Endovascular management of ureteroarterial fistula

Infection of the Aortic Stent Graft to Treat Arterioureteral Fistula

Arterioureteral fistula is a rare but life-threatening condition. An endovascular treatment approach is commonly used; however, there is a potential risk of infection. We present a case in which a patient presented with abdominal pain and was diagnosed with a ruptured internal iliac artery aneurysm and a subsequent arterioureteral fistula. An aortic stent graft was inserted to treat the arterioureteral fistula, but it subsequently became infected, resulting in the patient's death. This case underscores the importance of early diagnosis and treatment of arterioureteral fistula and the possibility of graft infection.

Uretero-arterial fistula: Six new cases and systematic review of the literature

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.

Minimally invasive treatment of vascular complications after neoaortoiliac system reconstruction using autologous vein grafts

Treatment of complications after neoaortoiliac system vein reconstruction is a complex clinical problem with poor results. Endovascular treatment might offer an acceptable outcome in selected cases. We report two rare complications after neoaortoiliac system vein reconstruction for an infected aortic graft. These complications were treated with minimally invasive endovascular techniques. A 54-year-old man presented with an arterioureteral fistula located between the right ureter and the right branch of the venous reconstruction. The second case describes a 71-year-old man who developed a large dilation proximally in the venous reconstruction.

Use of angioembolization in urology: a review

This review discusses current and developing indications for angioembolization (AE) techniques in urology cases, including trauma and non-trauma uses for kidney, prostate, and bladder conditions. AE methods, complications and technical and clinical outcomes are outlined for each indication for the purpose of aiding urologists in selecting ideal candidates for this procedure.

Endovascular Management of Ureteroarterial Fistula: Single Institution Experience and Systematic Literature Review

Background:

Ureteroarterial fistula (UAF) represents an uncommon complication after urological surgery; however, this is a well-documented condition in patients with predisposing risk factors. The aim of the present study is to report and analyze the endovascular management of a series of patients with UAF, treated in authors’ hospital, and to report and analyze the same data concerning patients retrieved from a systematic literature review.

Methods:

Authors conducted a retrospective analysis of prospectively collected data and a systematic literature review. The research was carried out through PubMed database searching the following keywords: “uretero arterial fistula” and “uretero iliac fistula.” It includes only articles reporting the endovascular management.

Results:

Forty-six articles were included in the present study for a total of 94 patients. Risk factors were as follows: chronic indwelling ureteral stents, pelvic surgery, radiotherapy, iliac artery pseudo-aneurysm, and chemotherapy. All patients had gross hematuria at presentation. Stent graft placement was performed in 89 patients, embolization in 5 patients, and iliac internal artery embolization combined with stent graft placement was performed in 24 patients. Four postprocedural complications were observed (4.2%). During a median follow-up of 8 months, 10 complications related to UAF were observed (10.6%): rebleeding (7 cases) and stent thrombosis (3 cases). Two patients died for causes related to UAF (2.1%): rebleeding (1) and retroperitoneal abscess (1).

Conclusion:

Based on the present data, endovascular treatment is feasible and safe with low postprocedural complications and mortality rate. Considering the increase in surgery and radiotherapy performed, UAF should be always debated in patients with massive hematuria.

Arterioureteral Fistula: Treatment of a Hemorrhagic Shock with Massive Hematuria by Placing a Balloon Catheter

Arterioureteral fistulas (AUF) are serious diseases with increasing incidence. This case report relates the management of AUF in a patient with a history of abdominal oncological surgery, pelvic radiotherapy, and a double J stent in place. The fistula was discovered during a hemorrhagic shock with massive hematuria. The bleeding was controlled by a balloon catheter which led to endovascular treatment consisting of a covered stent.

