Acute Endovascular Stent-Graft Occlusion after Treatment of an Arterioureteral Fistula

Editor: Arterioureteral fistulas (AUF) are rare but potentially life-threatening causes of hematuria that are being reported with increasing frequency over the past decade (1). The objective of traditional open surgical management of an AUF has two components: iliac artery exclusion with vascular bypass and urinary diversion. The recent market availability of endovascular stent-grafts has allowed application of these devices to evolve as an alternative treatment approach for this entity. This less invasive treatment can be associated with complications such as occlusion, infection, and recurrence of hematuria. We report a case of an acute occlusion of an endovascular stent-graft after the successful treatment of an AUF. A 54-year-old woman with stage IIB cervical cancer, treated with pelvic irradiation and total pelvic exenteration with urinary diversion via an ileal conduit for recurrent disease, was admitted to our institution for gross hematuria. Because of the development of an ileal conduit-colonic fistula, bilateral 8-F nephrostomies were inserted to promote fistula closure. The patient then developed blood transfusion dependent intermittent gross hematuria from the ileal conduit and left nephrostomy. On the current admission, the patient was hemodynamically unstable. The patient’s hemoglobin was 6.3 mg/dL (baseline 12.1 mg/dL), requiring 3 units of packed red blood cells. After informed consent, selective bilateral renal arteriography (Cobra-2, Cook, Bloomington, IN) was performed revealing no stigmata of arterial injury. Pelvic and selective left iliac arteriography (Fig 1a) demonstrated a pseudoaneurysm consistent with the typical location of an AUF originating in the left common iliac artery, just proximal to the division into the external and internal branches. In view of the patient’s extensive surgical history, an endovascular approach with a stent-graft covering the origin of the AUF and the internal iliac artery was believed to be the most optimal method for AUF management. The left internal iliac artery was then selectively catheterized (Cobra 2, Cook) and embolized at its origin with two 6-mm, 0.035-inch metallic coils (Vortex-35, Boston Scientific, Natick, MA) to prevent an endoleak. The ipsilateral common femoral artery was then percutaneously accessed and a 10-F sheath (Pinnacle; Boston Scientific) was inserted through which a 9-F 8-mm 50-mm stent-graft (Wallgraft, Boston Scientific) was deployed from the proximal left common iliac artery to the proximal external iliac artery. Completion arteriography demonstrated the pseudoaneurysm to be successfully excluded with brisk iliac arterial flow (Fig 1b). Manual compression was applied after all the devices were