Diagnostic and Interventional Imaging (2013) 94, 311—318

SHORT ORIGINAL ARTICLE / Cardiovascular imaging

Uretero-iliac fistula: Modern treatment via theendovascular route

L. Tselikasa,b, O. Pellerina,∗,b, M. Di Primioa,b,M. Ben Arfia,b, J. Joskina,b, B. Beyssena,b,N. Thiounna,c, M. Sapovala,b

a Faculté de Médecine, Université Paris Descartes, Sorbonne Paris-Cité,75270 Paris cedex 06, Franceb Department of Interventional Radiology, Hôpital Européen Georges-Pompidou,Assistance publique—Hôpitaux de Paris, 20, rue Leblanc, 75015 Paris, Francec Urology Department, Hôpital Européen Georges-Pompidou, Assistance publique—Hôpitauxde Paris, 20, rue Leblanc, 75015 Paris, France

KEYWORDSArterio-ureteralfistula;Endovascular;Endoprosthesis;

Abstract We report three cases of ureteral-iliac fistula (UIF) in patients referred for treatmentof macroscopic haematuria. Though it is a classic aetiology of haematuria, it is often difficultto diagnose and the treatment is not yet standardized. A diagnostic evaluation in combinationwith multidisciplinary approach improves the prognosis of the patients. Curative treatment viathe endovascular route is effective and safe, and has a rapidly favourable course in all of our

TM

Plug patients. The use of covered stents combined with the Amplatzer vascular plug makes theprocedure easy and safe.© 2012 Éditions françaises de radiologie. Published by Elsevier Masson SAS. All rights reserved.

Arterio-ureteral fistula is a rare pathology which is life-threatening. Mortality is estimatedto be approximately 9% and morbidity is 23% [1,2]. The diagnosis is difficult. Rarely pri-mary, and related to a disease of the arterial wall, arterio-ureteral fistulae are most oftensecondary to an outside factor that affects the arterio-ureteral crossing, such as radio-therapy, double J stent placement or loco-regional surgery. They mainly concern the iliacaxes, though other arteries can be involved, such as the lower mesenteric artery or eventhe aorta, particularly in relation with an aneurismal disease [3—5].

Several treatment modalities have been described, which are endoscopic surgical,endovascular or combination [6].

The precision and the time to diagnosis are also important prognostic factors in thisdisease.

∗ Corresponding author.E-mail address: olivier.pellerin@egp.aphp.fr (O. Pellerin).

2211-5684/$ — see front matter © 2012 Éditions françaises de radiologie. Published by Elsevier Masson SAS. All rights reserved.http://dx.doi.org/10.1016/j.diii.2012.10.005

3

tt

C

Acunutil

Fad

o(soamovsct

12

We report three cases of endovascular treatment of UIFhat illustrate both the presentation and the challenges ofhis pathology.

ase 1

56-year-old woman with a history of pelvic irradiation forervical cancer was referred by her treating physician to anrologist for the treatment of relapsing haematuria that wasot very abundant. While the urologist was performing endo-

reteral manoeuvres, a cataclysmic macroscopic haema-uria was observed via the left ureteral meatus. A retrogradenjection of an iodinated contrast material (ICM) in theeft ureter showed an uretero-iliac fistula by simultaneous

igure 1. Opacification of the left primitive iliac artery during left urterial route (b, c). PIA nipple (b, arrow) indicating the entry of the fistuilation of the left urinary tract (d). Final opacification after implantation

m0pn

L. Tselikas et al.

pacification of the ureter and the primitive iliac arteryPIA) (Fig. 1a). Faced with this observation, the patient wasent to interventional radiology for endovascular treatmentf this fistula. Through a left retrograde common femoralpproach, the angiography images showed spiculation of theiddle part of the left primitive iliac artery (PIA), without

pacification of the fistulous trajectory. This was visualizedia selective injection with a catheter placed against thepicule (Fig. 1b, c and d). The strategy that was adoptedonsisted of excluding the fistulous track using a bridge-ype implantation of a balloon-expandable covered stent

