Fistules urétéro-artérielles : six nouveaux cas et revue systématique de la littérature

06 septembre 2021

Auteurs : C. Ghouti, G. Leon, S. Seddik, K. Ait Said, L. Vaudreuil., X. Tillou
Référence : Prog Urol, 2021, 10, 31, 605-617




 




Introduction


With a mortality rate ranging from 7% to 23% [1, 2, 3], uretero-arterial fistula (UAF) is a rare but life-threatening disease that causes massive hematuria. Prevalence is unknown and probably underestimated. This uncommon condition requires a multidisciplinary team of urologists, vascular surgeons and interventional radiologists in order to be properly diagnosed and to offer the most efficient care. UAF is an abnormal communication between arterial vessels and the ureter, with the most common location being at the crossing of the ureter with the common iliac artery. There are two types of fistulas: primary and secondary fistulas. Risk factors responsible for secondary causes have been described in the literature.


The pathophysiology is uncertain; however, the fistulisation could be explained by damage to the vasa-vasorum. The repeated transmission of arterial pulsations through a rigid material, such as an ureteral stent, on an already pathological ureter, could cause irreversible lesions. In addition, surgery and radiation therapy could be responsible for inflammatory and devascularisation damage to the ureter. For radiation therapy, there is a strong link between the irradiation dose delivered and the damage caused to the arterial wall [4]. This may lead to a fibrosis reaction followed by necrosis of the ureter and the arterial wall at the point of contact.


The purpose of this work was to report and analyse six cases managed in our hospital, which were compared to the results of an exhaustive literature review of UAF. We also describe risk factors, diagnosis, treatment and the urologist's point of view for UAF management.


Method


Case series


We retrospectively studied a six patients cohort with secondary uretero-arterial fistulas (SUAF) by collecting data prospectively in our centre from 2010 to February 2020. These patients were treated by urologist and vascular surgeons. We excluded post-traumatic fistulas, aortic fistulas related to aortic aneurysm, secondary fistulas after vascular surgery whatever the time lapse. Demographic data were collected regarding gender, age, prior pathology, treatment of the prior pathology, cardiovascular risk factors. Additional data, such as clinical presentation, diagnosis modality, fistula site, fistula management and follow-up, were also collected.


Literature review, inclusion and exclusion criterion


A review of the literature from 2000 to 2020 was performed. Pubmed and Medline were used to conduct online searches of all case reports and case series of UAF. The keywords were: "uretero arterial fistula", "uretero iliac fistula", "arterio-ureteral fistula", "ilio ureteral" and "fistula". The search was then filtered to include only articles regarding the secondary fistula from the iliac vessels by using the PICO worksheet and search strategy protocol:

patient/problem: Secondary uretero-arterial fistulas whatever age and gender of patients;
intervention: Emergency surgical procedure, open or endovascular;
comparison: None;
outcome: Survival after a life-threatening pathology.


Various types of uretero-arterial fistula were described in these studies. However, only secondary fistula from the iliac vessels were included. We excluded studies with fistulas diagnosed post-mortem, post-traumatic fistulas, aortic fistulas, secondary fistulas after vascular surgery, and any study not written in English or French. The review is presented in the Prisma flow chart (Figure 1). The first author designed the search strategy and found all relevant documents from the targeted database. In order to minimise the selection bias, two other authors selected articles independently by scanning titles and abstracts. Disagreements and differences were solved by the last author. The full texts of related articles were studied carefully in order to make included or excluded grouping. Risks of bias are summarised in Figure 2 according to Prisma recommendations. Data were collected on Excel 2007 (Microsoft®). Medians were reported with 25th-75th percentile.


Figure 1
Figure 1. 

PRISMA flow chart.




Figure 2
Figure 2. 

Risk of bias summary.





