Angiographic evaluation and therapy of ureteroarterial fistulas

OBJECTIVE. Fistulas between the iliac artery and the ureter are extremely uncommon, life-threatening conditions usually seen in patients who have had pelvic irradiation or have indwelling ureteral stents. We describe our experience in the angiographic evaluation and therapy of these fistulas. MATERIALS AND METHODS. We retrospectively reviewed medical records for diagnoses of ureteroarterial fistulas. Patients' records were evaluated for potentially associated etiologic factors, clinical features and course, radiographic evaluation and findings, and therapy. RESULTS. Our review showed that four patients treated at our institution (all since 1990) had ureteroarterial fistulas. All four patients had indwelling ureteral stents and had had irradiation for pelvic cancer. Three had spontaneous brisk hemorrhage in the urinary tract. The fourth had hemorrhage after balloon dilatation of a ureteral stricture. Initial diagnosis was based on findings on iliac arteriography in three patients and on findings on retrograde ureterography in one. Angiographic techniques required to visualize the fistulas included selective arterial catheterization, use of multiple projections, and provocative maneuvers. Treatment of the ureteroarterial fistulas involved surgery in one case, isolated embolotherapy in one case, and a combination of embolotherapy and surgery in two cases. CONCLUSION. Specific angiographic maneuvers are often required to identify ureteroarterial fistulas. Transcatheter embolotherapy (with or without surgical bypass) is an effective form of treatment for this rare abnormality.