Endoureteral coil embolization of an ureteral arterial fistula

Background Ureteral arterial fistulas are rare but potentially life threatening. We present a female who developed a ureteral arterial fistula following a right robotic nephrectomy. After several endovascular interventions to control the bleeding had failed, we approached the fistula through the right ureteral stump with coil embolization. Methods Coil embolization of the right ureteral stump was performed. We utilized a 6Fr × 45 cm sheath inserted through one of the cystoscope channels to cannulate the right ureteral orifice. We then performed a retrograde ureterogram. After, we were able to visualize full length of the ureter, ahd we began placing several 10-12 mm Nester coils to pack the ureter and tamponade the fistula for hemostasis. After the ureter was packed, we injected 1 g of Vancomycin into the ureter. The sheath and cytoscope were removed and the patient did well and was sent to the recovery room. Results Postoperatively, the patient had no complaints of hematuria and her hemoglobin level remained unchanged. She was observed for a few days prior to being discharged to home. The patient's follow-up at six months revealed resolution of her hematuria. Conclusion Ureteral arterial fistula is a potentially life-threatening condition. Endovascular stenting has provided a safe, reliable alternative to open surgery. However, when endovascular options are not satisfactory, coil embolization of the ureteral stump may serve as a safe and effective alternative treatment for these cases.

Arterioureteral Fistula

Arterioureteral fistula is a rare clinical entity that has been reported more frequently over the past decade. The risk factors for arterioureteral fistula include previous pelvic or urologic surgery, ureteral stenting, pelvic irradiation, and previous vascular pathology. All patients who present with this clinical entity have at least one of these risk factors, and the majority of patients have more than one risk factor. Radiographic demonstration of an arterioureteral fistula may be difficult and often requires more than one diagnostic modality. Angiography and retrograde ureterography appear to be the most helpful in establishing a diagnosis. The literature suggests that patients with a diagnosis of arterioureteral fistula before surgery have an increased incidence of renal salvage and decreased mortality. Methods of repair have been varied, but in the past several years, endovascular approaches to this problem have become more common. The authors report two cases of arterioureteral fistulae, one managed operatively, and one managed by endovascular placement of a covered stent. The literature is reviewed, and etiology, diagnosis, surgical therapy, and endovascular therapy are discussed.

Endovascular Repair of an Iliac Ureteroarterial Fistula with Late Stent Thrombosis and Migration into the Bladder

BACKGROUND

Ureteroarterial fistulas are rare. We describe a case of ureteral-arterial fistulas (UAF) repaired with an endovascular stent graft and examine late complications associated with the procedure.

CASE REPORT

A 37-year-old woman with a history of complicated locally invasive cervical cancer treated with chemoradiation presented initially with right leg rest pain and chronic intermittent gross hematuria. She was found to have an ureteroarterial fistula and underwent successful endovascular exclusion with a covered stent with resolution of her symptoms. She returned 1 year later with stent-graft thrombosis manifesting as lower extremity rest pain, requiring a femoral-femoral bypass. She then returned 6 months later with imaging evidence of extravascular migration of the stent graft into the bladder. Because of a poor prognosis of recurrent gynecologic cancer, extraction was not attempted, and she underwent complete urinary diversion.

CONCLUSIONS

UAFs are a rare occurrence but may be treated successfully with endovascular stent grafting. Despite technical success, late complications such as stent thrombosis may occur even with anticoagulation. Extravascular stent migration may occur in the presence of a chronically dilated ureter.

Bilateral Ureteroarterial Fistula: A Case Report and Review of Literature

Ureteral arterial fistula (UAF) is an uncommon condition characterized by a direct fistulous communication between a ureter and an iliac artery resulting in bleeding into the ureter, which can be massive and life-threatening because of hemodynamic instability, as confirmed by the high mortality rate (7-23% overall).