Results


Case series


A total of six patients with 8 SUAF were treated in our centre. There were 4 males and 2 females. The median age at the time of diagnosis was 77 (71-81) years old. All patients had a history of pelvic cancer: 3 bladder cancers, 1 cervix cancer, 1 colorectal cancer and 1 prostate cancer. The most described risk factors included extensive abdominal or pelvic surgery (3 cystectomies with ileal conduit urinary diversion or ureterocutaneostomy, one hysterectomy, one rectal anterior resection, one abdominal pelvic amputation), chronic in-dwelling ureteral stents (6 patients), and pelvic irradiation (3 patients). The median time between the prior oncological treatment or ureteral stenting and the first symptoms was 42 (12-48) months. Regarding clinical signs, gross haematuria was present in all patients and was always the first symptom. Almost all patients experienced significant haematuria following a ureteral stent exchange (4 of six patients). Inaugural hematuria was followed by deglobulisation with blood transfusion in 3 patients, hydronephrosis in 3 patients, flank and back pain in one patient and sepsis in one patient. None of the patients experienced hypovolemic shock.


The diagnosis was based on injected CT scan followed by an arteriography, which confirmed the fistula in two out of six cases (Figure 3).


Figure 3
Figure 3. 

Left uretero-iliac fistula. A. Angiography before treatment. B. After angioplasty by left common iliac stent graft.




Regarding imaging findings, 2 cases of UAF were identified on 5 repeated CT scans. Also, 5 patients underwent an arteriography, confirming 2 other cases of fistulas. Bleeding from the ureteral orifice occurred in one patient who underwent a cystoscopy. In all patients, fistulas were located at the cross between the left ureter and the left common iliac artery.


For vascular management, stent graft placement was performed in 5 cases, and a surgical approach was performed in one case (suturing of the arterial defect) with surgical modification of urinary derivation into a bilateral ureterocutaneostomy. Ureteral management consisted of a ureteral stenting replacement in 5 cases. After the procedure, haematuria disappeared in all cases. The median follow-up was 22 months, except for 2 patients who died following a immediate recurrence of homolateral fistula. One more patient died and presented thrombosis and infection of the arterial stenting site 72 months after treatment.


Review of the literature


Of the 325 articles found in the database, 142 were excluded due to overlap between articles (Figure 1). Of the remaining 183 articles, 99 were excluded based on the title or after reading the abstract. An additional 28 studies were excluded after applying the inclusion criteria. Finally, 57 studies were included in the present study. Synthesised patients' characteristics are reported in Table 1. A total of 97 patients were included in the review. Forty-one publications (71.9%) were single-case series. The biggest study reported 11 patients' cases over an unknown time lapse. All studies are presented in Table 2, Table 3.


Discussion


Similarities


Results analysis allowed us to highlight many similarities between our cohort and cases found in the literature review. The three main risk factors reported in the literature [5, 6, 7, 8] for uretero arterial fistula were a history of pelvic surgery, as seen in 73 cases (75.26%), radiation therapy, as seen in 68 cases (70.10%), and chronic ureteral catheterisation found in 83 cases (85.57%). The number of patients with a history of vascular surgery was not significant [6, 9, 10, 11]. In the largest literature review published in 2009, Van Der Bergh reviewed 139 cases mixing UAF occurring after or without previous vascular surgery. Moreover, authors did not describe the median time lapse between the surgery and the onset of the first symptoms of UAF [3, 12]. It seems from few studies that the median time lapse was 2 years in the case of a previous cancer and 5 years or more in the case of a chronic ureteral stenting [6, 13]. The median time lapse calculated in our review of 97 cases was 57 months confirming this result.


On a clinical level, cataclysmic gross haematuria was the revelatory sign in 97.9% of cases. Okada et al. in 2013 indicated that gross haematuria was the most represented clinical indicator of the condition and was present in 100% of the cases. In 55% of cases, intermittent haematuria was also reported [13]. Episodes of chronic microscopic haematuria have also been described [5]. Flank pain caused by clotting in the upper tract urinary is also possible (13.40%). Regarding diagnostic management, an abdominal and pelvic angiogram was performed in over half the cases (56.70%), but failed to indicate the existence of a fistula in 69% of those cases. The CT-angiogram remained an exam with limited sensitivity and with poor contribution to the positive diagnosis of uretero-arterial fistula; however, it is feasible so long as the patient is stable. Bleeding and the extravasation of contrast agent allowing to confirm the diagnosis were not common [5, 6, 14, 15]. In the best of cases, it allowed visualisation of a narrow contact between the ureter and iliac artery or highlighted a pseudoaneurysm [16, 17]. Whether or not it is done by cystoscopy, the removal of the ureteral stent caused a gross hematuria with a pulsating jet in more than 50% of cases (16.6% in our series).


