A Bleeding Uretero-Arterial Fistula: Open Repair After Unsuccessful Endovascular Treatment

Vasc Endovascular Surg. 2021 Feb;55(2):171-176. doi: 10.1177/1538574420953964. Epub 2020 Sep 2.

Abstract

Introduction: Uretero-arterial fistula (UAF) poses major challenges in management and diagnosis due to the rarity of this condition and associated high morbidity/mortality rates.

Methods: We describe a case of a UAF associated with previous aorto-biiliac grafting, ureteric stenting and right nephrectomy because of chronic pielonephritis and complicated by surgical site infection. This case illustrates a very complex pathology, with a challenging diagnosis and multiple treatment options.

Results: A 72 year-old woman was referred to Vilnius Vascular Unit for open UAF repair. The patient had a history of open abdominal aortic aneurysm repair using a bifurcated graft 25 years ago. The right ureter was injured during the operation and a rigid indwelling ureteric stent was inserted. Six months prior to referral, she underwent a right nephrectomy due to a chronic pyelonephritis, complicated by surgical site infection, which was still present at the time of admission. Initial CTA demonstrated bilateral iliac aneurysms, but no signs of UAF. A further CTA revealed a UAF between the right ureteral stump and the right common iliac artery (CIA) para-anastomotic aneurysm. After unsuccessful attempts to embolize the UAF using both coils and glue, the patient was referred to Vilnius Vascular Unit for open repair. Left axillo-bifemoral bypass reconstruction was performed followed by UAF repair and bifurcated graft explantation. Follow-up after 2 years showed no recurrence of haematuria, good function of the remaining kidney and patent axillo-bifemoral bypass with no signs of infection around the prosthetic aortic stump.

Conclusions: Uretero-arterial fistula is a uncommon condition in everyday clinical practice. The rarity of this condition may lead to delayed or missed diagnosis which can result in life-threating consequences. A multidisciplinary approach involving urologists, vascular surgeon and radiologist are crucial to both the diagnosis and managment of this rare entity.

Keywords: Uretero-arterial fistula; endovascular repair; vascular surgery.

Publication types

  • Case Reports

MeSH terms

  • Aged
  • Aortic Aneurysm, Abdominal / surgery*
  • Blood Vessel Prosthesis Implantation / adverse effects*
  • Embolization, Therapeutic
  • Female
  • Hematuria / etiology*
  • Humans
  • Treatment Failure
  • Ureteral Diseases / diagnostic imaging
  • Ureteral Diseases / etiology
  • Ureteral Diseases / surgery*
  • Urinary Fistula / diagnostic imaging
  • Urinary Fistula / etiology
  • Urinary Fistula / surgery*
  • Vascular Fistula / diagnostic imaging
  • Vascular Fistula / etiology
  • Vascular Fistula / surgery*