Right common iliac artery pseudoaneurysm–ureteric fistula

Authors


CASE REPORT

An 83-year-old man presented for evaluation of recurrent episodes of gross painless haematuria and urosepsis. His medical history was significant for retroperitoneal fibrosis and an abdominal aortic aneurysm. He had the aneurysm repaired with a polyethylene terephthalate tube graft followed by ureterolysis with periodic ureteric stent changes. At a later ureteric stent removal, he developed massive haematuria necessitating an exploratory laparotomy and repair of a right ureter-common iliac artery fistula with a PTFE patch. After several admissions for urosepsis, he presented with a right-sided percutaneous nephrostomy tube. His physical examination showed no abnormalities; his serum creatinine level was 26 mg/L (baseline 22) and urine analysis was consistent with infection. An antegrade nephrostogram showed right hydronephrosis with a distal ureteric stricture communicating with an irregular ovoid structure, with no drainage into the bladder (Fig. 1). Unenhanced CT showed an atrophic left kidney and a 6.5 × 4 cm right-sided pelvic mass (Fig. 2). Abdominal ultrasonography identified the mass as a common iliac artery pseudoaneurysm. The patient received intravenous antibiotics and underwent an emergency left axillobifemoral bypass, excision of the pseudoaneurysm and infected graft, and closure of the arterio-ureteric fistula. His postoperative course was uneventful.

Figure 1.

An antegrade nephrostogram showing the right common iliac artery pseudoaneurysm-ureteric fistula.

Figure 2.

Unenhanced CT showing a large inflammatory right sided pelvic mass.

COMMENT

Arterio-ureteric fistulae are a rare but life-threatening source of gross haematuria in patients with a history of previous genitourinary surgery, prolonged ureteric stenting, vascular surgery, or irradiation [1]. Open vascular repair was indicated in the present patient because of an infected graft, but techniques including angiographic embolization with vascular bypass and endovascular stenting with autologous vein-covered grafts are becoming more common [2].

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