
of the stent graft)
- overview DSA pseu-
doaneurysma
Yes (pseudo-
aneurysm in CT
and DSA)
Viabahn
VBX + post-
dilatation
Yes No - Eliquis pause for 1
weeks
- LMWHd 20 mg s.c.
for 1 week
- ASAc 100 mg lifelong
Second recurrence
after 24 h
- overview DSA pseu-
doaneurysma
postdilata-
tion
Yes Yes

Page 7 of 15
Shamseldinetal. CVIR Endovascular (2024) 7:63
Table 1 (continued)
Case Age
(years) Gender Primary
disease and
therapy
Risk Factors of
UAF Symptoms Radiological
diagnosis UAF visualized UAF
location UAF
side Urinary
diversion UAF
treatment Technical
success Clinical
success Postinterventional
medication
7 77 M - Rectal cancer
resection
- Prostate
cancer radical
prostatec-
tomy + pelvic
lymphadenec-
tomy + post-
operative radi-
ation + LHRH
analogsj)
- Radiation
therapy
- ureteric catheter
(iatrogenic injury
of the distal ureter
and urinary blad-
der cystectomy
and ileum-con-
duit on the right
side)
- Enoxapa-
rin (chronic
immobility due
to tetraplegia)
- recurrent
Macro-
hematuria
- C T negative + ureter-
oarterial crossing
- selective DSA
negative
No EIA R Ye s - Coiling IIA
- Viabahn
Stents (2x)
Yes Yes - Enoxaparin 30 mg
8 82 M - Prostate
cancer radical
prostatec-
tomy + post-
operative radi-
ation + LHRH
analogsj)
- Radiation
therapy
- ureteric cath-
eter (recurrent
post radiogenic
and postinfec-
tious vesicointes-
tinal fistulas
cystectomy + ure-
terocutaneos-
tomy on the right
side)
- recurrent
Macro-
hematuria
- acute pain
of the left
flank
- R-UPGi positive
- CTA (2 months
ago) ureteroarterial
crossing
- overview DSA
negative
- selective DSA
with provocation
positive
Yes (direct in R-UPGi
and selective DSA
with provocation)
IMA -Yes Front door
– back door
coil emboli-
zation IMA
Yes Yes -
a TURP Transurethral resection of the prostate
b BPH Benign prostatic hyperplasia
c ASA Acetylsalicylic acid
d LMWH Low-molecular-weight heparin
e TVCAD Triple vessel coronary artery disease
f SVA Superior vesical arter y
g PAD Peripheral artery disease
h IVA Inferior vesical arter y
i R-UPG Retrograde ureteropyelography
j LHRH analogs Luteinizing hormone-releasing hormone analogs

Page 8 of 15
Shamseldinetal. CVIR Endovascular (2024) 7:63
condition with a few more than 600 cases in total pub-
lished in the literature. It is a potentially life threatening
condition leading to intermittent but usually massive
bleeding. Mortality is estimated to be approximately 9%
and morbidity is 23% [10,12].
UVF could be classified into primary and secondary
UVF based on the underlying pathology. e majority
of the cases are secondary (85%) due to previous pelvic
interventions including pelvic surgery to remove pelvic
tumors (89%) with combined radiation (67%) being an
additional risk factor. e most common risk factor is the
presence of a chronic ureteral stent in 73.7% of the cases
according to Das etal. triggering a chronic mechanical
erosion between the continuously pulsating artery or
nearby vessel and the stented ureter, triggering a local
inflammatory response and eventual necrosis at contact
point between the vessel and the ureter [3]. All our eight
patients (100%) had chronic ureteral stents support-
ing the contribution of this risk factor to the formation
of UVF. Other risk factors include previous pelvic sur-
gery and radiotherapy [9,12,13]. Primary UVF are rare
(15%) and involve primarily a vascular pathology such as
Table 2 Summary of UVF cases according to localization
Nr. of cases (%)
UVF without UD 384 (71.1)
• Aorta 4 (1)
• CIA 187 (48.7)
• EIA 69 (18)
• IIA (or its branches) 64 (16.7)
• Aortoiliac/-femoral bypass (incl. anastomosis) 52 (13.5)
• Others 8 (2.1)
UVF with UD 156 (28.9)
• Aorta 20 (12.8)
• CIA 100 (64.1)
• EIA 22 (14.1)
• IIA (or its branches) 7 (4.5)
• Aortoiliac/-femoral bypass (incl. anastomosis) 1 (0.6)
• Others 6 (3.8)
Total UVF included (including new patients) 540
Total UVF excluded 63
Total UVF published (before this study) 605
Table 3 List of rare and unexpected UVF locations in patients without UD
Vessel involved Urinary tract involved Study number Study name
1- Lower pole segmental renal artery Ureter 11 Castle et al
2- EIA Ureter of a failed atrophic kidney transplant 15 Geevarghese et al
3- Intrarenal segmental artery Ureter 18 Augustin et al
4- EIA Urinary bladder 38 Nakai et al
