Mid-term results after open surgical and endovascular management of arterio-ureteral fistula.

Abstract Background Arterio-ureteral fistula refers to the anomalous fistulous connection between the iliac artery and the ureter. It is often associated with pelvic malignancy, abdominal surgery and radiation. As it is a potentially life-threatening condition, prompt diagnosis and management is essential. Methods We performed a retrospective analysis of patients treated for arterio-ureteral fistula in a single vascular institution from January 2013 until March 2019. Preoperative assessment included physical and laboratory examinations and medical history, with diagnosis established through computed tomography angiography, digital subtraction angiography or ureteroscopy. Parameters analyzed included perioperative mortality and morbidity as well as treatment durability during mid-term follow-up. Results Nine patients with ten arterio-ureteral fistulas were included in the study. Macroscopic hematuria was the main presenting symptom, with two patients admitted due to hemorrhagic shock. Endovascular treatment was carried out in six patients. In four cases, single stentgraft deployment inside the common iliac artery was performed, in one case in combination with plugging of the internal iliac artery. One patient underwent implantation of an iliac-branched device, while in another patient coiling of the internal iliac artery sufficed for management of the fistula. Open surgical repair was carried out in three cases. Perioperative mortality was zero; one patient had prolonged hospital stay due to superficial wound infection. Recurrent hematuria and stentgraft infection were observed during follow-up in three patients following endovascular repair, all of them treated through open surgery with no further complications. One patient developed an enterocutaneous fistula after open repair during follow-up and required redo surgery. Discussion Arterio-ureteral fistula is a challenging clinical scenario demanding prompt diagnosis and management. Open surgery remains the treatment of choice in cases of pre-existing vascular reconstruction or manifest infection. Endovascular techniques offer a viable solution in significantly comorbid patients or in patients presenting with acute, life-threatening bleeding. Rigorous follow-up is required regardless of treatment modality due to the considerable rate of reinterventions.