SCVIR 2002 Film Panel Case 6: Hematuria Caused by Ureteroarterial Fistula

A 60-year-old woman presented with gross hematuria from a nephrostomy tube placed 1 month previously into her left upper urinary tract. Her medical history was remarkable for chronic stricture of the left ureter that had been managed previously with a retrograde left ureteral stent. In addition, the patient had atherosclerotic peripheral vascular disease which had been treated 3 years before admission with an aortobifemoral bypass graft. One month before admission, the graft became infected with Staphylococcus epidermidis. The graft infection was man-aged by surgical placement of a left-axillary-to-left-pro-funda synthetic graft coupled with the placement of a left-femoral-to-right-femoral cryopreserved vein graft. The infected synthetic aortobifemoral bypass graft was then excised. Because the patient had experienced con-tinued claudication with a patent aortobifemoral bypass graft, the surgeon was concerned that the left-axillary-to-left-profunda bypass graft would not provide adequate inflow to support both lower extremities. Therefore, it was elected to place an in-line aorto–left common femo-ral cryopreserved vein graft at the time of infected pros-thetic graft explantation. Postoperatively, the patient developed left flank pain. Ultrasonography showed left hydronephrosis. At-tempted retrograde replacement of the left-sided ureteral stent was unsuccessful, and a left-sided percutaneous nephrostomy was performed. The patient was dis-charged home in stable condition, but returned 1 month later with bloody urine draining from her nephrostomy tube. Physical examination revealed a chronically ill–ap-pearing woman in no acute distress. She was afebrile and mildly tachycardic to 100 bpm with a blood pressure of 104/60 mmHg. Laboratory evaluation results were as follows: hematocrit, 34 % (normal, 36%–46%); white blood cells, 8.3 109/L (normal, 3.4–10 109/L); plate-lets, 250 109/L (normal, 140–450 109/L); creatinine, 1.2 mg/dL (normal, 0.6–1.2 mg/dL); prothrombin time