5- Artery stump of a failed renal transplant Ureter 76 List et al
6- AVM of the internal iliac vessels Ureter 138 Sharma et al
7- Ureteral branch of a renal artery Ureter 156 Siablis et al
8- CIA Stump Ureteral stump after nephrectomy 157 Noh et al
9- IIA Ureteral stump after nephrectomy 119 Goldberg et al
10- CIA Ureteral stump after nephrectomy 132 Pozzilli et al
11- Retrograde filling of the non-functional CIA with CIA aneurysm
after aorto-bifemoral graft due to AAA Ureter 164 Van Damme et al
12- Lower pole segmental renal artery Ureter 174 Wagner et al
13- Iliac anastomosis of an aorto-biiliac bypass Ureteral stump after nephrectomy 185 Tijunaitis et al
14- CIA Ureteral stump after nephrectomy 190 Kibrik et al
15- Non-functional occluded right limb of an aorto- right iliac - left
femoral bypass graft Ureter 202 Wheatly et al
16- Right limb of an inverted Dacron graft prosthesis Ureteral stump after nephrectomy 229 Ferretti et al
17- Renal artery pseudoaneurysm of a renal transplant Ureter 236 Turunc et al
18- CIA Ureteral stump after nephrectomy 246 Baum et al
19- CIA Ureteral stump after nephrectomy 249 Schulz et al
20- Fourth right lumbar artery (L4) Ureter 265 Chen et al
21- Aortic anastomosis of a left aortofemoral bypass Ureteral stump after nephrectomy 291 Mironiuc et al
22- CIA Ureteral stump after nephrectomy 306 Hodges et al
23- Unidentified branch of the IIA Urinary bladder 307 Nicita et al
24- Iliac anastomosis of a right iliofemoral autogenous vein extra-
anatomic graft Urinary bladder 308 Jaha et al

Page 9 of 15
Shamseldinetal. CVIR Endovascular (2024) 7:63
Table 4 List of rare and unexpected UVF locations in patients with UD
Vessel involved Urinary tract involved Urinary diversion Study number Study name
1- EIA Ileal conduit Ileal conduit 106 Beaugie et al
2- Inferior mesenteric artery (IMA) Ureter cutaneous double-barrel ureterostomy 124 Dervanian et al
3- Aortic stump after excision
of the CIA with femoro-femoral bypass Ureter right cutaneous ureterostomy 149 Ishibashi et al
4- Aorta and CIA Ileal conduit Ileal conduit 157 Noh et al
5- EIA Ileal conduit Ileal conduit 217 Gómez et al.
6- Superior rectal artery (branch
of the IMA) Ileal conduit Ileal conduit 266 Altaha et al
7- CIA Ileal conduit Ileal conduit 267 Coello Tora et al
8- EIA Ileal conduit Ileal conduit 274 Sekito et al
9- EIA Ileal conduit Ileal conduit 275 Beaugie et al
10- CIA Ileal conduit Ileal conduit 276 Hindmarch et al
11- Aorta Ileal conduit Ileal conduit 277 Ishibashi et al
12- EIA Ileal conduit Ileal conduit 278 Sasaki et al
13- EIA Ileal conduit Ileal conduit 279 Castillo et al
14- EIA Ileal conduit Ileal conduit 280 Sukha et al
15- EIA Ileal conduit Ileal conduit 281 Morlacco and Zattoni et al
16- Inferior vena cava Ureter Bricker ileal conduit 290 Pultrone et al
17- CIA IP Neobladder Orthotopic neobladder 292 Tatsuishi et al
18- right inferior epigastric artery Ureter bilateral cutaneous ureterostomy 312 Nakama et al
19- left inferior epigastric artery Ureter left cutaneous ureterostomy 313 Fujinama et al
20- Inferior mesenteric artery (IMA) Ureter Cutaneous ureterostomy 316 Shamseldin et al
Table 5 List of Double vessel UVF
Study number Study name Vessel Fistula 1 Urinary tract
Fistula 1 Vessel Fistula 2 Urinary tract
Fistula 2 Urinary diversion
19 Moon et al EIA Ureter IIA Ureter -
97 Feuer et al CIA Ureter EIA Ureter Orthotopic bladder substitution
124 Dervanian et al CIA Ureter IMA Ureter Bilateral, cutaneous double-
barrel ureterostomy
227 Han et al CIA Ureter EIA Ureter Orthotopic bladder substitution
Table 6 List of complex UVF
Study number Study name Complex UVF Urinary
diversion
40 Diner et al Ureteric-Vascular (CIA)-Enteric (Hartman´s pouch) fistula -
48 Morgan et al Ureteric-Vascular (CIA)-Enteric (terminal ileum) fistula -
57 Joglekar et al Ureteric-Vascular-Cutaneous fistula -
198 Kurata et al Ureteric-Vascular (IIA)-Colonic (Rectum) fistula -
230 Policha et al Ureteric-Vascular (distal anastomosis of a right interposition CIA Dacron
graft bypass)-Colonic (Caecum) fistula -
243 Abdul Rashid et al Ureteric-Vascular (EIA)-Enteric (small bowel) fistula -
289 Amahzoune et al Ureteric-Vascular (IIA)-Colonic (Caecum) fistula -

Page 10 of 15
Shamseldinetal. CVIR Endovascular (2024) 7:63
aneurysms, vascular malformations and aberrant vessels
[5].