From a therapeutic level, endovascular treatments were the most common with 87.63% of patients having UAF covered by graft stent. Similarly, 83.33% of patients in our series received this treatment. Only 8.25% of patients were treated with a vascular bypass. Before technological improvement, standard management remains open surgery, but it is more invasive and access is often more difficult after pelvic surgery and radiation therapy. There is the added risk of the patient's comorbidities [18], such as atheroma, diabetes, hypertension, and anticoagulant treatment.


In fact, since the first use of endovascular stent by Gibbons in 1998 [19], there has been an upsurge in the use of endovascular surgery in the management of UAF cases [10, 20, 21, 22, 23].


Firstly, this approach presents multiple advantages. Encouraging results were shown in a 2018 literature review by Subiela et al. [24], which included the management of 94 patients diagnosed with fistulas and having endovascular treatment. Only four of the cases presented early complications in the 30 days following the intervention (thrombosis, infection, bleeding, fistula) and 17% of patients experienced complications during long-term monitoring. Malgor et al. [25] also demonstrated that therapeutic management of fistulas by endovascular stents was more efficient. Out of 20 patients, 55% were treated by endovascular technics versus open surgery. Only 27% of them presented complications in comparison to 63% for the patients treated by surgery [12, 25]. In the cohort by Leone et al., no complications were detected during the 31 months of follow-up after endovascular treatment [26]. The mortality rate for endovascular treatment was null [5]. This technique remains interesting because arterial flux can be maintained during the procedure and it avoids the mobilisation and resection of the ureter [10, 27]. The common iliac artery was more often the site of fistulas than the external or internal iliac artery.


Highlights of the literature review analysis


Of the 97 patients included in this review, almost half of the patients were impacted by a gynecological cancer. In fact, they involved significant pelvic surgeries responsible for a number of anatomic modifications.


None of the patients in our cohort received retrograde contrast of the upper urinary tract. Conversely, we observed that in the population of our review, only 19.50% of cases experienced a retrograde contrast. In 78.9% of cases, this led to the diagnosis of fistula. Therefore, it seems that ureteral retrograde contrast (URC) was an ally to diagnose UAF. As emphasised in the literature, the sensitivity of the URC for a positive diagnosis is between 30% and 60% depending on the study [3, 14, 16, 19, 28, 29]. Another diagnostic tool that has proven to be relevant over the past few years was percutaneus arteriography. The sensitivity of this exam ranged from 25% to 69% [3, 14, 16, 21, 30, 31]. In our review, the arteriography was performed in 73.20% of cases with a fistula detection rate of 63%, which concurs with the literature. According to some studies, the sensitivity could increase to 100% with provocative maneuvers (provocative angiogram) (back and forth movement of the ureteral stent along a guide in the ureter associated to a selective arteriography) [9, 13, 32, 33, 34, 35]. In 5 of the 97 cases, a provocative arteriography was performed in patients for whom a standard arteriography did not reveal any fistulas. In 100% of those cases, a fistula was discovered. In fact, the ureteral stent has a cushion effect on the ureteral wall, and therefore also on the arterial wall and diminishes the flow to the fistula. An arterial flux greater than 3mL/sec is necessary to view the extravasation of the contract agent from the artery towards the ureter with an arteriography [3]. In the case of a negative URC, there is a significant advantage to perform endo-ureteral maneuvers even though they are accompanied by a risk of additional bleeding. Nonetheless, a negative exam did not exclude the diagnosis of fistula and in this case, a covered arterial stent is placed at the contact of the ureteral stent.