This condition is actually increasing in frequency because of its relation to predisposing factors such as vascular pathology, previous radiation therapy, previous surgery, and necessity of ureteral stenting. Diagnosis is often challenging, as in most patients, the only symptom is hematuria and the treatment may require a multidisciplinary approach, including the expertise of the urologist, vascular surgeon, and interventional radiologist. Endovascular approach offers advantages over open surgery decreasing morbidity (reduced risk of injury to adjacent structure) and shortening hospital staying. There is no consensus regarding the safety of intentional occlusion of the hypogastric artery: proximal occlusion of a hypogastric artery typically produces little or no clinical symptoms due to well-collateralized pelvic arterial networks. On the contrary, significant complications, such as colonic ischemia, spinal cord paralysis, buttock claudication, or erectile dysfunction, are well-recognized adverse events after hypogastric artery embolization, especially in bilateral cases. We describe our experience of a bilateral UAF treated with bilateral endvascular approach.

Bilateral Ureteral-Iliac Artery Fistula in a Patient with Chronic Indwelling Ureteral Stents: A Case Report and Review

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.

Uretro-arterial fistulas

Ureteral arterial fistula (UAF) is an uncommon condition but one that has been increasing with over 100 cases reported. The presentation is gross hematuria in a patient with predisposing factors, such as prior pelvic surgery, past radiation therapy, and chronic ureteral stenting. When not correctly diagnosed, the associated mortality is significant. Diagnosis is best accomplished by careful angiography with frequent use of provocative maneuvers. The current best therapeutic option is sealing off the UAF by deploying a stent graft in the artery.

Ureteral perigraft fistula

Ureteral injury following aortic surgery occurs in less than 1% of all cases. Ureteral-arterial fistulae rarely occur in the current literature and only in case reports. This case involves a suspected ureteral aortic graft fistula presenting with acute hematuria with distant history of redo aortic bifemoral graft for aortoenteric fistula. Cystoscopy with retrograde pyelogram was performed and demonstrated what appeared to be a fistula between the left ureter and the aortic graft with a proximal hydroureter and hydronephrosis. After a detailed review of the films, we diagnosed a more benign ureteral perigraft fistula. Multidisciplinary management including urology and vascular surgery suggested conservative management. However, the patient later required more definitive therapy for his illness. This case demonstrates a ureteral perigraft fistula and displays how it appears radiographically. Here we present our experience with this new radiological diagnosis.

Endovascular Treatment for an Iliac Artery–Ureteral Fistula with a Covered Stent

Iliac artery-ureteral fistula (IAUF) is a rare entity that has a potential risk of life-threatening hemorrhage. It is difficult to diagnose and treat appropriately. Conventional treatment for the disease consists of surgical ligation and vascular reconstruction or coil embolization. Surgical treatment is usually difficult for patients with several risk factors. In recent years, endovascular stent-graft treatment for iliac artery pseudoaneurysm has been reported. The present report describes two cases in which endovascular covered stent-graft treatment was successfully applied to treat IAUF, with good clinical outcomes.

Percutaneous endovascular repair of a ureteroarterial fistula with a stent graft

Ureteroarterial fistula is a rare but life-threatening cause of hematuria. The predisposing factors of a ureteroarterial fistula includes pelvic exenteration, radiation therapy, infection, primary vascular disease, vascular reconstructive surgery, and indwelling ureteral catheters or stents. We report a case of ureteroarterial fistula between the right ureter and a pseudoaneurysm originating from the right proximal external iliac artery in a female patient presenting with intermittent massive hematuria. She had previously undergone an operation for cervical cancer, radiation therapy, and ureteral stent placement. She was treated successfully by percutaneous endovascular stent graft placement to exclude the pseudoaneurysm. Percutaneous stent graft placement appears to be an effective and safe therapeutic alternative in the treatment of ureteroarterial fistula.