TM

reteral opacification (a). Opacification of the fistula through thela track, directly opacified (c) by the selective injection. Significant

of a covered stent covering the starting point of the UIF (e, arrows).

easuring 12 × 41 mm (Advanta V12 , Atrium Hudson, NH,3051 USA). Because the distance between the stent distalart and the posterior iliac artery take-off was sufficient,o other stent, nor iliac internal artery embolization was

rou

oAwtAItfit

gac

Uretero-iliac fistula: Modern treatment via the endovascular

necessary to prevent any type of endoleak. At the end ofthe procedure, the angiographic controls confirmed the fulliliac arteries patency and showed effective exclusion of thefistula track (Fig. 1e). There were no complications afterthe procedure and the haematuria resolved.

Case 2

A 59-year-old male patient monitored for adenocarcinomaof the rectum was referred to us for the treatment ofmassive macroscopic haematuria. He also had a historyof endoscopic resection of the prostate for an adenoma.This haematuria occurred 1 year after the pelvic surgery

(pelvectomy with Bricker enterocystoplasty due to blad-der involvement of the rectal tumour) and the beginningof adjuvant radio-chemotherapy (FOLFOX-Avastin®). Thehaematuria was associated with acute renal insufficiency

rr(o

Figure 2. 3D scan reconstructions, frontal (a) and oblique (b) showinartery, along the right single J stent (white arrow) and the caliceal clotstime. At the level of the crossing of the right single J stent and the righthe ICM (white arrow).

te 313

bstructed by clots despite the single J ureteral stents.naemia with 7 g/dL of haemoglobin was observed. Facedith these signs and symptoms, the patient was transferred

o intensive care and had a transfusion of six red cell units.n abdominal-pelvic CT scan with and without injection of

CM was carried out (Fig. 2a, b and c). This examination, athe arterial and portal phases, revealed a right ilio-ureteralstula and confirmed the dilation of the pyelocaliceal cavi-ies due to bilateral clotting in the urinary tract.

First, the single J ureteral stents were changed overuidewires. Due to the continued macroscopic haematuria,nd in the absence of a possible surgical option, an endovas-ular treatment of this ilio-ureteral fistula was suggested.

The arteriography through the right common femoral

oute confirmed the presence of a fistula between theight external iliac artery (EIA) and the homolateral ureterFig. 3a and b). The treatment of this fistula consisted firstf embolising the right internal iliac artery (IIA) with an

g the extravasation of contrast medium of the right external iliac (arrowheads); c: the axial scan cuts after injection at the arterialt external iliac artery, the UIF is indicated by the extravasation of

314 L. Tselikas et al.

Figure 3. After the implantation of the AmplatzerTM vascular plug measuring 12 mm in diameter, using a 5F Destination® insertion device,and 45 cm in length (Terumo Leuven, B.). The long extremity of the desilet (a: arrow) and the extremities of the plug (a, b and c: arrowheads).Insertion of an Advanta V12® balloon-expendable covered stent 10 × 59 mm in length using a 7F insertion device (b, arrow). Angiographiccontrol from the front (c) showing good coverage of the fistula by the stent (white arrow) and occlusion of the right IIA by the plug(

AMda(bcAt(wc

C

AorpaAe

scorweotaileacrt1pn

arrowhead).

mplatzerTM vascular plug (St. Jude Medical, Inc. St. Paul,N, USA) measuring 12 mm in diameter. This embolisationevice was deployed in a proximal manner (Fig. 4a). Second,

balloon-expandable covered stent measuring 10 × 59 mmAdvanta V12TM) was implanted in the right iliac artery,ridging the ostium of the IIA (Fig. 4b and c). This endovas-ular approach made it possible to exclude the fistula.ngiographic controls at the end of the procedure showedhe tapering off of the flow of the arterio-ureteral fistulaFig. 5a and b). The clinical course was rapidly favourableith the resolution of the haematuria and restarting ofhemotherapy in the days following the procedure.

