Arterio-Ureteral Fistula: Systematic Review of 445 Patients.

PURPOSE: Arterio-ureteral fistula (AUF) is an uncommon diagnosis, but increasingly reported and potentially lethal. This systematic review comprehensively presents risk factors, pathophysiology, location and clinical presentation of AUF aiming to increase clinical awareness of this rare but life-threatening condition, and to put this entity into a contemporary perspective with modern diagnostic tools and treatment strategies. MATERIALS AND METHODS: This review was performed according to the PRISMA (Preferred Reporting Items for a Systematic Review and Meta-Analysis of Individual Participant Data) guidelines. A literature search in PubMed® and EMBASE™ was conducted. In addition, retrieved articles were cross-referenced. Data parameters included oncologic, vascular and urological history, diagnostics, treatment, and followup, and were collected using a standard template by 2 independent reviewers. RESULTS: A total of 245 articles with 445 patients and 470 AUFs were included. Most patients had chronic indwelling ureteral stents (80%) and history of pelvic oncology (70%). Hematuria was observed in 99% of the patients, of whom 76% presented with massive hematuria with or without previous episodes of (micro)hematuria. For diagnosis, angiography had a sensitivity of 62%. The most predominant location of AUF was at the common iliac artery ureteral crossing. AUF-specific mortality before 2000 vs after 2000 is 19% vs 7%, coinciding with increasing use of endovascular stents. CONCLUSIONS: AUF should be considered in patients with a medical history of vascular surgery, pelvic oncologic surgery, irradiation and/or chronic indwelling ureteral stents presenting with intermittent (micro)hematuria. A multidisciplinary consultation is necessary for diagnosis and treatment. The most sensitive test is angiography and the preferred initial treatment is endovascular.

Rare broncho-pulmonary arterial fistula in a healthy 9-year-old girl.

A 9-year-old previously well girl presented with multiple episodes of large volume haemoptysis and right sided consolidation. She continued to have haemoptysis despite intravenous antibiotics. CT chest suggested a right mainstem endobronchial lesion; this was not seen on bronchoscopy where an extensive blood clot was removed. Distal flexible bronchoscopy could not identify the source of bleeding. CT angiogram revealed a broncho-pulmonary arterial fistula, a rare cause of haemoptysis in children. Endovascular embolisation resulted in short-term symptom resolution; however, haemoptysis recurred months later, leading to re-embolisation. This case highlights a stepwise approach to the workup of large volume haemoptysis.

Role of Occlusion Position in Coronary Artery Fistulas with Terminal Aneurysms: A Hemodynamic Perspective.

PURPOSE: Thrombosis within an occluded coronary arterial fistula (CAF) may cause angina and myocardial infarction. This study aims to estimate how the occlusion position of CAFs with terminal aneurysm affects the risk stratification of thrombosis in the fistula in terms of hemodynamics. METHODS: Twelve CAF models were reconstructed based on patient-specific computed tomography angiogram (CTA) images. They were classified into three groups: preserved group (untreated fistula), aneurysm-reserved group (occluded at the fistula terminal: distal occlusion) and aneurysm-removed group (occluded before the aneurysm: proximal occlusion). Hemodynamics results were analyzed and compared with the clinical follow-up results. RESULTS: The results showed that: (1) Hemodynamic patterns within the fistula before and after treatment were significantly different among patients. (2) Aneurysm-removed occlusions showed better improvements with respect to the CAF blood-stealing phenomena. (3) Irrespective of whether aneurysms were removed or not, a disturbed flow pattern was observed. Areas having high OSI and low TAWSS were present in the post-occluded CAFs. The removal of the aneurysm, however, would alleviate the flow disturbance, and decrease the proportion of the area of OSI > 0.3. (4) The thrombosis region spotted in the follow-up patient CTAs was consistent with the computed high OSI area. CONCLUSIONS: A proximal occlusion, namely, removing the aneurysm of the CAF, may help in reducing the risk of thrombosis after surgery. However, follow-up studies with a larger cohort should be carried out to test and verify this speculation in the future.

A Complex Coronary Artery Fistula as a Potential Cause of Sudden Intraoperative Hemodynamic Compromise: A Case Report.

A patient with coronary artery fistula should be considered as high risk for intraoperative hemodynamic decompensation. In this article, we report the case of a 70-year-old man affected by a complex congenital coronary artery fistula defect. The patient underwent general anesthesia for spine surgery with permissive hypotension. The development of sudden intraoperative tachyarrhythmia with hemodynamic instability required immediate resuscitation and interruption of surgery. The claim advanced is that in patients with a coronary artery fistula permissive hypotension might be considered an option only if strictly necessary and real-time cardiac monitoring including transesophageal echocardiography is available to immediately detect and treat acute cardiac impairment.