There have been many therapeutic propositions; a therapeutic management diagram was proposed by Krambeck et al., which was later revised in 2011 by Fox et al. [15, 36]. Although the preferred vascular treatment of fistulas seems to be a mini invasive method. Fox et al. proposed an open surgery approach (repairing of the artery, ligature of the artery/embolisation and extra anatomical bypass) depending on the hemodynamic state of the patient and of the feasibility of the procedure (patients prone to surgery). The choice of urological treatment of the fistula still remains uncertain. Currently, the proposed treatments for fistulas are a nephrectomy or a total nephro-ureterectomy by open surgery, an anastomosis resection of the ureter, an ileal tube of the ureter, or ureteral stenting using double-J stent or proximal draining by nephrostomy. In our review, 6.17% of the population was treated by nephrectomy, 26.8% by nephrostomy and 25.77% by placing or changing an ureteral stent [37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50]. None of our 6 patients underwent a nephrectomy. None of the studies compared the different techniques/approaches for preservation of renal function; therefore, no reliable strategy was proven. Nonetheless, on an anatomical level, a renal surgery could be complex because of the handling of tissues. The patients, who received ureteral stent, were exposed to the risk of recurrent bleeding. To mitigate this risk in patients still requiring a long-term stenting, small calibre (CH6) flexible probes can be used. Considering the risk of recurrent fistulas in at-risk persons, prevention must be one of the urologist's concerns. Screening for pathological aneurysms before any ureteral surgery and avoiding long-term ureteral stenting should be considered. If the latter is required, the recommendations are to use a small calibre stent, ensure frequent changing of the stent and when it is necessary to have a urinary deviation, favour an ileal conduit urinary diversion or a high-level ureterocutaneostomy or perform an epiplopasty between the artery and the ureter.


The limitations of our study are that the data were retrospectively collected and from only a small number of patients. The literature review remains a case report review with much data missing, which may bias the results.


Conclusion


Uretero-arterial fistulas are rare, but life-threatening pathologies, especially when they are undetected. The urologist is at the forefront. Urologists must suspect this diagnosis when significant gross hematuria is present and the patient presents risk factors of fistula. To date, there are no strong recommendations for the management of UAF that would allow a standardised treatment of patients. A diagram of diagnostic and treatment management has been proposed in the literature. In fact, the mortality rate was reported as zero in patients where the diagnosis was made before the treatment was initiated. Only 22% of patients are properly diagnosed before starting their treatment. At this time, there are no strong recommendations on the management of UAF, which would allow a standardised management of patients. Mini-invasive surgery by use of endovascular stents is a procedure that is quick, reliable and efficient, particularly with patients presenting numerous surgical comorbidities. It is feasible with all stable patients. On the urological level, there is unfortunately no therapeutic standard. Treatment choice is led by clinical state of the patient, comorbidities and life expectancy.


Disclosure of interest


The authors declare that they have no competing interest.




Table 1 - Our series compared to literature synthesis.
  Our series
(n =6) 
Literature
(n =97) 
Gender  F= F=68 
  M= M=29 
Median age (25th-75th percentile)  77 (71-81)  63 (55-72) 
Prior pathology     
Gyn C.  1 (16.6%)  49 (50.5%) 
Rectal C.  1 (16.6%)  27 (27.8%) 
Bladder C.  3 (50%)  8 (8.2%) 
Others  0 (16.6%)  11 (11.3%) 
Risk factors     
Surgery  6 (100%)  73 (75.2%) 
RT  3 (50%)  68 (70.1%) 
CUS  6 (100%)  83 (83.5%) 
Urinary diversion     
Transileal  13 (13.4%) 
Unilateral ureterostomy  4 (66.6%)  2 (2%) 
Median time between risk factor and diagnosis of fistula (months - 25th-75th percentile)  42 (12-48)  57 (24-108) 
Clinical diagnosis     
Hematuria  6 (100%)  95 (97.9%) 
Hypovolemuc shock  15 (15.4%) 
Flanck pain  1 (16.6%)  13 (13.4%) 
Radiological diagnosis     
CT scan  5 (83.3%)  55 (56.7%) 
Angiography  5 (83.3%)  71 (73.2%) 
Ureteral retrograde  19 (19.6%) 
Arterial abnormality     
PA  1 (16.6%)  14 (14.4%) 
Fistula  2 (33.3%)  45 (46.4%) 
Ureter side     
Left  6 (100%)  33 (34%) 
Right  51 (52.5%) 
Artery     
CIA  6 (100%)  46 (47.5%) 
EIA  35 (36.1%) 
IIA  10 (10.3%) 
Vascular treatment     
Stent graft  5 (83.3%)  85 (87.6%) 
Open surgery  1 (16.6%)  13 (13.4%) 
Embolisation  30 (30.9%) 
Urologic treatment     
Ureteral stent  5 (83.3%)  25 (25.7%) 
NST  26 (26.8%) 
Nephrectomy  6 (6.2%) 
Specific mortality  3 (50%)  5 (5.2%) 



Légende :
C: cancer; S=surgery; RT=radiotherapy; CUS=chronic ureteral stenting; PA=pseudo-aneurism; F=fistula; RO=retrograde opacification; NS=non specified; CIA: common iliac artery; EIA: external iliac artery; IIA: internal iliac artery.



