Endovascular Treatment for Ureteroarterial Fistula in the Anastomotic Site of the Right Prosthetic Leg and Common Iliac Artery after Y-Graft Replacement for Abdominal Aortic Aneurysm / 日本心臓血管外科学会雑誌

A 63-year-old man underwent Y-graft (16×8 mm Hemashield Gold^®) replacement for an abdominal aortic aneurysm in our department in December 2008. In December 2010, the patient was given a diagnosis of right hydronephrosis in another department, for which a right ureteral stent was placed. The condition was resolved and the stent removed in July 2011. Thereafter in October, the patient developed abdominal distension and macroscopic hematuria. Under a diagnosis of recurrent right hydronephrosis, another ureteral stent was placed, though macroscopic hematuria persisted. He was referred to our department, and was admitted for detailed examinations and treatment. Contrast-enhanced computed tomography showed no obvious ureteroarterial fistula or contrast media leakage in the ureter. Because of the history of long-term ureteral stenting and prolonged macroscopic hematuria, regardless of the absence of a hemorrhagic lesion in the urinary tract, an ureteroarterial fistula in the anastomotic site of the right prosthetic leg and right common iliac artery was strongly suspected. There were no findings indicating an infectious complication, thus endovascular treatment was performed for hemostasis from a ureteroarterial fistula. We performed endovascular treatment with coil embolization (TORNADO^® 7 mm×3, 5 mm×2) of the right internal iliac artery and a covered stent (fluency plus^® 10 mm×80 mm) placement from the right prosthetic leg to the right external iliac artery, after which the hematuria disappeared. Although long-term outcomes following endovascular treatment for ureteroarterial fistula have not been reported, such treatment is considered to be quick and effective, with a low level of invasiveness, thus it should be considered as an effective therapeutic option for such cases in addition to open surgery.

Successful Endovascular Treatment of Ureteroarterial Fistula and Anastomotic Pseudoaneurysms / 日本心臓血管外科学会雑誌

A 79-year-old man who had undergone aneurysmectomy and graft replacement for an abdominal aortic aneurysm developed abdominal distension and massive hematuria. A computed tomography (CT) scan revealed the presence of anastomotic pseudoaneurysms and an ureteroarterial fistula between the ureter and iliac artery (distal anastomotic pseudoaneurysm). On admission, the patient's vital signs were stable. The patient was considered a high-risk case for open surgery because of his renal dysfunction which required dialysis, chronic heart failure and hostile abdomen. We initially recommended open surgery because of possible graft infection, however, the patient refused to undergo the high-risk open surgery. We performed emergency surgery for the ureteroarterial fistula via coverage with off-label use of the stent-graft leg. Intraoperative angiography revealed that there was no leakage. After 1 month, we confirmed that the inflammatory laboratory data was normalized, subsequently, we performed endovascular re-intervention for the proximal aortic anastomotic pseudoaneurysm. The endoleak was finally repaired after off-label use of the stent-graft (aortic cuff exclusion) twice within 2 months. The patient did not develop any operation-related adverse events for 4 months, but subsequently he died of pneumonia that developed from a common cold. Thus, we successfully performed endovascular treatment for a high-risk patient with an ureteroarterial fistula and pseudoaneurysms, without any surgery-related infection.