e occurrence of unexplained gross hematuria with
variable clot passage and flank pain in a patient with a
history of pelvic surgery, a chronic ureteral stent, and/
or history of pelvic radiotherapy is highly suspicious for
a UVF [9,14]. It is important to bear in mind that the
source of a urinary tract bleeding through the ureteral
orifice is not always the kidney. If the urologist and inter-
ventional radiologist do not keep that in mind, this could
lead to unnecessary renal embolization or even nephrec-
tomy due to misdiagnosis [6,12,15]. A high degree of
suspicion in patients with known risk factors for UVF is
the key to a correct diagnosis.
In our hospital, sufficient history would be taken as well
as clinical urological examination of the patient excluding
other more common cases of macrohematuria such as
trauma, recent renal surgery, kidney stones, renal tumor
and urinary tract infection. If based on history and exam-
ination, UVF was suspected, the side of the bleeding was
always initially identified using endoscopy. is step is
crucial to help minimize the planning time of the proce-
dure through focusing only on the course of the bleeding
ureter during examination of the subsequent CT scan.
During angiography, the sole examination of the bleed-
ing side instead of wasting time on the normal side would
also minimize the intraprocedural time, thereby reducing
the time to stop the bleeding and the radiation exposure.
Lock etal. [16] were able to show that there was no sig-
nificant difference in the location when it comes to the
side of the UVF. Stating the side of the fistula’s location
was in most cases irrelevant, especially in cases where no
UD was present, and therefore the side (right vs. left) was
not considered in our review. We mentioned the side in
our new patients in case future studies prove otherwise.
CT scan was helpful according to the literature in only
48% of the cases and ureteropyelography in 52% [17] to
directly visualize the UVF. We performed a biphasic CT
scan with arterial and portal venous phases was perfo-
med in six out of our eight patients. e aim of the CT
Fig. 2 a Anatomic locations of ureterovascular fistulae without urinary diversion. b Anatomic locations of ureterovascular fistulae with urinary
diversion

Page 11 of 15
Shamseldinetal. CVIR Endovascular (2024) 7:63
scan was mainly to identify the suspected vessel involved
in the fistula whether through vascular changes such as
pseudoaneuryms and vascular irregularities or through
proximity to the ureter on the bleeding side identified
during endoscopy. e remaining two patients had older
CT scans where the suspected vessel could be identi-
fied. A direct visualization of the bleeding through the
fistula between the vessel and the catheter bearing ure-
ter is often not possible to see on cross sectional imaging
[18] mainly due to the catheter usually closing the fistu-
lous opening from the ureteral side as well as the difficult
distinction of contrast medium due to the intraureteral
catheter. Only two of the six patients showed direct signs
of vascular injury in the CT scan contributing to 33% of
the cases.
Direct signs like vessel irregularities, compression
and pseudoaneurym at the site of the ureteral crossing
are clear evidence of the site of vascular involvement,
however quite uncommon [12, 19]. Even in the DSA
with or without a provocative maneuver—as a gold
standard for diagnosis—was only successful in 62% of
the cases [17]. However, a close relation between the
ureter and a nearby vessel per se in the cross sectional
imaging was in many cases enough to locate the UVF
indirectly. Due to the intermittent bleeding nature
of the UVF and the intraureteral catheter closing the
ureteral side of the UVF, an active bleeding during the
point of performing an angiography is not always pos-
sible. erefore, even if the UVF was not directly visu-
alized, the point of ureterovascular proximity should be
managed as the bleeding point.