Table 2 - Review of literature: Patients characteristics.
Authors  Year  M/F  Age  Prior pathology  Prior treatment  Risk factors 
Dalmas  2001  49  Cervix C.  RT, hyst  U stent, RT 
Dauvergne  2001  86  Rectal C.  Surgery  U stent 
Depasquale  2001  38  Cervix C.  Surgery, RT  RT 
Kato  2002  49  Colorectal C.  Surgery, Bricker  U stent 
Madoff  2002  57  Pelvis C.  Surgery, RT  U stent, RT 
Matsui  2002  71  Cervix C.  Hyst, RT  U stent, RT 
Rodriguez  2002  64  Cervix C.  Surgery, RT  U stent, RT 
Sherif  2002  67  Rectal C.  Rectal amputation  RT, NST, U stent 
Ferrante  2004  60  Aortobifemoral prothesis  Surgery  U stent 
    40  Ovarian C.  RT, CT, Surgery,  U stent, RT 
Hildebrand  2004  80  Aneurism  Aorto-bifemoral prothesis  NS 
Uzieblo  2004  55  Liposarcoma  RT, resection  U stent 
Bilbao  2005  F
F
M
55
54
74
74 
Cervix C.
Vaginal C.
Bladder C.
Cervix C. 
Surgery, RT
RT, surgery
Surgery
RT, surgery 
U stent, RT
U stent, RT
U stent
RT, U stent 
Kobayashi  2005  54  Cervix C.  RT, CT, surgery, NST  RT 
Amahzoune  2005  65  Rectal C.  Surgery, RT  RT, U stent 
Fu  2006  58  Cervix cancer  Hyst, RT  RT, U stent, PA REIA 
Lefebvre  2006  46  Anal C.  Amputation, RT  U stent, RT 
Muraoka  2006  78  Bladder C.  Cystectomy  U stent 
    60  Lymphoma  Surgery  U stent 
Tuite  2006  70  Colorectal C.  Surgery, CT, RT, NST  RT, U stent 
Escobar  2007  71  Cervix C.  RT, CT, cystectomy  RT, U stent 
Eisner  2007  62  Colorectal C.  Surgery, RT  U stent, RT 
Aarvold  2008  58  Cervix C.  Hyst, bricker, RT, stent REIA  RT, U stent 
Araki  2008  70  Bladder C.  Cystectomy, ureterostomy  U stent 
    70  Rectal C.  RT, rectal resection  U stent, RT 
Gallo  2008  66  RIA aneuvrism  Prosthesis  U stent 
Pappy  2008  87  Endometrial C  Hysterectomy, RT  RT, U stent 
Monchal  2008  84  NS  Right bypass iliofemoral  NS 
Kim  2009  68  Rectal C.  Rectal resection  U stent, RT 
Mitterberger  2009  64  Rectal C.  Surgery  RT, U stent 
Yamasaki  2009  72  Rectal C.  Surgery, RT  U stent, RT 
Aslam  2010  54  Cervix C.  Surgery, RT  RT, U stent 
Santarpia  2010  29  Rectal cancer  Total colectomy, CT, RT  RT, U stent 
Veenstra  2011  80  Colorectal C.  CT, colectomy, RT  RT, U stent 
McCullough  2012  42  Cervix C.  Hyst, CT, RT  U stent, RT 
Tselikas  2012  56  Cervix C.  RT  RT, U stent 
    59  Rectal cancer  Rectal resection & neobladder  RT, U stent 
    72  Rectal C. BPH  RT, TURP  RT, U stent 
Yuki  2012  74  Cervix carcinoma  Surgery, RT, CT  RT, U stent 
Atmaca  2013  54  Bladder C.  Cystectomy  NS 
Brizuela  2013  67  Ureteral stenosis  Prothesis  U stent 
Dormeus  2013  61  Rectal C.  Rectal resection  U stent, RT 
