Scientific letter
Endovascular Repair of an Arterial Pseudoaneurysm Due to Ureteral-Iliac Fistula
Reparación endovascular de seudoaneurisma arterial secundario a fístula ilíaco-ureteral
Ana María Miguel-Sánchez
, Ljubica Sarmiento-Marasovic, Jose Manuel Buisán-Bardají, Jorge Coghi-Granados, Ángel Duato Jané
Corresponding author
Servicio de Angiología y Cirugía Vascular, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
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=> array:2 [ "nombre" => "Ljubica" "apellidos" => "Sarmiento-Marasovic" ] 2 => array:2 [ "nombre" => "Jose Manuel" "apellidos" => "Buisán-Bardají" ] 3 => array:2 [ "nombre" => "Jorge" "apellidos" => "Coghi-Granados" ] 4 => array:2 [ "nombre" => "Ángel" "apellidos" => "Duato Jané" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Angiología y Cirugía Vascular, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Reparación endovascular de seudoaneurisma arterial secundario a fístula ilíaco-ureteral" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 700 "Ancho" => 1400 "Tamanyo" => 134643 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">CT angiography images: (A) retroperitoneal bleeding due to rupture of the left iliac pseudoaneurysm; (B) previously placed iliac stents and pseudoaneurysm due to distal leakage.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The presence of an ureteroiliac fistula (UIF) is an unusual cause of hematuria that should be suspected in patients with a history of pelvic surgery, arterial revascularization, pelvic inflammatory processes, radiotherapy or ureteral stent placement<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">1</span></a>; occasionally, it is also associated with the presence of an arterial pseudoaneurysm. One of the greatest advantages of endovascular procedures is the rapid control of bleeding with minimally invasive techniques.</p><p id="par0010" class="elsevierStylePara elsevierViewall">We present the case of a 53-year-old male with a history of dyslipidemia, peritonitis due to acute gangrenous appendicitis requiring laparoscopic appendectomy, and bladder cancer treated by transurethral resection and endocavitary chemotherapy. Three years later, he presented recurrence of said neoplasm with infiltration of the ureteral wall and meatus, lymph node involvement and bone metastases (invasive bladder cancer pT4 pN3 M1). The patient was treated surgically by the urology department, who performed radical cystectomy associated with extended bilateral iliac lymphadenectomy and cutaneous ureterostomy. The patient also required palliative chemotherapy.</p><p id="par0015" class="elsevierStylePara elsevierViewall">One month later, the patient came to the emergency department due to colicky pain in the left iliac fossa and bleeding through the ureterostomy. The interventional radiology unit injected iodinated contrast through the ureteral catheter, observing the presence of a left UIF, which they treated with the placement of 2 Fluency<span class="elsevierStyleSup">®</span> (Bard) 8×60<span class="elsevierStyleHsp" style=""></span>mm coated stents. Six months later, the patient once again presented the same symptoms. Computed tomographic (CT) angiography demonstrated a proximal leak of contrast material from the stents. The patient was again treated by the interventional radiology unit with the placement of another 8×60<span class="elsevierStyleHsp" style=""></span>mm Fluency<span class="elsevierStyleSup">®</span> stent.