Iliac Artery-Uretero-Colonic Fistula Presenting as Severe Gastrointestinal Hemorrhage and Hematuria: A Case Report and Review of the Literature

An Asymptomatic Sigmoid Colonic Fistula Arising from a Large Aneurysm of the Internal Iliac Artery Was Discovered during a Medical Examination

The rupture of an internal iliac artery aneurysm in the colon is a rare but potentially fatal complication. We report a rectal fistula of an asymptomatic internal iliac artery aneurysm that was discovered incidentally during a medical examination. A 77-year-old man presented at a local hospital for a general medical examination. Although the blood reports revealed severe anemia, the patient did not complain of any associated symptoms including dizziness and hematochezia. Moreover, there was no palpable mass in the patient's abdomen, and there was no evidence of hematochezia, as the patient had been using a bidet. Interestingly, computed tomography (CT) revealed a large right internal iliac artery aneurysm. There was a suspicious finding of a fistula within the colon in the CT, but it was undetected in the preoperative sigmoidoscopy. Furthermore, operative findings showed a protruding retroperitoneal mass adhering to the mesentery of the sigmoid colon. During aneurysm resection, the presence of a fistula was unclear. However, a fistula tract, devoid of any infectious bacteria such as tuberculosis, was found in the specimen after colon resection. After a recovery period of approximately one week, the patient was discharged from the hospital without any unusual findings on the post-operative CT. Sigmoid colonic fistulas arising from iliac artery aneurysms are rare. Also, diagnosis may be delayed in special circumstances wherein a patient routinely uses a bidet.

Aortoiliac graft-enteric fistula presenting as gastrointestinal hemorrhage: A report on a complex case management

Key Clinical Message

Iliac artery-enteric fistula is a rare cause of lower GI bleeding and can cause life-threatening consequences. A high degree of clinical suspicion is needed in patients with previous aortic surgery to allow early multidisciplinary intervention.

Abstract

This case study discusses the staged management of a 78-year-old patient presenting with life-threatening lower gastrointestinal (GI) bleeding secondary to an aortoiliac graft-enteric fistula (GEF) into the sigmoid colon on the background of an adenocarcinoma and diverticular disease. The patient had an aorto bi-iliac synthetic dacron graft repair of an abdominal aortic aneurysm (AAA) some 20 years ago. Here, we present a case of successful endovascular treatment of massive hemorrhage as a bridge to definitive second-stage dacron graft explant and autologous vein reconstruction with a simultaneous anterior resection.

A systematic review of management of uretero-arterial fistula

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.

Arterial-enteric fistula after pelvic lymphadenectomy in secondary cytoreductive surgery for recurrent ovarian cancer

In 6.2% of gynaecologic malignancies, vascular involvement is reported. Cytoreductive surgery presents in those cases a higher rate of major complications. Arterial-enteric fistula is a very rare post-surgical complication with serious repercussions on the patient's life due to intestinal haemorrhage and the overlapping sepsis. This is the first case report about iliac-colonic fistula formation in recurrent ovarian cancer with lymph-node metastasis after laparoscopic secondary cytoreductive surgery in a 75-year-old woman and its successful surgical management. A literature review about arterial-enteric fistula formation in gynaecologic cancer treatment, specifically ovarian cancer, is also reported, hypothesising the risk factors of this severe postoperative complication and possible surgical solutions.

Successful Bridge Therapy with Initial Endovascular Repair for Arterioenteric Fistula Resulting from Pseudoaneurysm Rupture with Massive Gastrointestinal Hemorrhage after Pancreas Transplantation

Pseudoaneurysm after pancreas transplantation has a reported incidence of 1.4 to 8.0% and may be caused by perioperative infection. Subsequent pseudoaneurysm rupture is a rare cause of arterioenteric fistula. Only 28 cases of arterioenteric fistula after pancreas transplantation have been reported in the past 20 years. We experienced a rare case of arterioenteric fistula resulting from pseudoaneurysm rupture after pancreas transplantation. We successfully treated the arterioenteric fistula with multistaged bridge therapy composed of initial endovascular aneurysm repair, secondary isolation of the fistula, and definitive open repair with extraanatomic bypass. No complications occurred in 1 year of follow-up; this staged therapy seems feasible for patients with arterioenteric fistula.

Iliaco-enteric fistula after robot-assisted comprehensive surgical staging of endometrial cancer: a case report

Fistula formation between bowel and blood-vessel is a very rare complication after intraabdominal surgery. We report a case of iliaco-enteric fistula following robot-assisted surgical staging of endometrial cancer. A 71-year-old woman subjected to comprehensive endometrial cancer staging presented with hematochezia 35 days postoperatively. A retroperitoneal right-sided abscess and an iliaco-enteric fistula was confirmed upon imaging. The patient received endovascular repair of the aneurysm in her right common iliac artery and the segments of the small bowel containing the fistula were resected via laparotomy. If a patient presents with new onset postoperative hematochezia after pelvic and/or paraaortic lymphadenectomy, fistulation between bowel and the major abdominal blood vessels should be part of the differential diagnoses.

Iliac Artery-Uretero-Colonic Fistula Presenting as Gastrointestinal Hemorrhage and Hematuria: A Case Report

Background: The experience with uretero-arterial fistulas has been limited. However, the aggressive treatment of pelvic tumors with surgical resection and radiotherapy, along with liberal use of ureteral catheters, has been attributed to an increase in their incidence. Unless they are promptly diagnosed and treated, uretero-arterial fistulas are associated with considerably high rates of morbidity and mortality. Urologists need maintain a high degree of suspicion for uretero-arterial fistula in high-risk patients. We herein present the clinical course of an iliac artery-uretero-colonic fistula.