Based on the above steps, a standard approach to
localize suspected UVF in our institute was constructed
(Fig.3). e side of the bleeding was initially identified
using endoscopy, usually during an exchange of ureteral
stents. Identifying the suspected artery was performed
using a contrast medium biphasic CT scan with arte-
rial and portal venous phases. An angiography was then
routinely performed through a right femoral access to
try to disclose the UVF with and without applying a
provocative maneuver through temporarily removing
the ureteric catheter and applying contrast medium at
the point of ureteral crossing. In some cases, the only
way to visualize the UVF was a selective injection of
contrast medium in the direct proximity of the sus-
pected crossing point. If the UVF is still not visible, a
re-evaluation of the CT scan to determine the most
suspected vessel is recommended before proceeding
with endovascular therapy.
Historically, different treatment options including sur-
gery or surgery combined with transarterial embolization
have been described. More recently, SG placement has
been reported as an effective alternative treatment [20].
Considering the absence of treatment guidelines, there is
a clear trend that the endovascular therapy of UVF is pre-
ferred due to the minimally invasive nature of the proce-
dure when compared to surgical therapy in multi-morbid
patients. However, multicentric prospective studies are
needed in order to provide strong, evidenced-based rec-
ommendations and treatment guidelines.
e endovascular treatment of UVF involving the
CIA and EIA is quite similar necessitating covering the
ureteral crossing using a SG. In case the SG would be
covering the origin of the IIA, a coil embolization of
the IIA should be performed prior to the embolization
to avoid recurrence through retrograde perfusion from
the gluteal arteries (Patients 6 and 7, Table1). An alter-
native to coils would be using a vascular plug (Patient 5,
Table1). If the source of the bleeding is the main stem
of the IIA or one of its two main branches, namely the
anterior or posterior trunk, a front door – back door
embolization of the bleeding point should be sufficient
(Patients 1, Table1) or in combination with another
embolization agent like glue eg. 1:1 mixture of N-Butyl
Cyanoacrylate Glue and Lipiodol (Patient 1, Table1).
However, if a more distal branch of the IIA is involved,
a more distally reaching embolization agent is recom-
mended like glue eg. 1:4 mixture of N-Butyl Cyanoacr-
ylate Glue and Lipiodol or particles eg. Embospheres
between 100 and 500 µm (Patients 2 and 3, Table1).
But due to the potentially life-threatening nature of
the condition, all patients involving the IIA or any of
its branches was aggressively managed with succes-
sive coiling of the IIA and/or covering the origin of the
IIA using a SG (Patients 1–4, Table1). Other unusual
locations of UVF should be treated correspondingly. In
our case, where the IMA was involved, a front door –
back door coil embolization was necessary (Patient 8,
Table1). Below, two of the cases are further discussed.
An interesting patient was patient 6 who suffered
from rectal cancer and underwent rectal resection,
radiation therapy and chemotherapy. e patient
received a ureteric stent due to a post radiogenic stric-
ture and was receiving acetylsalicylic acid and Apixa-
ban due to ischemic cardiomyopathy. e initial UVF
of the CIA was managed successfully for three years
through a simultaneous treatment of an abdominal aor-
tic aneurysm through the iliac leg graft and coiling of
the IIA (Fig.4a, b, c). However due to the known risk
factors in addition to new anticoagulation therapy for
atrial fibrillation, a recurrence at the distal end of the
SG took place with a visible pseudoaneurysm in the
DSA (Fig.4d). is was managed by elongating the SG
distally (Fig.4e). Due to the massive improvement of
the material used in the field of interventional radiol-
ogy, we used the balloon expandable VBX stent grafts

Page 12 of 15
Shamseldinetal. CVIR Endovascular (2024) 7:63
Fig. 3 Recommended algorithm of the workflow to diagnose UVF

Page 13 of 15
Shamseldinetal. CVIR Endovascular (2024) 7:63
(Gore, Delaware, USA) which are lightly remodeled
using larger balloons reaching much higher diameters
in case the obstruction of the UVF was not enough
due to elongation or segmental ectasia or aneurysm
of the vessel. A new recurrence this time occurred
within 24 h. e DSA revealed a persistent pseudoa-
neurysm which was successfully managed by sufficient
postdilatation of the VBX stent graft (Fig.4f, g, h). e
uniqueness of this case is the multiple recurrences of
the bleeding due to an insufficient initial therapy and
how the development of endovascular material such as
VBX stent grafts allow simple post-dilatation of a pre-
existing SG to reach the desired diameter and block the
UVF in case of a primarily undersized stenting of the
vessel.
