Panamerican Journal of Trauma, Critical Care & Emergency Surgery

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VOLUME 7 , ISSUE 3 ( September-December, 2018 ) > List of Articles

CASE REPORT

Complex Uretero-arterial Fistula Following a Gunshot Wound

Nancy N Wang, Craig E Stauffer, Jeffrey Sung, Catherine R Harris

Keywords : Hematuria, Penetrating wounds, Urinary fistula, Vascular fistula

Citation Information : Wang NN, Stauffer CE, Sung J, Harris CR. Complex Uretero-arterial Fistula Following a Gunshot Wound. Panam J Trauma Crit Care Emerg Surg 2018; 7 (3):219-223.

DOI: 10.5005/jp-journals-10030-1228

License: CC BY-NC 4.0

Published Online: 01-12-2018

Copyright Statement:  Copyright © 2018 Jaypee Brothers Medical Publishers (P) Ltd.


Abstract

Aim: To highlight and discuss the presentation, diagnosis and management of a complex uretero-arterial fistula following a penetrating trauma. Background: Uretero-arterial fistulas are a rare but dangerous connection, usually between the ureter and iliac artery. Gunshot wounds to the abdomen usually result in injuries to multiple intraabdominal structures. Despite a normal appearing ureter, delayed necrosis and subsequent fistulization can occur following a penetrating trauma. Patients may present with life-threatening hemorrhage and diagnosis is often imprecise. Case description: We report the case of a 52-year-old male who presented with a single gunshot wound to the right lower abdomen and was found to have multiple enterotomies as well as a right iliac vein injury. Although the ureter appeared uninjured during the intraoperative assessment, the patient developed a urine leak two weeks after the injury. A ureteral stent and nephrostomy tube were placed to facilitate healing and divert urine. However, the patient re-presented 46 days after initial injury with significant hematuria and diagnosis of a uretero-arterial fistula. Conclusion: Penetrating traumas, especially blast injuries such as gunshot wounds, have a higher risk for delayed injuries secondary to tissue devascularization or necrosis. Ureteral vascular supply is especially delicate and clinicians should have a high suspicion for delayed ureteral complications when a blast injury occurs nearby. It is important to maintain a low threshold for pre-emptive ureteral stenting or excision and repair of an at-risk segment even when the ureter appears intact on initial inspection. Clinical significance: Uretero-arterial fistulas can be fatal, especially as its presentation often occurs suddenly, with large volume blood loss, and diagnosis can be difficult. Prompt and appropriate treatment requires a high level of suspicion and awareness of its potential.


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