Cardiac remodeling secondary to chronic volume overload is attenuated by a novel MMP9/2 blocking antibody.

OBJECTIVE: Monoclonal antibody derivatives are promising drugs for the treatment of various diseases due to their high matrix metalloproteinases (MMP) active site specificity. We studied the effects of a novel antibody, SDS3, which specifically recognizes the mature active site of MMP9/2 during ventricular remodeling progression in a mouse model of chronic volume overload (VO). METHODS: VO was induced by creating an aortocaval fistula (ACF) in 10- to 12-week-old C57BL male mice. The VO-induced mice were treated with either vehicle control (PBS) or with SDS3 twice weekly by intraperitoneal (ip) injection. The relative changes in cardiac parameters between baseline (day 1) and end-point (day 30), were evaluated by echocardiography. The effects of SDS3 treatment on cardiac fibrosis, cardiomyocyte volume, and cardiac inflammation were tested by cardiac staining with Masson's trichrome, wheat Germ Agglutinin (WGA), and CD45, respectively. Serum levels of TNFα and IL-6 with and without SDS3 treatment were tested by ELISA. RESULTS: SDS3 significantly reduced cardiac dilatation, left ventricular (LV) mass, and cardiomyocyte hypertrophy compared to the vehicle treated animals. The antibody also reduced the heart-to-body weight ratio of the ACF animals to values comparable to those of the controls. Interestingly, the SDS3 group underwent significant reduction of cardiac inflammation and pro-inflammatory cytokine production, indicating a regulatory role for MMP9/2 in tissue remodeling, possibly by tumor necrosis factor alpha (TNFα) activation. In addition, significant changes in the expression of proteins related to mitochondrial function were observed in ACF animals, these changes were reversed following treatment with SDS3. CONCLUSION: The data suggest that MMP9/2 blockage with SDS3 attenuates myocardial remodeling associated with chronic VO by three potential pathways: downregulating the extracellular matrix proteolytic cleavage, reducing the cardiac inflammatory responses, and preserving the cardiac mitochondrial structure and function.

Emergent Endovascular Treatment in Primary Ilio-enteric Fistula.

Aortoenteric fistula (AEF) is a rare cause of gastrointestinal (GI) bleeding. If not promptly diagnosed and treated, the associated mortality is very high. The role of endovascular treatment is not yet defined. In this article, we report a clinical case of a 94-year-old male patient admitted in the emergency department with rectal bleeding. Owing to the detection of a pulsatile abdominal mass, a computed tomography angiography (CTA) scan was performed, which established the diagnosis of aorto-enteric fistula due to a left common iliac artery aneurysm (CIAA) ruptured to the sigmoid colon and also revealed an abdominal aortic aneurysm (AAA) and an internal iliac artery aneurysm (IIAA). Given the age of the patient, general condition and technical difficulty inherent to the treatment of the IIAA by conventional surgery, we chose endovascular treatment. However, we wanted to avoid contact between the endograft and the colon orifice because of the risk of infection. The patient was treated emergently with an aorto-right uni-iliac graft and a femoro-femoral bypass, IIAA embolization and 2 left iliac excluders (at the origin of the common iliac and distally in the external iliac artery). It was decided to treat colon lesion conservatively. In this case, the aorto-uni-iliac graft excluded the aortic inline flow, the distal occluder prevented retrograde flow from the external iliac, and the embolization prevented retrograde flow and treated the IIAA. This way, no arterial pressure and no prosthetic material existed inside the ruptured artery, hopefully allowing the spontaneous closing of the orifice leading the sigmoid colon to heal. The postoperative period was uneventful, and the patient was discharged at the 8th postoperative day. The patient outcome is a strong argument on the merit of the treatment strategy.

Surgical Ligation for the Treatment of an Unusual Presentation of Type II Abernethy Malformation.

Abernethy malformation is a very rare congenital vascular malformation consisting of diversion of portal blood away from liver, and it is commonly associated with multiple congenital anomalies. Here, we present a case of a male from China with nonspecific abdominal pain associated with an unusual pattern of type II Abernethy malformation, whose was diagnosed with a portosystemic shunt via a giant portal-inferior vena cava fistula (17.22 mm in diameter). The patient underwent a surgical ligation of the portocaval shunt and recovered well. We believe that this is the first case of a type II Abernethy malformation presenting as a portosystemic shunt via the giant portal-inferior vena cava fistula.

A Case of Recurrent Secondary Aortoenteric Fistula 4 Months after Surgery Treated by Endovascular Coiling of the Aortic Stump and Bilateral Chimney Stent Grafts to Renal Arteries.

