Ureteroarterial fistulaRaghu L. Motaganahalli, MD, FRCS, FACS,a Alok Gupta, MD,a Virgillio George, MD,b and

Stephen Beck, MD,c Indianapolis, Ind

The patient was a 54-year-old man with an aortobifemoral bypass (AFB) for occlusivedisease done in 2007. Three years later, he had an excision of the infected AFB graft within situ reconstruction using a cryopreserved vein as well as ureteral stent placement. Hewas lost for follow-up for 4 months when he presented at an outside hospital withmassive hematuria. A urologist at the outside facility noted hematuria from the left ureterorifice. Additional bleeding was encountered during attempted removal of stent. Thepatient was transferred to our facility with an inflated balloon for tamponade in the leftureter.

A 12F sheath was placed into the left limb of the cryopreserved AFB graft via a leftfemoral artery exposure. Angiographic evaluation with the deflated ureteric balloonconfirmed ureteroarterial fistula (A). An iliac extension stent graft of 16 � 9.5 cm wasdeployed across the fistula (B) with a revision of the ureteric stent. During this admission,he also had an incidental diagnosis of rectal cancer. He was planned for an abdomino-perineal resection. He continued to have recurrent urinary tract infections (UTIs)despite being on antibiotics. An indium-labeled white cell scan suggested no stent graftinfection. Due to persistent UTIs, the iliac stent graft was explanted at the time ofabdominoperineal resection. The patient had intense inflammation around the ureterand bypass graft (C). The fistula was disconnected (D) and the primary ureteralreconstruction was performed over a stent. Vascular reconstruction was performed withan interposition cryopreserved artery. An omental pedicle was placed between the ureterand left limb of the bypass graft.

Ureteroarterial fistula is a rare life-threatening complication that may result withdegeneration of the ureteral wall due to disruption of the arterial supply by radiation,pelvic surgery, vascular surgical procedures, and pressure necrosis by prolonged ureteralstent placement.1 Symptoms include intermittent to life-threatening hematuria. Treat-ment includes excision of the involved arterial segment with extra-anatomic bypass orprimary repair. Stent grafts are increasingly used to control life-threatening hematuriafollowed by delayed open surgical revision to reduce the risk for recurrent UTIs,bleeding, and stent graft complications.2

REFERENCES

1. Batter SJ, McGovern FJ, Cambria RP. Ureteroarterial fistula: case report and review of the literature. Urology1996;48:481-9.

2. Fox JA, Krambeck A, McPhail EF, Lightner D. Ureteroarterial fistula treatment with open versus endovascularmanagement: long-term outcomes. J Urol 2011;185:945-50.

Submitted Dec 13, 2011; accepted Dec 18, 2011.

From the Section of Vascular Surgery,a Section of General Surgery,b and Section of Urology,c Indiana UniversitySchool of Medicine.

Author conflict of interest: none.E-mail: rmotagan@iupui.edu.The editors and reviewers of this article have no relevant financial relationships to disclose per the JVS policy that

requires reviewers to decline review of any manuscript for which they may have a conflict of interest.J Vasc Surg 2013;57:8490741-5214/$36.00Published by Elsevier Inc. on behalf of the Society for Vascular Surgery.doi:10.1016/j.jvs.2011.12.050

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