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Two months later, the patient came to the emergency department again due to intense pain in the left hemiabdomen and thigh, which required the extremity to be maintained in flexion. CT angiography revealed a left common iliac pseudoaneurysm with a maximum diameter of 65<span class="elsevierStyleHsp" style=""></span>mm and active bleeding (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A and B), so the patient was referred to our service. Given the patient's surgical history and high risk, we opted for endovascular treatment, reserving open surgery for use as a last resort. Due to the antalgic position of the limb, the procedure had to be done under general anesthesia. Using left retrograde femoral puncture and following Seldinger's technique, a diagnostic arteriography was performed through a 6 Fr introducer sheath, which revealed a contrast leak through the distal portion of the previously placed endoprostheses (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>A). With the help of a 0.035<span class="elsevierStyleHsp" style=""></span>inch hydrophilic guidewire and through a Vanschie II type catheter, the common iliac artery was canalized and 2 Fluency<span class="elsevierStyleSup">®</span> coated stents were implanted (10×80<span class="elsevierStyleHsp" style=""></span>mm and 8×80<span class="elsevierStyleHsp" style=""></span>mm). As a prophylactic measure, 1.5<span class="elsevierStyleHsp" style=""></span>g of cefuroxime was administered according to protocol, and no anticoagulation therapy was applied due to the active bleeding.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">The postoperative angiographic study confirmed the cessation of bleeding and the permeability of the iliac axis (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>B). The postoperative evolution was satisfactory, with no new episodes of hematuria.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The increased risk factors and the longer survival of patients with genitourinary neoplasms have increased the incidence of UIF in the recent literature, although it is still uncommon.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">2</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">In chronic inflammatory processes, fibrosis and precarious vascularization of the <span class="elsevierStyleItalic">vasa vasorum</span> create an adhesion between the ureter and artery, which is the main cause of the formation of fistulae. These are mainly located in the iliac axis, with a preference for the external iliac artery, and can be associated with abscesses or pseudoaneurysms.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">3</span></a> The latter are formed by localized arterial rupture with extravasation of blood encompassed by the layers of connective tissue.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">4</span></a> The persistence of the leak point makes them pulsatile, and the pseudoaneurysm may grow until it ruptures.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">5</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">UIF should be suspected in a patient with severe or microscopic hematuria over the course of several days and risk factors due to previous surgeries or inflammatory processes.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">6</span></a> In addition to hematuria, the patient may present with lumbar pain, urinary retention or infection. Pain in the flank may be secondary to obstruction of the ureter due to blood clotting<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">2</span></a> or the rupture of a pseudoaneurysm.</p><p id="par0045" class="elsevierStylePara elsevierViewall">The technique of choice for the diagnosis of UIF is selective arteriography, as it identifies the exact location of the fistula.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">5,7</span></a> Meanwhile, CT angiography is selected for the diagnosis of a pseudoaneurysm as it offers preoperative information about possible rupture, size and relationship with neighboring structures.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">8</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Classically, surgical repair of a UIF involves femorofemoral crossover bypass with exclusion of the affected iliac artery (embolization or ligation), or less frequently <span class="elsevierStyleItalic">in situ</span> reconstruction. Endovascular treatment with the placement of coated stents is a minimally invasive alternative that provides quick control of the bleeding and clear advantages in patients with unfavorable anatomy. The selection of patients for one procedure or another is based on comorbidity, clinical presentation, anatomical difficulties, presence of infection, enteric contamination or the need to preserve pelvic perfusion due to contralateral arterial disease.