After radical prostatectomy and radiation therapy, our
patient number 8 suffered from recurrent vesicointesti-
nal fistulae. is was managed by cystectomy and uret-
erocutaneostomy on the right side with bilateral ureteral
stents. e patient presented with recurrent macrohema-
turia and acute pain of the left flank. During an exchange
of the left ureteral stent, the patient started bleeding
massively after removal of the stent. An immediate
tamponade of the bleeding and then a quick retrograde
ureteropyelogaphy (R-UPG) was sufficient to see a con-
nection to the arterial vascular system (Fig.5a). A pre-
vious CT (2 months prior) showed the possible vascular
contacts to the left ureter. Initially, it was believed to be
the aorta due to the massive bleeding and due to the pre-
vious publications of aortic involvement in UVF (Fig.5b).
Immediately before the angiographic examination, a
direct proximity of the ureter to the IMA was noticed
and was considered as a possible vascular component of
the UVF (Fig.5c). e initial DSA was negative (Fig.5d)
and thereby a selective DSA of the IMA with provocation
by partially pulling the catheter by the urologist before
injecting contrast medium was performed, revealing the
direct fistula’s connection (Fig.5e). A front door – back
door coil embolization of the IMA was performed to
prevent any possible retrograde bleeding over the arc of
Riolan successfully (Fig.5f). erefore, it is important to
consider every vessel in proximity of the ureteral course
as a possible vascular side of the UVF. A careful analysis
of the cross-sectional imaging in this case was the key to
avoid unnecessary implantation of an aortic stent graft,
which would have made any future endovascular therapy
of the case extremely difficult since the origin of the IMA
would have been blocked by the stent graft. Another crit-
ical take home message to consider.
Limitation of the study was the dispute in some cases
to whether the UVF location was the CIA or the EIA due
to the anatomical fact that the ureter crosses the CIA
immediately proximal to the iliac bifurcation. is dis-
pute was settled in this review for the CIA, which would
Fig. 4 a CT scan showing the point of vascular crossing over the distal CIA with a ureteral stent seen (arrow). b A negative DSA shortly prior
to a planned endovascular aortic repair (EVAR) due to an aortic aneurysm. During this angiography session, a kidney bleeding was also excluded
(not seen). c Coiling of the IIA (star) and coverage of the origin of the IIA using the left leg of the SG (arrow) were performed during the EVAR
procedure. d Pseudoaneurysm at the distal end of the stent graft denoting the first recurrence after 3 years (arrow). e Distal elongation of the SG
using a Viabahn VBX SG with complete closure of the pseudoaneurysm in the immediate control image. f DSA after 24 h due to recurrent
macrohematuria showing recurrence of the pseudoaneurysm (arrow). g Post-dilatation of the Viabahn VBX SG using a larger balloon (star) at the site
of the visible pseudoaneurysm. h Complete obliteration of the pseudoaneurysm

Page 14 of 15
Shamseldinetal. CVIR Endovascular (2024) 7:63
slightly increase the percentage attributed to the CIA at
the expense of the EIA. In some other cases, UVF could
not be directly visualized, but the location would still be
considered and included as long as the main criteria such
as vascular changes (e.g. irregular wall, stenosis, pseu-
doaneurysm, etc.) or direct contact to the vessel was pro-
vided through a sufficient imaging modality (usually CT
angiography).
Acknowledgements
I would like to thank our amazing team of devoted angiography nurses.
Authors’ contributions
MS collected and analyzed the data from the literature, added and analyzed
the internal cases, wrote the manuscript. HH provided raw data of his study for
further analysis, provided urological consultation required for the data analysis.
TS revised the urological information in the manuscript. RP supervised the
angiographic management of the internal cases and the study. All authors
read and approved the final manuscript.
Funding
The study and authors did not receive any funding.
Availability of data and materials
Internal PACS system of Helios Klinikum Erfurt.
Declarations
Ethics approval and consent to participate
Not applicable.
Consent for publication
Not applicable.
Competing interests
There are no competing interests to be declared.
Author details
1 Department of Radiology, Helios Klinikum Erfurt, Nordhäuser Str. 74,
Erfurt 99089, Thuringia, Germany. 2 Department of Urology, Universitätsklini-
kum Gießen Und Marburg, Marburg, Germany. 3 Department of Urology, Helios
Klinikum Erfurt, Erfurt, Thuringia, Germany.
Received: 20 May 2024 Accepted: 7 August 2024
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