Division of Interventional Radiology, University Health Network, Toronto General Hospital, Toronto, ON, Canada.
Diagnostic and Interventional Radiology Resident, Joint Department of Medical Imaging, University of Toronto, 1 Dunsmore Gdns., Toronto, ON, M3H 3M1, Canada.
BMC Urol. 2022 Jan 31;22(1):11. doi: 10.1186/s12894-022-00961-5.
Uretero-arterial fistulas (UAFs) are uncommon and pose a diagnostic dilemma, making them life threatening if not recognized and treated expediently. UAFs to small arteries such as a branch of the inferior mesenteric artery (IMA) are very uncommon and present a further diagnostic and treatment challenge. There should be a high index of suspicion for UAFs when intervening on patients with history of treated pelvic cancers and long-standing ureteric stents experiencing hematuria not attributable to another cause.
We present a case of a fistula formed between a distal branch of the IMA-superior rectal artery-and an ileal-conduit in a patient with a long-standing reverse nephroureterostomy (Hobbs) catheter presenting with abdominal pain and hematuria through the conduit. During a tube exchange, contrast injection demonstrated a fistula with the superior rectal artery, multiple ileal intraluminal blood clots, and active extravasation. The patient became tachycardic and hypotensive, actively bleeding through the ileal-conduit, prompting a massive transfusion protocol. Successful endovascular coiling of the superior rectal artery was performed with resolution of active extravasation and stabilization of the patient. The patient recovered and was discharged in stable condition 10 days later.
Although UAFs are uncommon, our case demonstrated key predisposing risk factors to fistula development; pelvic cancer surgery, pelvic radiation, and a prolonged ureteric stent through the ileal-conduit. Typically, UAFs arise from communication with the iliac arterial system, however in this instance we have demonstrated that fistulization to other arterial vessels is also possible. Endovascular management has become the preferred method of therapy, typically involving the placement of covered stents when involving the iliac arterial system. In this instance stent grafting was not possible due to the small caliber vessel and therefore had to be embolized.
输尿管-动脉瘘（UAFs）并不常见，构成诊断难题，如果不能及时识别和治疗，可能危及生命。输尿管与较小动脉（如肠系膜下动脉[IMA]的分支）之间形成瘘管非常罕见，进一步增加了诊断和治疗的难度。对于有盆腔癌症治疗史和长期留置输尿管支架的患者，出现血尿且无其他原因时，应高度怀疑 UAFs。
我们报告了一例患者的病例，该患者在长期逆行肾盂输尿管再吻合术（Hobbs）导管存在的情况下，IMA-直肠上动脉远端分支与回肠导管之间形成瘘管，表现为腹痛和通过导管出现血尿。在导管更换过程中，造影剂注射显示瘘管与直肠上动脉相通，回肠腔内有多个血栓，且有明显的外渗。患者出现心动过速和低血压，通过回肠导管大量出血，遂启动大量输血方案。成功地对直肠上动脉进行了血管内线圈栓塞，活动性外渗得到解决，患者情况稳定。10 天后，患者康复出院，情况稳定。
尽管 UAFs 并不常见，但我们的病例显示了瘘管形成的关键易患因素，包括盆腔癌症手术、盆腔放疗和通过回肠导管长期留置输尿管支架。通常，UAFs 是由与髂动脉系统的沟通引起的，但在本例中，我们证明瘘管化也可能发生在其他动脉血管。血管内治疗已成为首选的治疗方法，当涉及髂动脉系统时，通常涉及放置覆膜支架。在本例中，由于血管口径较小，无法放置支架移植物，因此必须进行栓塞。
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