Arterioureteral fistula: overview of clinical characteristics, endovascular management, and outcomes

Three cases of recurrences after stent-graft placement for arterio-visceral/arterio-luminal fistulas in long-term follow-up

We report 3 patients with recurrences after stent-graft placement for arterio-visceral/arterio-luminal fistulas in long-term follow-up. Two patients had ureteroarterial fistulas and the other had a tracheo-innominate artery fistula. All 3 patients had hemorrhage on initial presentation and underwent a stent-graft placement for an arterio-visceral/arterio-luminal fistula. Recurrences occurred over a period of 8-26 months and were diagnosed by contrast-enhanced computed tomography; pseudoaneurysms were found in contrast-enhanced computed tomography images in all cases. Pseudoaneurysms may be noted on contrast-enhanced computed tomography as the only finding of recurrences during long-term follow-up after stent-graft placement for arterio-visceral/arterio-luminal fistulas.

Challenges in Diagnosis of Uretero–Arterial Fistulas after Complex Pelvic Oncological Procedures—Single Center Experience and Review of the Literature

Introduction: Uretero–arterial fistula (UAF) represents a rare condition that manifests as massive or intermittent hematuria and requires collaboration between a urologist, vascular surgeon and interventional radiologist. In this article, we present our experience with UAF diagnosis, treatment pathways and the results of a nonsystematic review of the literature published in the last decade regarding modern diagnostic procedures. Material and method: We analyzed the clinical data of nine consecutive patients from our institution diagnosed with UAF in the interval of 2012–2022 who underwent open or endovascular surgical treatment. We reviewed patient characteristics, diagnoses and treatment pathways. The literature search resulted in 14 case series, published from 2012 to 2022, describing a total of 670 cases of UAF. Results: The mean age of patients in our cohort was 65.3 years (IQR: 51–79). UAFs were more common in women (77.7%). All patients presented a history of surgical intervention and ir-radiation for pelvic malignancy with permanent ureteric stenting. Overall, 88.8% of patients had urinary diversion, either via ileal conduit or cutaneous ureterostomy. The most common clinical manifestation of UAF was gross hematuria with or without clots accompanied by flank pain due to stent obstruction, while three patients presented with hypovolemic shock. Angiography represents the best option for diagnosis, followed by angioCT, with a sensitivity of 59.83% and 47.01%, respectively. There is no definitive imaging modality associated with high accuracy in detecting UAF and negative findings do not exclude the disease. In emergency cases with massive bleeding, surgical exploration remains the most appropriate management option for both diagnosis and treatment. Endovascular stent graft placement is preferred over open surgery in stable hemodynamic patients. Conclusions: Uretero–arterial fistulas represent a life-threatening complication and must be treated with great awareness. Angiography represents the best modality for diagnosis, followed by computed tomography. However, there is no definitive imaging modality and, in some cases, open approach remains the only option for diagnosis and treatment.

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.

Arterioureteral Fistula in the Setting of Radical Cystoprostatectomy and Ileal Conduit Creation

Arterioureteral fistulas (AUF) following ileal conduit reconstruction are rare and not well-studied. We present a life-threatening bleed from an AUF due to an ileal conduit urinary diversion. In addition, we identify the challenges in the diagnostic process as well as management strategies. We present a 63-year-old male with ileal conduit reconstruction for bladder cancer with an AUF developing years after the reconstruction, which was ultimately managed with angioplasty.

Endovascular coil embolization of inferior mesenteric artery to ileal-conduit fistula: a case report

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.

Management and endovascular therapy of ureteroarterial fistulas: experience from a single center and review of the literature

Background

Ureteroarterial fistula (UAF) is a rare but potentially life threatening disease. The aim of this study was to evaluate the outcome of endovascular therapy for UAF treatment.

Methods

This retrospective case series evaluates a single center experience of percutaneous stent graft (SG) angioplasty and/or coil embolization for UAF. Patient follow-up included technical and early clinical success, complications and revisional procedures. We also conducted a systematic review of the literature reporting on endovascular UAF management.

Results

We identified 17 UAF in 16 patients (12 male, 4 female, mean age 69.8 ± 11.3 years) who underwent endovascular UAF therapy at our tertiary hospital. All patients presented with hematuria. 5/17 (29.4%) presented with flank pain, in 7 (41.2%) cases patients were in hypovolemic shock. Risk factors of UAF included chronic indwelling ureteral stents in all fistulas, major pelvic surgery in 13 cases (76.5%). In 6 cases (35.3%) SG were placed from the common iliac artery (CIA) to the external iliac artery (EIA) following coil embolization of the proximal internal iliac artery (IIA). SG placement without previous coil embolization was performed in 10 fistulas (58.8%). In one case only coil embolization of the IIA was performed. Mean follow-up was 654 (range: 1–3269) days. All procedures were technically successful and no procedure related deaths occurred during follow-up. During the initial hospital stay hematuria disappeared in 14/17 cases (82.4%). Overall, four patients suffered recurrent hematuria, which in three cases resolved after a secondary intervention. One recurrent UAF related death occurred during follow-up 229 days after initial treatment.

A total of 152 UAF cases were additionally analyzed from our systematic literature review: SG placement with or without embolization was performed in 140 cases (92.1%) while embolization alone was done in 12 cases (7.9%). Complications included UAF recurrence (18/152, 11.8%), SG thrombosis (7/140, 5%), and SG infections (5/140, 3.6%) with an overall complications rate of 13.8%. Five patients died due to UAF (3.3%).

Conclusion

Endovascular therapy offers high technical success rates and rapid bleeding control of UAF. Severe complications like SG occlusions or SG infections are rare but significant. Antibiotic treatment and single anti-platelet therapy improve SG durability as well as close and long follow-up to timely perform repeated endovascular or surgical treatment if necessary.

Evidence-based medicine

Level 4, case series.