Endovascular Treatment of a Ureteroiliac Fistula Associated with Ureteral Double J-Stenting and an Aortic-Bifemoral Stent Graft for an Inflammatory Abdominal Aortic Aneurysm

We report an unusual case of a ureteroiliac fistula due to prolonged ureteral stenting for hydronephrosis combined with an aortic-bifemoral stent graft in an inflammatory abdominal aortic aneurysm (AAA), treated with an endovascular stent graft. In a 77-year-old man ureteral J-stents were placed for bilateral hydronephrosis due to retroperitoneal fibrosis caused by an inflammatory AAA. The aneurysm was treated with an endovascular aortic-bifemoral stent graft. Three months later, the patient suffered from severe hypovolemic shock. Emergency angiography showed a fistula between the right ureter and the right common iliac artery just distal to the right leg of the stent graft. The ureteroiliac fistula was treated with a wall graft (10F). The patient recovered well and remained asymptomatic. Ureteroiliac fistula remains a rare complication of ureteral stenting. Several risk factors have been described before. This case emphazes the increased risk of an arterial-ureteral fistula due to an indwelling ureteral stent and an inflammatory AAA, especially in combination with an additional stent graft for this inflammatory AAA.

Ureteroarterial fistula with ruptured anastomotic pseudoaneurysm: successful management with vascular exclusion, extra-anatomic bypass and nephrectomy--a case report

Ureteroarterial fistula is a rare but life-threatening condition most often arising as a consequence of combined vascular and urologic pathology. Only about 70 cases are reported in the English literature. Principles of repair include complete vascular isolation, extra-anatomic bypass, and urinary stream diversion away from major vascular conduits. The case presented herein is only the second reported instance of fistulization to an anastomotic pseudoaneurysm of an iliopopliteal bypass.

Treatment of Ureteroarterial Fistulae with Covered Vascular Endoprostheses and Ureteral Occlusion

BACKGROUND

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.

METHODS

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.

RESULTS AND CONCLUSION

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.

Fistule artério-urétérale, à propos de trois cas

On connection with four cases of arterio-uro-enteric fistula in three patients and after a review of the literature, the authors propose to make light on this extremely rare complication describing aetiologies factors and the diagnostic means and therapeutics. Two patients had had a pelvic exenteration with respectively Bricker and Kock pouch. The third patient had had an anterior resection in block with the right deferent duct and right seminal gland. All three received high doses of radiotherapy. These fistulas had appeared by abundant haemorrhages. The surgical operation in urgency had made it possible to treat these fistulas with success in two patients. The other patient had deceased of cataclysmic haemorrhage.

Occlusion of an intraluminal endovascular stent graft after treatment of a ureteral-iliac artery fistula

Ureteral-arterial fistulas are rare causes of intermittent and often massive hematuria. We report the case of a patient presenting with massive hematuria and shock caused by a ureteral-iliac fistula initially treated with a covered endovascular stent graft. Eight months after deployment, the stent occluded, and the patient required a femoral-femoral bypass. This is the first known case of endovascular stent graft occlusion when used for this purpose.

[Urinary fistula: update]

The urinary fistulas are not a frequent problem in our urological rutinary work, being the vesicovaginal ones the most common. However, it will be necessary to know them to be able to diagnose and treat them in the best way. In this article we classificate the different urinary fistulas (uro-gynecologicals, uro-vasculars, uro-cutaneous and entero-urinarys), explaining the possible etiologies and the correct management.

Endovascular management of ureteral-iliac artery fistulae with Wallgraft endoprostheses

BACKGROUND

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.

CASES

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.

CONCLUSION

Endovascular therapy with covered stents is a safe, effective, and readily available method for the treatment of ureteral-iliac artery fistulae.

[Hematuria secondary to arterioureteral fistula. Endovascular treatment]

Presentation of case of patient with macroscopic anemic hematuria caused for the presence of a fistula between the external iliac artery and the ureter. After the diagnosis, a treatment with endovascular mangement was made. The arterioureteral fistulae are a very rare entie, which supposes a vital emergency. The diagnosis depend upon the clinical evidences (complementary explorations rarely provide specific findings). Classic treatment is bases on open surgery, while endovascular treatment may be an alternative with less aggressiveness.

Arterio-ureteral fistula--a systematic review

OBJECTIVE

To review published reports on arterio-ureteral fistula.

METHOD

Literature search.

RESULTS

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.

CONCLUSION

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.