Endovascular treatment of arterio-ureteral fistulae with covered stents: Case series and review of the literature

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.

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.

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 treatment of arterio-ureteral fistula with new-generation balloon-expandable stent graft using a 7-French system

Arterio-ureteral fistulas are relatively rare, but a potentially life-threatening condition because of the possible massive bleeding. An 82-year-old woman with a history of hysterectomy and irradiation for uterine cancer was treated with ureteric stents for recurrent bilateral ureteral stenosis. During the adjustments of the stent, removing the right ureteric stent immediately resulted in massive hematuria. Computed tomography showed that the right ureter coursed above and seemed to be connected to the right external iliac artery. From the clinical history and computed tomography findings, an arterio-ureteral fistula between the right external iliac artery and right ureter was strongly suspected. The GORE^® VIABAHN^® VBX Stent Graft was deployed from the common iliac artery to the external iliac artery via a 7-French femoral system, followed by post-dilatation. The patient did not develop any complications or recurrence of hematuria after the procedure during the 11-month follow-up. The VBX is a useful device, with a low- profile device and a size-adjustable balloon-expandable stent that depended on the individual vessel size for post-dilatation. However, there are several concerns, such as risk of infection, stent thrombosis/stenosis, and chronic outcome while using stent grafts for treatment. Patients with arterio-ureteral fistulas who were treated using stent grafts should be carefully followed up.