Case Presentation: A 67-year-old woman with a history of colon cancer who underwent laparoscopic high anterior resection in July 2010. A ureteral stent inserted to right ureteral stricture, which developed as a result of local recurrence of the tumor in September 2010. She had undergone chemoradiotherapy, but the lesion had slowly increased in size. During the replacement of the ureteral stent in April 2016, she immediately experienced bladder tamponade, bloody bowel discharge, and hypotension. Contrast CT revealed a complex fistula between the right distal ureter and the right internal iliac artery. Furthermore, contrast medium flowed into the intestinal tract through the tumor. The patient was therefore diagnosed with internal iliac artery-uretero-colonic fistula. Arteriography revealed a right uretero-internal iliac artery fistula, and the embolization of the right internal iliac artery was performed. The right ureteral stent was removed. Her hematuria and bloody bowel discharge disappeared, but right nephrostomy was performed because she presented with acute pyelonephritis to ureteral obstruction.

Conclusion: In the present case, the uretero-arterial fistula was caused by the long use of an indwelling stent, chemoradiotherapy, infection, and an increase in the size of the lesion. When a suspected uretero-arterial fistula is accompanied by bloody bowel discharge, we should consider the possibility of traffic to the intestinal tract.

Two cases of recurrent uterine cervical cancer with arterio-enteric fistula treated by femoro-femoral artery bypass in hybrid operation room

Little has been reported regarding aortic-enteric fistula (AEF) as a complication of gynecologic cancers because of its rarity. However, since it is lethal if left untreated, medical practitioners involved with gynecologic diseases should be aware of this deadly condition. In our hospital, we encountered two cases of cervical cancer complicated by AEF. In both cases, contrast computed tomography (CT) revealed leakage of the contrast material from an artery into the small intestine, indicating AEF. Endovascular procedures with complete embolization of the affected arteries and femoro-femoral artery bypass (f-f bypass) were performed in the hybrid operation room. The activities of daily living improved dramatically for both patients, and they survived for 3 months before dying from cervical cancer. While embolization by endovascular methods and f-f bypass performed in a hybrid operation room is, therefore, an available option for treating AEF, literature is lacking and more research is required to improve long-term outcomes for this disease.

Editor's Choice - Management of Secondary Aorto-enteric and Other Abdominal Arterio-enteric Fistulas: A Review and Pooled Data Analysis

OBJECTIVES

To compare management strategies for secondary abdominal arterio-enteric fistulas (AEFs).

METHODS

This study is a review and pooled data analysis. Medline and Scopus databases were searched for studies published between 1999 and 2015. Particular emphasis was given to short- and long-term outcomes in relation to AEF repair type.

RESULTS

Two hundred and sixteen publications were retrieved, reporting on 823 patients. In-hospital mortality was 30.7%. Open surgery had higher in-hospital mortality (246/725, 33.9%), than endovascular methods (7/98, 7.1%, p < .001, OR 6.7, 95% CI 3-14.7, including staged endovascular to open surgery, 0/13, 0%). In-hospital mortality after graft removal/extra-anatomical bypass grafting was 31.2% (66/226), graft removal/in situ repair 34% (137/403), primary closure of the arterial defect 62.5% (10/16), and for miscellaneous open procedures 41.3% (33/80), p = .019. Among the subgroups of in situ repair, homografts were associated with a higher mortality than impregnated prosthetic grafts (p = .047). There was no difference in recurrent AEF-free rates between open and endovascular procedures. Extra-anatomical bypass/graft removal and in situ repair had a lower AEF recurrence rate than primary closure and homografts. Late sepsis occurred more often after endovascular surgery (2-year rates 42% vs. 19% for open, p = .001). The early survival benefit of endovascular surgery was blunted during follow-up, although it remained significant (p < .001). Within the in situ repair group, impregnated prosthetic grafts were associated with the worst overall and AEF related mortality free rates and vein grafts with the best. No recurrence, sepsis, or mortality was reported following staged endograft placement to open repair after a mean follow-up of 16.8 months (p = .18, p = .22, and p = .006, respectively, compared with patients in other groups).

CONCLUSIONS

Endovascular surgery, where appropriate, is associated with better early survival than open surgery for secondary AEFs. Most of this benefit is lost during long-term follow-up, implying that a staged approach with early conversion to in situ vein grafting may achieve the best results in selected patients.

Late Stent Graft Infection after the Emergency Endovascular Repair of a Secondary Iliac Artery-Enteric Fistula Treated with Graft Removal and In Situ Aortic Reconstruction Using Femoral Veins

An arterioenteric fistula is a devastating and life-threatening condition that requires urgent treatment. Less-invasive endovascular treatment has emerged as an alternative to conventional open repair, but postoperative graft infection remains a major concern. We herein report a case of late stent graft infection after emergency endovascular repair of a secondary iliac artery-enteric fistula. The patient was a 63-year-old male who presented with a fever, who had undergone successful endovascular stent grafting for a secondary common iliac artery-enteric fistula 29 months prior. The diagnosis of a stent graft infection was confirmed via computed tomography. He underwent graft removal and in situ reconstruction with femoral vein grafts. At 6-month follow-up, the patient is in a good general condition without any symptoms.