Okada  2013  76  Cervix C.  Hysterectomy  RT, U stent 
    86  Retroperitoneal fibrosis  NS  U stent 
    88  Cervix C.  Hysterectomy  RT, U stent 
    59  Cervix C.  NS  U stent 
    82  Bladder C.  Cystectomy, ureterostomy  U stent 
    70  Bladder C.  Cystectomy, ureterostomy  U stent 
    71  Rectal C.  Rectal resection  U stent 
    62  Retroperitoneal liposarcoma  Incomplete resection  RT, U stent 
    72  Rectal cancer  Pelvic exenteration  U stent 
    52  Cervix C.  Hysterectomy  RT, U stent 
Muradi  2014  76  Cervix C.  Hyst, CT  U stent 
Patel  2014  F
44
71 
Cervix C.
Cervix C. 
Hyst, RT, CT
Surgery, CT 
RT
RT, U stent 
Copelan  2014  70  Endomet C.  Surgery, RT  U Stent, RT 
Siorek  2015  64  Cervix C.  Pelvic exenteration, RT, CT, bricker  RT, U stent 
Rittenberg  2016  62  Cervix C.  RT, surgery  U stent, RT 
Coelho  2016  66  Aortic aneurism  By pass  Surgery 
Liang  2016  37  Cervix C.  RT, CT, RCIA stent  RT, U stent, surgery for vesico/rectovaginal fistula 
Melegari  2016  50  Endometrial cancer  Hyst, CT, RT  RT, U stent 
Nduwayo  2016  76  Abdominal aneurism  Prothesis  Vascular disease 
Sarwal  2016  66  Cervix carcinoma  RT, CT  RT, U stent 
Guntau  2017  67  Rectal cancer  NS  RT, U stent 
    75  Rectal cancer  NS  RT, U stent 
    75  Rectal cancer  NS  RT, U stent 
    35  Endomet C.  NS  NS 
    66  Cervix C.  NS  RT, U stent 
    66  Cervix C.  NS  RT 
    58  Vaginal C.  NS  U stent 
    77  Rectal C.  NS  RT, U stent 
    68  Rectal C.  NS  RT, U stent 
    62  Bladder C.  NS  U stent 
    61  Endometrial cancer  NS  U stent 
Hernandez  2017  74  Bladder C.  Cystectomy  U stent 
    61  Rectal C., RT  Abdominoperineal resection  U stent, RT 
    54  Ovarian C., CT  Surgery  U stent 
Yang  2017  51  Cervix C.  Surgery, RT, CT  RT, U stent 
Mahlknecht  2018  86  Endomet C.  Hyst, RT  RT, U stent, 
Titomihelakis  2019  70  Cervix C.  Hyst, RT  U stent, RT 
    77  Endomet C.  Hyst, RT  U stent, RT 
    58  Cervix C.  RT  U stent, RT 
    F
58
56 
Rectal C.
Rectal C. 
Surgery, RT, CT
Surgery, RT, CT 
U stent, RT
U stent, RT 
Gao  2019  43  Cervix C.  RT, surgery  U stent, RT 
Leone  2019  66  Cervix carcinoma  Surgery, RT  U stent 
    57  Cervix carcinoma  Surgery, RT  U stent 
    73  Cervix carcinoma  Surgery, RT  U stent 
Massman  2020  66  Cervix carcinoma  Hysterectomy, RT, CT  U stent, RT 
    41  Cervix carcinoma  Hysterectomy, RT, CT  U stent, RT 
    55  Cervix carcinoma  Hysterectomy, RT, CT  U stent, RT 
    67  Rectal cancer  Rectal resection, RT, CT  U stent, RT 
    44  Cervix carcinoma  Hysterectomy, RT, CT  U stent, RT 



