Endovascular treatment of ureteroarterial fistula using a covered stent, evaluated by intravascular ultrasound: a case report

Abstract

Background: Ureteroarterial fistula is a rare life-threatening complication of indwelling ureteral stents. The mechanism has not yet been fully evaluated using intravascular imaging. Case presentation: An-84-year-old female was referred to our unit because of large volume pulsatile bleeding from the left ureter during routine stent exchange in the urology department. The hematuria was initially managed by rapidly exchanging for a new stent; however, the patient went into hypovolemic shock due to acute blood loss. The patient underwent implantation of the bilateral ureteral stents due to urinary retention caused by retroperitoneal fibrosis 2 years ago. To prevent ureteral infection, occlusion of the stents and stone formation, the stents were exchanged every 6 months. Computed tomography revealed contact between the left ureter and the common iliac artery. Therefore, ureteroarterial fistula was suspected and endovascular therapy was performed. Although angiography did not show definite blood flow into the ureter, a soft guidewire was advanced from the subintima of the external iliac artery to the left ureter. The diagnosis of ureteroarterial fistula was confirmed. Intravascular ultrasound identified the stent in the ureter and its connection to the subintima of the external iliac artery. The ureter did not contact directly to the inner lumen of the iliac arteries according to the ultrasound findings; therefore, we considered that the risk of stent-graft infection might not be high. After coil embolization of the ipsilateral internal iliac artery, a covered stent was implanted in the external iliac artery to seal the subintimal entry. The patient had no further episodes of any gross hematuria on dual anti-platelet therapy, when the ureteral stent was exchanged three time during 1 year after the endovascular therapy. Conclusions: We demonstrated a case of ureteroarterial fistula, in which intravascular ultrasound allowed to visualize the communication between the ureter and the subintimal lumen in the external iliac artery.

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

“…The most common risk factor to develop an UAF is the presence of a chronic indwelling ureteral stent (Das et al, 2016 ). This is possibly due to the fact that mechanical fixation of the ureter triggers inflammation and fibrosis in the adjacent pulsating artery (Horie et al, 2019 ).…”

Results of Endovascular Therapy of Ureteroarterial Fistulas: A Single Center Experience 

“…The most common risk factor to develop an UAF is the presence of a chronic indwelling ureteral stent (Das et al, 2016). This is possibly due to the fact that mechanical xation of the ureter triggers in ammation and brosis in the adjacent pulsating artery (Horie et al, 2019).…”

Clinical case of successful endovascular correction of an arterio-ureteral fistula

“…Клиническая картина включает в себя задержку мочи, лихорадку, боль в животе, однако наиболее частый признак -гематурия различной интенсивности [3; 4]. Среди пациентов женского и мужского пола АМФ распространены в соотношении 3 : 2 [3][4][5]. Основные факторы риска -постоянный мочеточниковый стент в мочеточниках, злокачественное новообразование в анамнезе, хирургическое вмешательство на органах брюшной полости и малого таза [5][6][7].…”

“…Среди пациентов женского и мужского пола АМФ распространены в соотношении 3 : 2 [3][4][5]. Основные факторы риска -постоянный мочеточниковый стент в мочеточниках, злокачественное новообразование в анамнезе, хирургическое вмешательство на органах брюшной полости и малого таза [5][6][7].…”

“…Первичное диагностическое обследование включает ангиографию, компьютерную томографию, уретерографию. Симптомы патологии неспецифические и на момент обследования могут отсутствовать [1][2][3][4][5]. Есть данные о проведении провокационных тестов при цистоскопии, инициирующих гематурию из фистулы, однако метод может вызвать неконтролируемое кровотечение и геморрагический шок [3][4][5][6][7].…”