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">7</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Although the risk of infection and recurrence of bleeding are not well defined, these procedures are safe and effective, although not free from complications that may become severe in certain cases.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Miguel-Sánchez AM, Sarmiento-Marasovic L, Buisán-Bardají JM, Coghi-Granados J, Duato Jané Á. Reparación endovascular de seudoaneurisma arterial secundario a fístula ilíaco-ureteral. Cir Esp. 2018;96:123–125.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 700 "Ancho" => 1400 "Tamanyo" => 134643 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">CT angiography images: (A) retroperitoneal bleeding due to rupture of the left iliac pseudoaneurysm; (B) previously placed iliac stents and pseudoaneurysm due to distal leakage.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 701 "Ancho" => 1400 "Tamanyo" => 112068 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Diagnostic (A) and postoperative (B) arteriographies.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:8 [ 0 => array:3 [ "identificador" => "bib0045" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Ureteroarterial fistula" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "D.H. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 October | 6 | 6 | 12 |
| 2024 September | 13 | 8 | 21 |
| 2024 August | 11 | 3 | 14 |
| 2024 July | 15 | 4 | 19 |
| 2024 June | 9 | 5 | 14 |
| 2024 May | 14 | 8 | 22 |
| 2024 April | 32 | 5 | 37 |
| 2024 March | 34 | 4 | 38 |
| 2024 February | 11 | 1 | 12 |
| 2024 January | 28 | 4 | 32 |
| 2023 December | 27 | 3 | 30 |
| 2023 November | 12 | 3 | 15 |
| 2023 October | 15 | 4 | 19 |
| 2023 September | 17 | 0 | 17 |
| 2023 August | 9 | 0 | 9 |
| 2023 July | 8 | 2 | 10 |
| 2023 June | 18 | 8 | 26 |
| 2023 May | 57 | 5 | 62 |
| 2023 April | 54 | 1 | 55 |
| 2023 March | 25 | 3 | 28 |
| 2023 February | 11 | 6 | 17 |
| 2023 January | 25 | 2 | 27 |
| 2022 December | 40 | 6 | 46 |
| 2022 November | 31 | 7 | 38 |
| 2022 October | 20 | 15 | 35 |
| 2022 September | 16 | 11 | 27 |
| 2022 August | 24 | 11 | 35 |
| 2022 July | 16 | 13 | 29 |
| 2022 June | 19 | 7 | 26 |
| 2022 May | 27 | 6 | 33 |
| 2022 April | 15 | 6 | 21 |
| 2022 March | 30 | 9 | 39 |
| 2022 February | 36 | 7 | 43 |
| 2022 January | 47 | 5 | 52 |
| 2021 December | 28 | 6 | 34 |
| 2021 November | 15 | 6 | 21 |
| 2021 October | 19 | 10 | 29 |
| 2021 September | 20 | 11 | 31 |
| 2021 August | 46 | 8 | 54 |
| 2021 July | 13 | 11 | 24 |
| 2021 June | 18 | 7 | 25 |
| 2021 May | 51 | 7 | 58 |
| 2021 April | 89 | 23 | 112 |
| 2021 March | 28 | 7 | 35 |
| 2021 February | 28 | 5 | 33 |
| 2021 January | 38 | 9 | 47 |
| 2020 December | 39 | 6 | 45 |
| 2020 November | 44 | 6 | 50 |
| 2020 October | 27 | 7 | 34 |
| 2020 September | 14 | 11 | 25 |
| 2020 August | 41 | 10 | 51 |
| 2020 July | 18 | 5 | 23 |
| 2020 June | 21 | 11 | 32 |
| 2020 May | 22 | 7 | 29 |
| 2020 April | 17 | 6 | 23 |
| 2020 March | 23 | 3 | 26 |
| 2020 February | 23 | 7 | 30 |
| 2020 January | 23 | 11 | 34 |
| 2019 December | 28 | 5 | 33 |
| 2019 November | 8 | 7 | 15 |
| 2019 October | 23 | 0 | 23 |
| 2019 September | 28 | 5 | 33 |
| 2019 August | 13 | 3 | 16 |
| 2019 July | 15 | 15 | 30 |
| 2019 June | 63 | 7 | 70 |
| 2019 May | 117 | 4 | 121 |
| 2019 April | 48 | 14 | 62 |
| 2019 March | 3 | 0 | 3 |
| 2019 February | 10 | 4 | 14 |
| 2019 January | 3 | 0 | 3 |
| 2018 December | 0 | 3 | 3 |
| 2018 November | 11 | 1 | 12 |
| 2018 October | 8 | 2 | 10 |
| 2018 September | 10 | 5 | 15 |
| 2018 August | 6 | 1 | 7 |
| 2018 July | 8 | 1 | 9 |
| 2018 June | 3 | 2 | 5 |
| 2018 May | 3 | 1 | 4 |
| 2018 March | 0 | 2 | 2 |
| 2018 February | 0 | 1 | 1 |
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