ase 3

72-year-old patient with a history of endoscopic resectionf an adenoma of the prostate and pelvic radiotherapy forectal cancer 10 years earlier was referred by his general

ractitioner as an emergency for macroscopic haematuriassociated with acute renal insufficiency due to an obstacle.

double J stent had been placed in the left ureter via thendoscopic route. Since the implantation of the double J

TciI

tent, the patient had signs of haemorrhagic shock asso-iated with haematuria. After haemodynamic stabilisationf the patient, a CT scan was performed. A voluminousetroperitoneal fluid collection adhering to the left ureteras shown. The primitive iliac artery (PIA) and the homolat-ral internal iliac artery (IIA) were enhanced after injectionf ICM during the arterial phase (Fig. 5a). The diagnosishat was retained was uretero-iliac fistula complicated by

pseudo-aneurism. Endovascular treatment was proposedmmediately. The initial angiographic evaluation, via aeft common femoral retrograde approach, confirmed thexistence of a fistula associated with a voluminous pseudo-neurism of the convergence of the PIA and IIA (Fig. 5b and). Due to the important obliquity of IIA take-off, a right ret-ograde femoral approach was necessary to make it possibleo embolise with an AmplatzerTM vascular plug measuring2 mm. The plug was implanted away from the neck of theseudo-aneurism due to the complex anatomy of fistulaeck involving both IIA take-off and PIA. (Fig. 6a and b).

hen, via the left femoral route, two balloon-expandableovered stents measuring 10 × 61 mm (Advanta V12TM) weremplanted in a bridge-like manner on the ostium of theIA so as to widely cover the neck of the pseudo-aneurism

Uretero-iliac fistula: Modern treatment via the endovascular route 315

Figure 4. Arteriography centred on the right iliac bifurcation, from a 30◦ left anterior oblique perspective, showing the leak of contrastmaterial from the antero-external part of the right external iliac artery in contact with the single J stent (a and b, white arrow).

Figure 5. The injector scan (a) shows the existence of a circulating (star) voluminous pseudo-aneurism (arrows), developed due to contactwith the vasculo-ureteral clamp. The left iliac angiography confirms the presence of this pseudo-aneurism (b, arrows) associated with anUIF that is visible due to the two spiculations (c, arrows).

316 L. Tselikas et al.

Figure 6. These four figures sum up the strategy that has been developed. Embolisation of the IIA with an AmplatzerTM vascular plug (a,s ts ina noted

aaflhi

D

TafisceIagit

icpMsuvai

itaTia

tar), followed by implantation of two Advanta V12TM covered stenrrows). The extent of the neck of the pseudo-aneurism should be

nd the fistula (Fig. 6c). At the end of the procedure, thengiographic images confirmed the slowing down of theow of the fistula and the pseudo-aneurism (Fig. 6d). Theaemodynamic clinical condition of the patient correctedtself rapidly and the haematuria resolved.

iscussion

he three cases presented here illustrate the efficacynd safety of the endovascular treatment of uretero-iliacstulae. This technique has the advantage of a less inva-ive, rapid and simple approach. It is suitable to the manyomorbidities of the patients. It is perfectly suited to themergency situations that uretero-iliac fistulae represent.mplementation of this technique within a multidisciplinary

pproach (anaesthetist-intensive care physicians, urolo-ists, radiologists and interventional radiologists) makest possible to set the patient from the diagnostic to thereatment.

matt

order to widely cover the UIF and the ostium of the IIA (b and c, in Fig. 6a (arrows). Fig. 6d confirms the exclusion of the UIF.

Uretero-iliac fistulae are the consequence of chronicnflammatory events that create a fibrous and poorly vas-ularised uretero-vascular adhesion. They often occur inatients with a history of surgery and pelvic radiotherapy.ost often, these inflammatory events are caused by a

tenosis of the ureter. The many cases of trauma to thereter that occur during repeated endo-ureteral manoeu-res (changing of ureteral catheters) or the activity ofnticancer biotherapies (case 1) are the cause of the repeatschaemic events that are the source of the UIF [7].