The treatment of recurrent aortoenteric fistula (AEF) previously repaired by surgery is challenging, with a high mortality rate. Open repair is often limited by "hostile abdomen," while endovascular treatment is difficult when the distance between the aortic stump and the origin of the renal arteries is short, with high risk of their occlusion. We describe a recurrent AEF repaired by surgery 4 months earlier, treated by endovascular coiling of the aortic stump after deployment of 2 renal artery stent grafts with the chimney technique.

Heart failure due to aorto-right atrial fistula and successful treatment with percutaneous closure.

Aorto-atrial fistula is a rare anomaly of the heart that may be the result of congenital or acquired conditions, such as bacterial endocarditis, paravalvular abscess, aortic dissection, or a complication of cardiac surgery. A 50-year-old female patient presented at the clinic with the complaint of dyspnea and abdominal distention due to ascites. On admission, her functional capacity was New York Heart Association (NYHA) class III. A physical examination revealed a systolic murmur, which was best audible in the right parasternal side, ascites, and hepatomegaly. An aorto-right atrial fistula was detected using transthoracic echocardiography and confirmed with transesophageal echocardiography and aortography. The patient had a history of previous cardiac surgery, anticoagulant use, and heart failure; therefore, percutaneous intervention was preferred to surgery as a result of the high surgical risk. A successful closure of the fistula was performed with an Amplatzer Duct Occluder II device. The patient demonstrated a dramatic response to the treatment, resulting in a decrease in the ascites and halving of her diuretic dose within 1 week. Her functional capacity improved to NYHA class II, and right atrial pressure decreased to 8 mmHg after a month.

Trans-radial closure of coronary artery fistulae using Amplatzer vascular plug IV: A case series.

BACKGROUND: Trans-catheter closure of coronary artery fistulae (CAF) has become a successful alternative to cardiac surgery with excellent results and acceptable low rate of complications. Different techniques and devices are available to treat the extreme anatomical variability of CAF. AIM: We retrospectively describe our case series of five patients trans-radially treated using an Amplatzer vascular plug IV (AVP-IV) with telescoping catheter technique. RESULTS: Trans-radial closure of CAF using the "Child in Mother" technique with dedicated catheters to deliver the vascular plugs AVP-IV was successfully performed in all patients, in one case for a complex CAF, an hybrid step approach using coils and plugs was needed. CONCLUSIONS: Trans-radial closure of CAF using AVP-IV and a telescoping catheter appeared to be safe and feasible in our case series. A persistent closure of CAF was achieved in all patients at 2 year coronary angiography follow-up.

A 57-Year-Old Man With Subacute Progressive Hemoptysis and Fevers.

CASE PRESENTATION: A 57-year-old man was admitted for 1 month of accelerating hemoptysis and hematemesis. Two weeks earlier, he first presented with fevers and hemoptysis of 2 weeks' duration and was diagnosed with community-acquired pneumonia treated with 5 days of ceftriaxone and azithromycin. He improved and was discharged, but his hemoptysis recurred 1 day after discharge and progressed over 9 days, leading to the present admission. He endorsed an 5-kg weight loss, daily fevers up to 39.4°C, and night sweats since discharge. His medical history was significant for peptic ulcer disease complicated by a perforated gastric ulcer 30 years ago, type 2 diabetes, and Barrett esophagus with recent normal upper endoscopy. The patient had coarctation of the aorta repaired 35 years ago. The patient takes aspirin, atorvastatin, and pantoprazole. He emigrated from Mexico 10 years before presentation and lives in Texas with his family. He returns to Mexico several times per year, most recently 2 days before admission. He works at a supermarket. He does not smoke, drink, or use illicit drugs. He denied sick contacts, pets, or incarceration.

Primary aortoduodenal fistula associated with abdominal aortic aneurysm with presentation of gastrointestinal bleeding: a case report.

BACKGROUND: Primary aortoduodenal fistula (ADF) is a rare cause of gastrointestinal (GI) bleeding and is difficult to diagnose as the clinical presentation is subtle. Clinicians should keep a high level of suspicion for an unknown etiology of GI bleeding, especially in older patients with or without abdominal aortic aneurysm (AAA). Computed tomographic angiography (CTA) can be used to detect primary ADF. Open surgery or endovascular aortic repair (EVAR) for ADF with bleeding will improve the survival rate. CASE PRESENTATION: We report a rare case of AAA complicating ADF with massive GI bleeding in a 73-year-old Taiwanese man. He presented with abdominal pain and tarry stool for 5 days and an initial upper GI endoscopy at a rural hospital showed gastric ulcer only, but hypotension with tachycardia and a drop in hemoglobin of 9 g/dl from 12 g/dl occurred the next day. He was referred to our hospital for EVAR and primary closure of fistula defect due to massive GI bleeding with shock from ADF caused by AAA. Diagnosis was made by CTA of aorta. CONCLUSIONS: A timely and accurate diagnosis of primary ADF may be challenging due to insidious episodes of GI bleeding, which are frequently under-diagnosed until the occurrence of massive hemorrhage. Clinical physicians should keep a high index of awareness for primary ADF, especially in elderly patients with unknown etiology of upper GI bleeding with or without a known AAA.

