Erosion of Aorto-femoral Dacron Graft into Urinary Bladder Sixteen Years after Surgery, A Case Report
Article Outline
Dacron graft fistulation following aorto-iliac reconstruction into gastrointestinal tract is far commoner than fistulation into the urinary bladder. We reported the first case of erosion of an aorto-bifemoral Dacron graft into the urinary bladder, sixteen years after the initial aortic surgery. A high index of suspicion is necessary in patients presenting with significant urinary symptoms, who have had past history of vascular reconstruction.
Keywords: Erosion, Fistulation, Dacron graft, Arterio-vesical
Introduction
Making a diagnosis of arterio-vesical fistulation could be challenging. It is important to consider history of vascular reconstruction in patients presenting with urinary symptoms.
Report
A 58 year old man presented to the urology outpatient clinic with a six week history of dense lower abdominal pain associated with lower urinary tract symptoms. He had a left iliac femoral graft sixteen years ago.
Physical and digital rectal examinations were normal apart from a moderately enlarged benign prostate. Blood tests and X rays were normal. Ultrasound scan of the abdomen and pelvis showed that the urinary bladder with a grossly thickened wall measuring at least 23.9
ml, and calcification in the bladder wall suggestive of urinary stone (Fig. 1). No structure was seen adherent to it. Flexible cystoscopy revealed a friable vascular mass high on the left wall of the bladder, which was biopsied. There was a torrential bleed after the biopsy that necessitated an emergency laparatomy.
At laparatomy, the left side of the bladder was densely adherent to the wall of the pelvis and required separation by sharp dissection. The bleeding was from a fistulation of an old dacron ilio-femoral graft into the bladder wall. There was no false aneurysm and the resulting defect in the bladder was closed in two layers. The graft was dissected for lengthening after vascular control and an end-to-end anastomosis was fashioned. The postoperative period was uneventful. The histology of the bladder biopsy showed three fragments of light brown tissues of 4×3×3mm. Microscopy showed granulation tissue with marked acute and chronic inflammatory infiltrates but no signs of malignancy. At follow up there were no urinary symptoms and lower limb circulation was satisfactory.
Discussion
Dacron grafts are frequently used for abdominal aortic surgery. Erosion or fistulation into adjacent structures such as oesophagus, stomach, small intestine, colon and appendix, is a common complication. Erosion into urinary bladder is very rare. Most erosions or fistulations present between several months to few years of the initial operation.
Fistulation can be primary or secondary. Primary fistulation is associated with degenerative disease of the arterial wall, forming an aneurysm and fistulating into surrounding structures.1 Secondary fistulation is more common than primary fistulation, and maybe seen after combination of procedures e.g. pelvic extirpative surgery, radiation and ureteric stenting, and vascular synthetic graft.1 The first description of ureteroiliac artery fistula was in 1939, and there have been many reports since then.2 Cystoscopy remains important investigation for haematuria. An arteriography to determine the arterial source of bleeding is essential.3
This case report demonstrates delayed fistulation occurring 16 years after initial vascular reconstruction. There is no consensus about the average time to expect secondary fistulation. Muller-B-T et al., in a review of 16 patients with secondary aorto-enteric fistula, reported a mean period of 51 months.4
End-to end anastomosis of the vascular fistulation and direct closure to repair the bladder defect might suffice in arterio- vesical fistulation with or without the use of an autograft or a synthetic graft. Extra-anatomical arterial reconstruction may be added to the repair if necessary. The use of trans-arterial embolisation of the arteries with extra anatomical by-pass and endovascular application of covered stent,5 which provides an alternative minimal invasive treatment, has also been advised.
A high index of suspicion and early collaboration amongst radiologists, vascular and urological surgeons should be made, to diagnose arterio-vesical fistulation.
References
- . Arterio-ureteral fistula. Systematic review. Eur J Vasc Endovasc Surg. Sep 2001;22(3):191–196
- . Treatment of ureteroarterial fistulae with covered vascular end prosthesis and ureteric occlusion. Cardiovasc Intervent Radiol. Mar–April 2005;25(2):159–163
- . Ureteroiliac artery fistula: diagnosis and treatment algorithm. Urology. Nov 2005;66(5):990–994
- . Diagnosis and therapy of second aortoenteric fistulae: results of 16 patients. Chirurg. 1999 Apr;70(4):415–421
- . Endovascular techniques in the management of acute arterio-enteric fistulas. J Endovasc Ther. 2004 Feb;11(1):89–93
PII: S1533-3167(07)00002-7
doi:10.1016/j.ejvsextra.2006.12.001
© 2007 Elsevier Ltd. All rights reserved.
Refers to article:
- Erosion of Aorto-femoral Dacron Graft into Urinary Bladder Sixteen Years after Surgery, A Case Report , 03 February 2007