The UIFs mainly concern the iliac axes, with preferentialnvolvement of the external iliac artery but can involvehe terminal aorta, PIA or take-off of the IIA [8]. Pseudo-neurism (case 3) or abscesses are frequently associated.he diagnosis has a crucial role in the treatment. It makes

t possible and set the procedure. The excellent timend space resolution of the CT scans associated with

ulti-planar reconstructions make it possible to perform

precise morphological evaluation [5,9]. Arteriography,hough it has sensitivity that is superior to non-invasiveechniques (sensitivity > 50%), must be reserved for the

rou

tToetfitbrpcut

tuitd

tc

Uretero-iliac fistula: Modern treatment via the endovascular

immediate preprocedural evaluation, due to its invasivenature [10]. The semiology of UIFs is varied. The directimage of the fistula is inconstant. Most often, it is a nippleof the arterial wall located at the crossing of the ureter thatindicates the entry of the fistula (case 1, Fig. 1b and c) [11].Selective catheterism of the fistulous track can be carriedout and makes it possible to refine its anatomical location.However, it presents a risk of worsening the haematuria.

Historically, the treatment was surgical. It mainly com-bined ureteral tutorization with a catheter and the surgicalapproach of the IA [12]. However, the complex dissectionand difficulty in performing the prosthetic bridges or exo-grafts have left room for the endovascular approach [2].This procedure is possible due to the use of a covered stent.These stents are covered with a thin membrane of biocom-patible PTFE. We chose the balloon-dependent PTFE stentfor our patients. It has four advantages. First, stents thatare balloon-mounted provide implantation precision that issuperior to that of self-expanding stents [13]. Second, thecompatibility of the stent with a 6Fr sheath makes it pos-sible to easily control the puncture point at the end of theprocedure. Third, the possibility of over-dilating the stent tomake it conform in an optimal manner to the various diam-

eters of the target arteries without a major loss in length.And fourth, the use of PTFE provides increased resistance tobacterial colonisation in case of deployment of the stent ina septic environment [14].

abcF

Figure 7. Adaptation of the algorithm for the treatment of macroscop

te 317

Depending on the location of the fistula track with regardo the iliac confluent, occlusion of the IIA can be necessary.o prevent the onset of a type II endoleak wide coveragef the fistula neck is necessary. Furthermore, proximal IIAmbolization could be needed when fistula neck is closeo the IIA take-off [15]. For these patients, we used therst generation AmplatzerTM vascular plug. This embolisa-ion device can be easily implanted and repositioned if neede. In addition, it ensures proximal occlusion of the IIA thatespects the crossing between the anterior trunk and theosterior trunk of the IIA. This technique is useful to over-ome buttock claudication [16]. In addition to the ease ofse, the AmplatzerTM vascular plug is a less costly alternativeo embolisation via coils [16].

The main limit to endovascular treatment of UIF remainshe absence in the literature of long-term patient follow-p. Arterial permeability and the course of the fistulatself remain poorly studied due to the importance ofhe comorbidities of the patients that are the cause ofeath.

Krambeck et al. suggested a treatment strategy for thisype of haematuria [17]. Using the identification of the clini-al symptomatology (based on the patient’s medical history

nd clinical presentation of the haematuria), it is mainlyased on the diagnostic CT scan examination. The endovas-ular approach is the primary treatment suggestion. Onig. 7, we propose an algorithm that, contrary to that of

ic haematuria and uretero-iliac fistula by Krambeck et al. [17].

3

Kf

emmo

D

Tc

R

[

[

[

[

[

[

[

18

ramback et al., makes the endovascular approach the toolor diagnosis and treatment.

