Successful surgical treatment of an elderly patient with critical lower limb ischemia, infected graft and arterio-ureteral fistula

Abstract

The article describes an example of successful surgical treatment of an elderly patient with an arterio-ureteral fistula in the presence of an infected vascular graft after numerous arterial reconstructions on the aortoiliac segment with the multidisciplinary team support. Restoration of the magistral blood flow in the aortoiliac region using bypass surgery or graft implantation relates to a technically sophisticated surgeries, especially in patients with severe concomitant diseases and previously implanted graft infection. This is associated with the high incidence of complications, which varies from 19.2 to 45% according to different sources. In such cases, extra-anatomic reconstructive interventions that are low-traumatic may be the method of choice for relieving critical ischemia. This approach in most cases becomes the only opportunity to save a limb in such clinical situation. A pronounced cicatrical adhesion process in the abdomen and retroperitoneum caused by numerous reconstructive surgeries on the infrarenal aorta in some cases can be the cause of ureteral strictures, which requires the involvement of a urologist in the treatment of such patients. Arterio-ureteral fistula (AUF) is an uncommon but potentially lethal complication. Despite increased number of reported cases and clinical awareness, AUF is not always detected in a timely manner. The prognosis in such cases can vary depending on the time interval from onset of clinical symptoms to the start of treatment. In the vast majority of cases, the AUF is located at the site where the ureter crosses over the bifurcation of the common iliac artery. Angiography is deemed the most effective procedure to diagnose AUF, although its sensitivity is only 62%. According to most authors, implantation of an endovascular stent graft for AUF is preferred over open surgery (mortality rate is 4 and 11%, respectively). However, an individual treatment strategy is developed in each specific case

Keywords

• geriatric surgery
• atherosclerosis
• cicatrical adhesion process in the abdomen
• repeated arterioplasty
• ureteral injuries
• stentgraft placed in iliac artery