Peripheral Vascular Surgery Society

#12 STENT-GRAFT EXCLUSION OF A URETEROARTERIAL FISTULA: A TEMPORARY SOLUTION FOR EXSANGUINATING HEMORRHAGE.

Kellie R. Brown, MD, Robert A. Cambria, MD, William S. Rilling, MD, Jessie M. Jean-Claude, MD, Gary R. Seabrook, MD, and Jonathan B. Towne, MD

Medical College of Wisconsin, Milwaukee, WI.

Fistulous communication between the iliac artery and the ureter is a rare, potentially life threatening complication in vascular surgery. Even in the face of massive hematuria, radiographic demonstration of the fistula is difficult to obtain. Durable reconstruction of both the arterial and urinary systems can be difficult or impossible to achieve. We present a case of ureteroarterial fistula, and review the available literature on this topic.

A 78-year-old man presented with gross hematuria from an ileal conduit. His history was significant for prostate carcinoma treated by pelvic irradiation, with resultant radiation proctitis and cystitis, eventual diverting colostomy, Hartmann's pouch, and cystectomy with ileal conduit. History was also significant for an abdominal aortic aneurysm repair with aorto-biiliac endoaneurysmorrhaphy. Angiography did not delineate the pathology, however contrast injection into the left urinary system demonstrated a fistula between the iliac artery and the left ureter. Brisk hematuria led to hemodynamic instability and cardiopulmonary arrest. Resuscitation was successful and emergency placement of a stented graft into the left iliac artery excluded the fistula. Hematuria recurred several weeks later, and retrograde pyelogram once again demonstrated the fistula. At exploration, a large defect in the ureter was noted in direct communication with the stented graft, which had been placed across previous iliac artery anastomosis. The left graft limb, stented graft, and native iliac bifurcation were excised. The left ureter was ligated. A permanent nephrostomy tube allowed preservation of the left kidney, and cross-femoral bypass perfused the left lower extremity. The patient recovered well.

This case demonstrates many of the characteristics of ureteroarterial fistulae. They are difficult to demonstrate radiographically, and the diagnosis is frequently made at operation. Antecedent pathology of both the urinary and arterial system is common. Stent graft exclusion, although potentially lifesaving, as in our patient, does not provide a durable solution.

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Last updated January 1,2000