Due to its efficacy, safety and rapid implementation, thendovascular approach to UIFs within the framework of aultidisciplinary treatment is becoming the reference treat-ent. The pre-treatment scan is a key point in the treatment

f these patients and conditions the prognosis.

isclosure of interest

he authors declare that they have no conflicts of interestoncerning this article.

eferences

[1] van den Bergh RC, Moll FL, de Vries JP, Yeung KK, Lock TM.Arterio-ureteral fistula: 11 new cases of a wolf in sheep’s cloth-ing. J Urol 2008;179(2):578—81.

[2] van den Bergh RC, Moll FL, de Vries JP, Lock TM. Arterio-ureteral fistulas: unusual suspects-systematic review of 139cases. Urology 2009;74(2):251—5.

[3] Dervanian P, Castaigne D, Travagli JP, Chapelier A, Tabet G, Par-quin F, et al. Arterio-ureteral fistula after extended resectionof pelvic tumors: report of three cases and review of the liter-ature. Ann Vasc Surg 1992;6(4):362—9.

[4] Bergqvist D, Parsson H, Sherif A. Arterio-ureteral fistula — asystematic review. Eur J Vasc Endovasc Surg 2001;22(3):191—6.

[5] Dana A, Helenon O. Urinary tract imaging: conventional radi-ology and ultrasound. J Radiol 2004;85(2 Pt 2):169—70.

[6] Amahzoune M, Hilal R, Gouillat C, Berard P. Arterio-ureteral

fistula, report of three cases. Ann Chir 2005;130(4):257—60.

[7] Keller FS, Barton RE, Routh WD, Gross GM. Gross hematuria intwo patients with ureteral-ileal conduits and double-J stents.J Vasc Interv Radiol 1990;1(1):69—77 [discussion—9].

[

L. Tselikas et al.

[8] Madoff DC, Gupta S, Toombs BD, Skolkin MD, CharnsangavejC, Morello Jr FA, et al. Arterio-ureteral fistulas: a clinical,diagnostic, and therapeutic dilemma. AJR Am J Roentgenol2004;182(5):1241—50.

[9] Renard-Penna R, Ayed A, Barrou B, Grenier P. Prekidney-transplant evaluation of donors and recipients. J Radiol2011;92(4):358—66.

10] Batter SJ, McGovern FJ, Cambria RP. Ureteroarterial fis-tula: case report and review of the literature. Urology1996;48(3):481—9.

11] de Baere T, Ousehal A, Kuoch V, Sapoval M, LagrangeC, Roche A. Endovascular management of bleeding iliacartery pseudoaneurysms complicating radiation therapy forpelvic malignancies. AJR Am J Roentgenol 1998;170(2):349—53.

12] Jacobs BL, Maranchie JK. Embolization with Tornado coils tocontrol bleeding from an arterio-ureteral fistula. Can J Urol2007;14(6):3770—2.

13] Stampfl U, Sommer CM, Bellemann N, Weitz J, Böckler D,Richter GM, et al. The use of balloon-expandable stent graftsfor the management of acute arterial bleeding. J Vasc IntervRadiol 2012;23(3):331—7.

14] Bergamini TM, Bandyk DF, Govostis D, Kaebnick HW, Towne JB.Infection of vascular prostheses caused by bacterial biofilms. JVasc Surg 1988;7(1):21—30.

15] Heye S, Nevelsteen A, Maleux G. Internal iliac artery coilembolization in the prevention of potential type 2 endoleakafter endovascular repair of abdominal aortoiliac and iliacartery aneurysms: effect of total occlusion versus residual flow.J Vasc Interv Radiol 2005;16(2 Pt 1):235—9.

16] Pellerin O, Caruba T, Kandounakis Y, Novelli L, Pineau J,Prognon P, et al. Embolization of the internal iliac artery: cost-effectiveness of two different techniques. Cardiovasc Intervent

Radiol 2008;31(6):1088—93.

17] Krambeck AE, DiMarco DS, Gettman MT, Segura JW. Uretero-iliac artery fistula: diagnosis and treatment algorithm. Urology2005;66(5):990—4.