Cline MassiveBleedfromNephroureteralTract 11-20-2015

MASSIVE BLEEDING FROM NEPHROURETERAL STENT TRACT DURING

TUBE EXCHANGE

Resident(s): Michael Cline M.D.

Attending(s): Kyung Cho M.D.

Program/Dept(s): University of Michigan/Interventional Radiology

Chief Complaint & HPI

▪ Chief Complaint ▪ 62 year old female presents with recurrent hematuria

History of Present Illness

The patient has a history of an indwelling right percutaneous nephroureteral stent catheter for 12 years. The patient had been having intermittent hematuria per her nephroureteral stent catheter. On the day of admission, she noted increased blood drainage which was dark, thick and clotting.

Relevant History

▪Past Medical History ▪Stage IIB ovarian and stage IIA uterine adenocarcinoma s/p chemotherapy/XRT

▪Past Surgical History ▪TAHBSO and lymphadenectomy ▪Ex-lap with lysis of adhesions and right pelvic sidewall biopsy ▪Right percutaneous nephroureteral stent placement for ureteral obstruction

▪Family & Social History ▪Mother- hypertension and “liver cancer”, Father- lung cancer, Brother- colon, prostate and lung cancer

▪Review of Systems ▪Positive for hematuria, otherwise negative

▪Medications ▪Ampicillin, ciprofloxacin, fluconazole, hydrocodone-acetaminophen, insulin, iron

▪Allergies ▪Diphenhydramine

Diagnostic Workup

▪Physical Exam

▪General: Chronically ill appearing, no apparent distress

▪GU: Right percutaneous nepheroureteral stent draining red urine, vesicocutaneous fistula drain in pelvis, indwelling Foley catheter

▪Laboratory Data

▪INR-0.9, PTT- 21.7

▪Non-Invasive Imaging

▪CT Urogram and CTA- Right collecting system dilatation with high attenuation fluid suggesting blood products/clot. No active extravasation. Right percutaneous nephroureteral stent in place.

6.6

6.5

19.8

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4.0

109

23

23

1.33

131

Diagnostic Workup

Axial CTA image at the level the ureters cross the iliac vessels. No source of bleeding could be identified.

Coronal CTU reformat demonstrating a dilated right collecting system filled with high attenuation fluid.

CTA 3D reformat. No source of

bleeding could be identified.

Diagnosis

▪Differential diagnosis. ▪Renal arterial injury/pseudoaneurysm

▪Iliac artery-ureteral fistula

Massive bleeding during a nephroureteral stent change

▪The presumed cause of hematuria was ureteral irritation from the indwelling catheter, the request from the referring physician was to convert a nephroureteral stent to a percutaneous nephrostomy.

▪After withdrawal of the catheter over a guidewire, a massive amount of pulsatile blood came gushing from the nephrostomy tract.

▪A new catheter was quickly placed to tamponade the tract.

▪Given the pulsatile blood flow, renal arterial injury was suspected and the right common femoral artery was accessed for right renal angiography.

▪Right renal arteriogram was performed both with and without the nephrostomy catheter in place.

Right renal arteriogram with and without the nephroureteral catheter

▪No evidence of arterial injury on right renal digital subtraction arteriogram, both with and without the nephrostomy catheter in place.

▪Given the lack of renal arterial injury, attention was turned to the right iliac arteries.

Right iliac Arteriogram with iodinated contrast

▪Right iliac arteriograms in RAO and LAO projections with iodinated contrast did not demonstrate evidence of arterial injury. Note the left iliac artery visualization due to contrast reflux.

▪Repeat arteriogram was then performed with CO2.

Question

1) Which of the following is demonstrated in this right iliac CO2 arteriogram?

A: Normal right iliac arteriogram

B: A right common iliac pseudoaneurysm

C: A right iliac artery-ureteral fistula

D: Free extravasation of contrast from the right iliac artery

1) Which of the following is demonstrated in this right iliac CO2 arteriogram?

A: Normal right iliac arteriogram

B: A right common iliac pseudoaneurysm

C: A right iliac artery-ureteral fistula

D: Free extravasation of contrast from the right iliac artery

arteriogram in the RAO projection after the injection of 20 mL of CO2 demonstrates retrograde filling of the right ureter consistent with a right iliac-ureteral fistula.

Correct!

Return to Case

1) Which of the following is demonstrated in this right iliac CO2 arteriogram?

A: Normal right iliac arteriogram

B: A right common iliac pseudoaneurysm

C: A right iliac artery-ureteral fistula

D: Free extravasation of contrast from the right iliac artery

arteriogram in the RAO projection after the injection of 20 mL of CO2 demonstrates retrograde filling of the right ureter consistent with a right iliac-ureteral fistula.

Sorry, that’s incorrect.

Return to Case

Right iliac arteriogram with CO2

▪Repeat arteriogram in RAO and LAO projections after the injection of 20 mL of CO2

demonstrates retrograde filling of the right ureter, documenting the iliac artery-ureteral fistula.

Embolization of the right internal iliac artery

▪To prevent recurrent bleeding from retrograde flow, the right internal iliac artery was embolized with platinum coils. Repeat arteriograms demonstrated complete occlusion.

▪Note the right iliac vein Wallstent that had been previously placed due to tumor compression.

▪A 9 x 50 mm Viabahn covered stent was placed across the origin of the right internal iliac artery and the iliac artery-ureteral fistula.

▪The stent was dilated up to 7 mm and post-dilation arteriogram with CO2 demonstrates complete occlusion of the fistula.

Covered stent placement

Clinical Follow Up

▪Following the procedure, the patient did very well with stable HCT and no further evidence of bleeding.

▪She was discharged from the hospital four days following the procedure.

▪She has required no further intervention and was most recently seen by IR in September 2014 for a nephrostomy catheter exchange without complication.

Summary & Teaching Points

▪In summary, conventional angiography with iodinated contrast can be negative in cases of iliac artery-ureteral fistula due to intermittent bleeding.

▪ CO2 with low viscosity is more sensitive than iodinated contrast in demonstrating the iliac artery-ureteral fistula allowing precise covered stent placement for treatment.

▪This case highlights the advantage of CO2 over iodinated contrast for this rare diagnosis. Other advantages include: ▪Non-allergenic

▪Non-nephrotoxic

▪Low viscosity ▪Large volumes can be injected via small catheters and sheaths.

▪CO2 will fill more proximal vessels

▪Low cost

References & Further Reading

▪Cho, Kyung J., and Irvin F. Hawkins. Carbon Dioxide Angiography: Principles, Techniques, and Practices. New York: Informa Healthcare, 2007. Print.

▪Krambeck, Amy E., David S. Dimarco, Matthew T. Gettman, and Joseph W. Segura. "Ureteroiliac Artery Fistula: Diagnosis and Treatment Algorithm." Urology 66.5 (2005): 990-94.

▪Madoff, David C., Sanjay Gupta, Barry D. Toombs, Mark D. Skolkin, Chusilp Charnsangavej, Frank A. Morello, Kamran Ahrar, and Marshall E. Hicks. "Arterioureteral Fistulas: A Clinical, Diagnostic, and Therapeutic Dilemma." American Journal of Roentgenology 182.5 (2004): 1241-250.

▪Muraoka, Noriaki, Toyohiko Sakai, Hirohiko Kimura, Nobuyuki Kosaka, Harumi Itoh, Kazuya Tanase, and Osamu Yokoyama. "Endovascular Treatment for an Iliac Artery–Ureteral Fistula with a Covered Stent." Journal of Vascular and Interventional Radiology 17.10 (2006): 1681-685.