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

Abstract

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.

Arterioureteral fistula after radical cystectomy and ureterocutaneostomy: two case reports and a systematic literature review

“…Enhanced CT has less sensitivity in identifying bleeding but can be highly beneficial if active haemorrhage or a pseudoaneurysm is exist. It can also be used to rule out renal haemorrhages and plan endovascular treatment [ 15 ]. Cystoscopy may contribute to localized bleeding of the ureter.…”

Arterio-ureteral fistula: a nationwide cross-sectional questionnaire analysis

“…Krambeck et al [ 4 ] only describe seven AUF patients between 1975 and 2004, while Omran et al [ 5 ] and Simon et al [ 6 ] describe 25 AUF patients between 2011 and 2020 and 16 AUF patients between 2005 and 2020, respectively. This suggests that the reported incidence is increasing.…”

“…Noteworthy, in our cohort four new secondary AUFs were seen within 1 year and one ACF, all successfully treated by an endovascular stent. Simon et al [ 6 ] and Omran et al [ 5 ] describe recurrent AUFs, but no literature was found on new secondary AUFs. A possible explanation could be that these patients were > 70 years and all had radiation therapy in the past.…”

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

“…The endovascular approach has gained popularity due to its efficacy and safety profile [ 1 , 5 , 7 , 8 ]. In addition to the early recovery, the endovascular occlusion of the fistula while maintaining the arterial flow decreases the usage of revascularization procedures, which are often required after open surgery [ 27 ]. In addition, it eliminates the need for ureteric surgery, which, in some cases, may lead to the loss of the involved renal unit [ 22 , 27 , 29 ].…”