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
6.5
6.6

139

109

23

171
19.8

131

4.0

23

1.33

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.

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

Correct!
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.
Return to Case

Sorry, thats incorrect.

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.
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 arteryureteral 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.

Covered stent placement

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 postdilation arteriogram
with CO2 demonstrates
complete occlusion of
the fistula.

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 ArteryUreteral Fistula with a Covered Stent." Journal of Vascular and
Interventional Radiology 17.10 (2006): 1681-685.