Lessons learned from endovascular management of ureteroarterial fistula

Endovascular and open surgical options in the treatment of uretero-arterial fistulas

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.

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.

Management Strategy for Ureteral-Iliac Artery Fistula

BACKGROUND

Ureteral-iliac artery fistula (UIAF) is a rare but a potentially life-threatening condition. In this study, we reported our results of UIAF treated by open surgical and endovascular treatment.

METHODS

In this single-center, retrospective observational cohort study, we reviewed 6 consecutive patients who were diagnosed with a UIAF and received either open surgical or endovascular treatment based on the specific risk profile of each patient.

RESULTS

All patients had an indwelling ureteral stent for a ureteral stricture, with an average ureteral stenting duration of 22 months (range, 1-74 months), and 2 patients had a history of endovascular treatment with stent grafts for UIAF. Contrast-enhanced computed tomographic angiography was positive in 4 patients. Blood and urine cultures were positive in 2 and 4 patients, respectively. Four patients, including 2 with previously failed endovascular treatment, received open surgical repair. The remaining 2 patients received either endovascular treatment with stent grafts or a hybrid procedure. During the mean follow-up period of 20.3 months (range, 6-29 months), there was no symptomatic recurrence of the UIAF.

CONCLUSIONS

A multidisciplinary approach is highly preferable for treating potentially life-threatening UIAF. Endovascular treatment with stent grafts is currently recommended in selected patients whenever possible, but open surgical treatment is required in certain patients with enteric contamination, abscess, local sepsis, or previously failed endovascular treatment.