Légende :
F: female; M: male; C.: carcinoma; Hyst: hysterectomy; Endomet: endometrium; Hydro: hydronephrosis; NS: nephrostomy; U stent: ureteral stent; CT: chemotherapy; BPH: benign prostate hyperplasia; TURP: trans-urethral resection of prostate.



Table 3 - Review of literature: Diagnosis, treatments and outcomes.
Authors  Symptoms  Diagnosis  Fistula site  Treatment  Follow up 
Dalmas  Ht, hydro  Angiography  REIA-RU  SG+bypass  6 months 
Dauvergne  Ht, infection, deglo  Provocative angiography  LEIA-LU  SG  3 months 
Depasquale  Ht, deglo  Angiography  REIA-LU  Open surgery  Death 
Kato  Ht, deglo  Angiography  LCIA-LU  SG  12 months 
Madoff  Ht on stent removal  Angiography  LCIA- LU  SG, NST  12 months 
Matsui  Ht  Pyelography  IIA- LU  U stent, embolisation, NST  Death after 2 months 
Rodriguez  Ht on stent removal  Angiography  REIA-RU  SG  12 months 
Sherif  Ht, Hydro, Shock  Angiography  LCIA-LU  SG, NST  5 months 
Ferrante  Ht, infection, pain  Angiography  Prothesis-LU  Bypass  15 days 
  Ht, infection, hydro  RP  RCIA-RU  Open surgery bypass, NST  NS 
Hildebrand  Ht, hydro  PA on CT scan  RCIA-RU  Bypass, U stent  3 months 
Uzieblo  NS  Angiography  REIA-RU  SG  2 months 
Bilbao  Ht, hydro
Ht, hydro
Ht, hydro
Ht, hydro 
Angiography
Angiography
Angiography
Angiography 
NS
NS
NS
NS 
SG
SG, NST
SG, NST
SG, NST 
5 months
9 months
11 months
25 months 
Kobayashi  Ht, hypotension  PA on angiography  LCIA-LU  SG, NST  NS 
Amahzoune  Ht  NS  LIIA-LU  Open surgery, NST  Death 
Fu  Ht  PA on CT scan  REIA-RU  SG, NST  6 months 
Lefebvre  Ht on stent removal  Angiography  LCIA-LU  Open surgery  Death 
Muraoka  Ht  CT scan  LCIA-LU  SG  6 months 
  Ht, Shock  PA on CT scan - angiography  REIA-RU  SG  75 months 
Tuite  Ht  RP  LEIA-LU  SG, NST  15 months 
Escobar  Ht, deglo  Angiography  NS  NS  NS 
Eisner  Ht  Angiography  LCIA-LU  SG, embolisation, NST  NS 
Aarvold  Ht  Angiography  REIA-RU  SG  6 months 
Araki  Ht  Angiography  LCIA-LU  SG  3 months 
  Ht  Angiography  REIA-RU  SG  19 months 
Gallo  Ht  Provocative angiography  RCIA-RU  SG, NST  NS 
Pappy  Ht, hydro  Angiography  LIIA-LU  Embolisation  7 months 
Monchal  Ht, hydro  RP  RCIA-RU  Bypass, NST  1 months 
Kim  Ht, hydro, flank pain  RP  RCIA-RU  SG, NST  2 months 
Mitterberger  Ht, hypotension  Angiography  RCIA-RU  SG  12 months 
Yamasaki  Ht, flank pain  Angiography  LCIA-LU  SG, embolisation, left NST  13 months 
Aslam  Ht, hydro  RP  RCIA-RU  SG  2 months 
Santarpia  Ht, hydro, hypotension  CT scan  RCIA-RU  SG  4 months 
Veenstra  Ht, hydro  RP  RCIA-RU  SG, right NST, renal embolisation  4 months 
McCullough  Ht, Hturia on stent removal  RP  LIIA- LU  Embolisation, NST  Death 
Tselikas  Ht  RP  LCIA- LU  SG  22 months 
  Ht, deglo  CT-scan  REIA-RU  SG, NST  NS 
  Ht, hypotension  PA on CT-scan  LCIA-LU  SG  NS 
Yuki  Ht  PA on angiography  RIIA-RU  Embolisation, NST  2 months 
Atmaca  Ht  Angiography  REIA-RU  SG  1 month 
Brizuela  Ht  PA on angiography  LEIA-LU  SG, embolisation IIA  6 months 
