A case of iliac-artery-ureteral fistula managed with a combined endoscopic approach

The iliac-artery–ureteral fistula is a rare, but potentially lethal entity. In this Case Study by Gallo et al. the case of a 66-year-old man who presented with hematuria is used to illustrate the successful diagnosis and management of this condition using only endoscopic techniques. Background A 66-year-old man presented to hospital with gross hematuria and clots. He had previously undergone surgical repair of a right iliac artery aneurysm with placement of a vascular prosthesis at the same hospital, which had resulted in iliac urethral stricture that required the placement of a right ureteral stent. He had attended repeatedly for recurrent ureteral stent replacement, with the most recent replacement having occurred 1 month before the current presentation. Investigations Ultrasonography, cystography, retrograde pyelography and provocative arteriography via a percutaneous right femoral arterial approach. Diagnosis An iliac-artery–ureteral fistula between the right ureter and a pseudoaneurysm of the right common iliac artery. Management The patient underwent placement of a covered, self-expandable vascular stent with angioplasty balloon, which resulted in complete exclusion of the pseudoaneurysm and fistula and resolution of the patient's hematuria. A pigtail catheter was placed in the right ureter for 5 days and replaced with a double-J ureteral stent on day 6 after exclusion of the pseudoaneurysm; the patient was discharged from hospital on the same day. Color-Doppler ultrasonography of the right iliac vessels performed 2 months later showed patency of the right iliac artery. The patient's ureteral stent has been replaced every 2 months since his discharge without recurrence of hematuria.