J Vasc Interv Radiol.2013 Sep;24(9):1409-1412

Successful Endovascular Treatment of Iliac Arteriovesical Fistula with Secondary Stent-Graft infection.

Motoki Nakai MD, PhD1; Hirotatsu Sato MD1; Morio Sato MD, PhD1; Akira Ikoma MD, PhD1; Yoshiharu Nishimura MD, PhD2; Yoshitaka Okamura MD, PhD2

1Department of Radiology, Wakayama Medical University,

2Department of Thoracic and Cardiovascular Surgery, Wakayama Medical University,

811-1 Kimiidera, Wakayamashi, Wakayama 641-8510, Japan


A female in her 50s initially presented with massive gross hematuria. Contrast-enhanced CT and angiography revealed a pseudoaneurysm of the left iliac artery (Fig.1). The Excluder® leg (W. L. Gore & Associates, Inc., Flagstaff, AZ, USA) was deployed at the iliac artery to exclude the pseudoaneurysm. Endovascular stent-graft repair achieved complete exclusion of the pseudoaneurysm and successfully controlled the bleeding (Fig. 2). The patient was diagnosed with iliac arterio-vesical fistula based on the cystoscopy findings showing an orifice of the fistula and on the retrograde cystography findings showing leakage of the contrast media through the fistula.

Prolonged fever and inflammatory reaction with a high C-reactive protein (CRP) level were observed 30 days after stent-grafting. Retrograde stent-graft infection from the bladder through the fistula was suspected. Contrast-enhanced CT performed 50 days after endovascular treatment revealed dilatation of the stent-graft, perigraft air, and soft-tissue attenuation around the left iliac artery (Fig. 3, AC). Based on the clinical symptoms, positive blood culture, and CT findings, the patient was diagnosed with graft-related sepsis. Although the patient underwent long-term antibiotic intravenous administration based on the sensitivity of blood cultures, this treatment did not resolve the sepsis.

She underwent hysterectomy, pelvic irradiation, and left nephroureterectomy for uterine cancer 30 years earlier. Surgical removal was considered life-threatening and unfeasible because of her severe adhesion in the pelvis caused by previous surgery and radiotherapy.

Therefore, endovascular embolization of the infected stent-grafts was performed to isolate the source of infection from the systemic circulation and to confine the graft infection. After femoro-femoral bypass, the stent-grafts was embolized completely using detachable coils and n-butyl cyanoacrylate (NBCA)-lipiodol mixture (ratio: 1:2, injected volume: 3 mL) (Fig. 4).

The CRP level progressively decreased and returned to normal level after the endovascular embolization. Blood culture was negative and fever subsided. The patient recovered from sepsis and was discharged one month after stent-graft embolization. Thirty-two months after the stent-grafting procedure, the patient has no clinical or radiological signs of graft infection or sepsis.


Feasibility of endovascular embolization of the infected stent-grafts for graft-related sepsis

Stent-graft infection is a rare but potentially serious complication after endovascular treatment, being associated with high morbidity and mortality rates. The overall mortality rate of stent-graft infections was reported to be 18.0%–27.4% (1, 2). Failure to treat this complication can result in sepsis and eventually death.

Several characteristic features of vascular prosthetic graft infection have been reported. For example, perigraft air, and fluid and soft tissue attenuation around the stent-graft can be visualized by CT, and are suggestive of graft infection (3, 4). Contrast-enhanced CT revealed dilatation of the stent-graft, in addition to perigraft air and soft tissue attenuation in our patient. These finding indicate that the iliac arterial wall might have been autolyzed by the graft infection (5).

Conservative and surgical treatments have been reported for treating graft infection. Although excision of the infected graft with extra-anatomical bypass or in situ reconstruction is recommended as first-line treatment, some patients receive conservative treatments for graft infection because of the presence of comorbidities or the anatomic location of the infected graft (1, 6). Although our patient received long-term antibiotic treatment postoperatively, this did not resolve the sepsis. Open surgical management with infected graft removal, including bladder resection, is generally preferred in such circumstances because graft infection is considered to be due to persistent perigraft infection via the bladder fistula. However, surgical removal of the graft and bladder was unfeasible because of the possible severe adhesion in the pelvis following prior surgery and radiotherapy. Therefore, we performed endovascular embolization of the infected stent-grafts to isolate the source of infection from the systemic circulation and to confine the graft infection.

NBCA is a permanent embolic material, with polymerization occurring immediately in the blood, leading to instant and complete occlusion of the vessel (7, 8, 9). NBCA may also be suitable as an embolic material to confine infection.

Although removal of the infected graft is a general method for treating graft infection, endovascular embolization of infected stent-grafts may be an efficacious and feasible alternative treatment for graft-related sepsis in patients who are refractory to conservative treatment and those with high surgical risk for graft excision.

Our case report highlights the possibility of new therapeutic strategies for stent-graft infection and graft-related sepsis.



1. Ducasse E, Calisti A, Speziale F, Rizzo L, Misuraca M, Fiorani P. Aortoiliac stent graft infection: current problems and management. Ann Vasc Surg 2004; 18:521–526.

2. Fiorani P, Speziale F, Calisti A, et al. Endovascular graft infection: preliminary results of an international enquiry. J Endovasc Ther 2003; 10:919–927.

3. Modrall JG, Clagett GP. The role of imaging techniques in evaluating possible graft infections. Semin Vasc Surg 1999; 12:339–347.

4. Bruggink JL, Slart RH, Pol JA, Reijnen MM, Zeebregts CJ. Current role of imaging in diagnosing aortic graft infections. Semin Vasc Surg 2011; 24:182–190.

5. Schneider JR, Patel NH, Hashemi F, Kim S, Verta MJ. Infected Viabahn stent graft in the superficial femoral artery. Eur J Vasc Endovasc Surg. 2011;42:699-703

6. Lawrence PF. Conservative treatment of aortic graft infection. Semin Vasc Surg 2011; 24:199–204.

7. Kish JW, Katz MD, Marx MV, Harrell DS, Hanks SE. N-butyl cyanoacrylate embolization for control of acute arterial hemorrhage. J Vasc Interv Radiol 2004; 15:689–695.

8. Song JK, Gobin YP, Duckwiler GR, et al. N-butyl 2-cyanoacrylate embolization of spinal dural arteriovenous fistulae. AJNR Am J Neuroradiol 2001; 22:40–47.

9. Nakai M, Sato M, Sanda H, et al. Percutaneous fluoroscopically guided n-butyl cyanoacrylate (NBCA) injection for iatrogenic femoral arterial pseudoaneurysm under temporary balloon occlusion of arterial blood flow. Jpn J Radiol. 2012; 30:365-9.


 Fig.1Fig. 1— Angiography shows a pseudoaneurysm of the left external iliac artery (arrow).

Fig.2Fig. 2— Contrast-enhanced CT (3D-CT) obtained one week after endovascular stent-graft repair shows complete exclusion of the pseudoaneurysm.




Fig. 3— Contrast-enhanced CT obtained 50 days after endovascular stent-graft repair shows dilatation of the stent-graft (white thick arrows in A and C), and perigraft air (white thin arrow in B) and soft tissue attenuation (arrowheads in A and B) around the left iliac artery. (A, B: Axial images, C: 3D-CT image)


Fig. 4 Digital angiography after endovascular embolization of the infected stent-grafts. The stent-graft of the left iliac artery was completely embolized using metallic coils and NBCA-lipiodol mixture.

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