Dormeus  Ht, hydro  Angiography  RCIA-RU  SG  22 months 
Okada  Ht  Angiography  CIA  SG, embolisation  24 months 
  Ht  NS  CIA  SG, embolisation  10 months 
  Ht  CT scan  EIA  SG, embolisation  Death 
  Ht  NS  EIA  SG, embolisation  11 months 
  Ht  Angiography  Aorta  SG  Death 
  Ht  CT scan  CIA  SG, embolisation  5 months 
  Ht  Angiography  EIA  SG  35 months 
  Ht  NS  EIA  SG, embolisation  20 months 
  Ht  NS  CIA  SG  32 months 
  Ht  CT scan  EIA  SG, embolisation  1 months 
Muradi  Ht, hypotension  CT scan  LCIA-LU  SG, embolisation  22 months 
Patel  Ht, shock
Ht, shock 
Angiography
Angiography 
LEIA-LU
RCIA-RU 
SG
SG, NST 
12 months
3 months 
Copelan  Ht, deglo  Angiography  RCIA-RU  SG
Embolisation, NST 
NS 
Siorek  Ht, Ht on stent removal  Angiography  RCIA-RU  SG, embolisation  19 months 
Rittenberg  Ht, deglo  Pyelography  REIA-RU  SG  NS 
Coelho  Ht, deglo  Pyelography  LCIA-LU  Open surgery, U-stent  3 months 
Liang  Ht, pain, hydro  Angiography  RCIA-RU  SG, NST  18 months 
Melegari  Ht, hydro  RP, angiography  Both side  SG, U-stent, embolisation IIA  12 months 
Nduwayo  Ht  CT scan  RIIA-LU  SG, embolisation  NS 
Sarwal  Ht, infection  Angiography  LIIA-LU  NS  NS 
Guntau  Ht  Angiography  RCIA-RU  SG  NS 
  Ht  Angiography  RCIA-RU  SG  NS 
  Ht  Angiography  RCIA-RU  SG  NS 
  Ht  Angiography  RCIA-RU  SG  NS 
  Ht  RP  LCIA-LU  SG  NS 
  Ht  RP  RCIA-RU  SG  NS 
  Ht  RP  LCIA-LU  SG  NS 
  Ht  RP  RCIA-RU  SG  NS 
  Ht  RP  LCIA-LU  SG  NS 
  Ht  RP  LCIA-LU  SG  NS 
  Ht  RP  RCIA-RU  SG  NS 
Hernandez  Ht  CT scan  LCIA-LU  SG, embolisation  24 months 
  Hturia  CT scan  LCIA-LU  SG, embolisation  4 months 
  Ht  CT scan  RCIA-RU  SG  Death 
Yang  Ht  Angiography  REIA-RU  SG, NST  48 months 
Mahlknecht  Ht, hypotension,  CT scan  RCIA-RU  SG, NST  4 months 
Titomihelakis  Ht  Angiography  LEIA- LU  SG  NS 
  Ht  Angiography  RIIA-RU  SG, embolisation  12 months 
  Ht, deglo  Angiography  RIIA-RU  SG  10 months 
  Ht
Ht 
Pyelography
NS 
REIA-RU
LIIA- LU 
SG
SG 
7 months
3 months 
Gao  Ht, Shock, back pain  Angiography  RCIA-RU  SG, embolisation  6 months 
Leone  Ht  Angiography  RIIA-RU  SG  42 months 
  Ht  Angiography  RIIA-RU  SG  63 months 
  Ht  Angiography  LEIA-LU  SG  25 months 
Massman  Ht on stent removal  PA on CT scan  REIA-RU  SG  NS 
  Ht on stent removal  PA on CT scan  RCIA-RU  SG  NS 
  Ht on stent removal  PA on CT scan  RCIA-RU  SG  NS 
  Ht on stent removal  PA on CT scan  RCIA-RU  SG  NS 
  Ht on stent removal  PA on CT scan  RCIA-RU  SG  NS 



Légende :
Ht: hturia; Hydro: hydronephrosis; Deglo: deglobulisation; LU: left ureter; RU: right ureter; RP: retrograde pyelography; LCIA: left common iliac artery; RCIA: right common iliac artery; LEIA; left external iliac artery; REIA: right external iliac artery; RT: radiotherapy; NS: not specified; PA: pseudo-aneurism; CT: chemotherapy; SG: stent graft.


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