Aorto-Right Atrial Fistula After Sutureless Valve Implantation.

Aortic valve replacement with sutureless valves has many potential applications including in redo surgery, minimally invasive scenarios, and heavily calcified aortic roots. Herein we report a case of the development of an aorto-right atrial fistula after replacement of a Medtronic Freestyle stentless subcoronary bioprosthesis (Medtronic Inc, Minneapolis, MN) with a Perceval sutureless valve (LivaNova PLC, London, UK). This eventually necessitated repair with repeat surgery and aortic valve replacement with a stented valve. For patients with failing stentless bioprostheses returning for reintervention, we suggest removal of only Freestyle leaflet tissue without supra-annular debridement to avoid weakening of the native root tissue.

Coronary Fistula and Myocardial Ischemia: What is the Relationship?

Coronary artery fistula is a rare anomaly; large fistulae may result in myocardial ischemia from coronary steal. We present the case of a 73-year-old male who presented with exertional angina; imaging demonstrated severe coronary artery disease and a large coronary artery fistula. Ligation of the fistula resulted in severe right ventricular failure and cardiogenic shock. After reestablishing flow to the fistula, the patient recovered. We speculate that the ischemia-induced angiogenesis from the congenitally present fistula made what may have otherwise been an innocent fistula into an important nutritive supply, which remained important despite distal revascularization. To our knowledge, this is the first report describing the critical nutritive value of a coronary fistula.

Characteristics of Congenital Coronary Artery Fistulas Complicated with Infective Endocarditis: Analysis of 25 Reported Cases.

Congenital coronary artery fistulas (CAFs) are infrequent congenital coronary artery anomalies. Complications such as left-to-right shunt, congestive heart failure, myocardial infarction, pericardial effusion, aneurysm formation, rupture, hemopericardium, pulmonary hypertension, infective endocarditis (IE), syncope, stroke, and sudden death may occur with a variable low frequency. To describe the clinical characteristics of patients with CAFs complicated by IE. A search was conducted through PubMed using the terms "CAFs" and "IE." Papers with a full description of the fistula characteristics and detailed data regarding bacterial endocarditis were included for evaluation. In the overall group of reviewed subjects (n = 25, 9 females), the mean patient age was 42.5 years (range: 16 and 87). The right coronary artery (RCA) and left coronary artery (LCA) contributed equally to fistula formation. Terminations into the right heart side occurred in 19 (76%) fistulas. The majority of the fistulas (92%) were unilateral. The cultured microorganism was Streptococcus in 14 (56%) and Staphylococcus in 4 (16%) of the reviewed subjects. Echocardiographic single or multiple valvular regurgitation was found in 8 (32%) of the reviewed subjects. Small and large intracardiac vegetations were detected in 18 patients (72%). Antibiotic therapy was initiated in 20 (80%) subjects and 16 fistulas were treated surgically. During surgery, spontaneous closure of the fistula was observed in one patient. Percutaneous therapeutic embolization (PTE) was successfully performed in two subjects. CAFs complicated by IE may affect all age groups with a slight male preponderance. Unilateral fistulas, either arising from the right or left coronary artery, are predominant, draining mainly into the right heart side. It is emphasized that antibiotic prophylaxis is strongly advised for pediatric and adult patients with congenital CAFs.

Spontaneous Intrahepatic Portal Venous Shunt: Presentation and Endovascular Treatment.

Spontaneous intrahepatic portal venous shunts are rare with only few case reports published. Treatments using various endovascular techniques have been described, although no single technique has been shown to be preferred. We present a patient who was referred for treatment of a spontaneous portal venous shunt and describe our treatment approach and present a review on previously reported cases.

Extracorporeal Membrane Oxygenation as a Bridge to Surgery for Infective Endocarditis Complicated by Aorto-Atrial Fistula and Cardiopulmonary Collapse.

The timing of surgery for active infective endocarditis is challenging when patients exhibit mechanical dysfunction and hemodynamic compromise. Extracorporeal membrane oxygenation has been described in treating sepsis but not, insofar as we know, in treating the acute mechanical sequelae that arise from infective endocarditis. We report perhaps the first case that shows the usefulness of extracorporeal membrane oxygenation as a bridge to definitive treatment in a 35-year-old man who had infective endocarditis followed by aorto-atrial fistula and cardiopulmonary collapse.