Spontaneous arteriovenous fistulas of the lower extremities: angiographic demonstration in five patients with peripheral vascular disease

The Epidemiology of Micro-arteriovenous Fistulas in the Lower Legs

BACKGROUND

Patients presenting with edema, skin redness, pain, and itching in their lower legs are common and encountered often in daily practice. However, although commonly recognized diseases such as deep venous thrombosis, stasis dermatitis due to varicose veins, lymphedema, and cellulitis are diagnosed correctly in most cases, micro-arteriovenous fistulas (AVFs) may often be overlooked due to low awareness and rarity. This study was carried out to evaluate the prevalence of micro-AVF in patients presenting with foot skin symptoms.

METHODS

A total of 134 patients (184 limbs) visited the Department of Vascular Surgery at Kesennuma City Hospital with edema, skin redness, pain, and itching in their lower legs from January to September 2017 and were enrolled and followed up until November 2017. All patients received ultrasonic inspection of their symptomatic limb, and a blood test (white blood cell count, C-reactive protein, and d-dimer) was performed if needed. When micro-AVF was detected in one limb, the other limb was routinely inspected by ultrasonography. A computed tomography scan was performed with the patient's consent. Patients diagnosed with micro-AVF started compression therapy immediately and were followed up for at least 2 months. A surgical procedure was considered if the symptoms worsened.

RESULTS

Micro-AVFs were detected in 24 limbs (13%, 24/184) of 14 patients (7 males and 7 females; age 70 ± 11.7 years). Four patients had unilateral skin symptoms with unilateral micro-AVFs and 7 patients had unilateral skin symptoms and bilateral micro-AVFs. Three patients had bilateral skin symptoms and bilateral micro-AVFs. Asymptomatic micro-AVFs were detected in 7 limbs. Subjective symptoms disappeared and skin appearance normalized in 14 limbs of 12 patients during the first 2 months with compression therapy only. Compression therapy was not effective in 3 limbs of 2 patients and they underwent vein ligation surgery. None of the patients had a surgical history or history of trauma in their lower legs.

CONCLUSIONS

Among the lower legs presenting with skin symptoms, we detected micro-AVFs in 13% of limbs; therefore, micro-AVF of the lower leg is not as rare as previously thought. In addition, 10 of 14 patients (71%) had micro-AVFs of the lower leg bilaterally.

Two Cases of Micro-Arteriovenous Fistula in the Lower Extremity with Misdiagnosis of Refractory Cellulitis

We report our experience of two cases of refractory cellulitis caused by peripheral micro-arteriovenous fistulas (AVFs) in the lower extremity. The micro-AVFs were so small that they could not be located accurately; further, the patients' symptoms differed markedly from those previously reported for AVF. AVF is known to cause ischemic symptoms. In contrast, micro-AVF causes congestive symptoms and remains undetected in the majority of patients. Identification of this pathology is crucial to enable effective treatment by the ligation of the incompetent perforator vein that increases venous hypertension, leading to congestive symptoms.

Endovascular Management of a Penetrating Zone III Retroperitoneal Gunshot Wound Injury; A Case Report

Traumatic iliac vessels injuries secondary to gunshot wound can often be fatal at the scene. One of the intriguing complications of vascular injuries is arteriovenous fistula. If the patient survives, these lesions may often not be diagnosed on first evaluation and patients may present with clinical signs and symptoms years later. Open surgical repair can have prohibitive morbidity and mortality and endovascular techniques, an effective treatment alternative, can interrupt the abnormal vascular communication and preserve artery vein patency. We describe a unique case of iliac arteriovenous fistula (AVF), secondary to a bullet injury, identified by imaging studies and subsequently treated with endovascular surgery. In conclusion, traumatic AVF are rare. Traditional teaching mandates that zone III pelvic retroperitoneal hematomas secondary to penetrating trauma be explored.

An unusual cause of postdialysis dyspnea: Percutaneous endovascular management

Vascular access through femoral vein is commonly used for hemodialysis treatment in patients with end-stage renal disease. Consequently, iatrogenic complications, such as femoral arteriovenous fistula, are increasingly being reported in these patients. Percutaneous endovascular management of such iatrogenic arteriovenous fistulas with stent graft placement is a minimally invasive technique with decreased morbidity and hospital stay compared with surgical repair. Here, we report a case with postcatheterization arteriovenous fistula between superficial femoral artery and femoral vein which was successfully managed with a placement of a self-expanding stent graft.

Contrast-enhanced magnetic resonance angiography of the peripheral arteries: technique, tips, pitfalls and problems

Contrast-enhanced magnetic resonance angiography is a reliable way to assess peripheral vascular disease. This article reviews the basic physics behind this technique and discusses our institution's experience with regard to the clinical role, recent advances in image acquisition and use of contrast agents. Problems that can affect image quality and interpretation are also highlighted.

Iatrogenic arteriovenous fistula as a cause for leg ulcers: a case report

An 80-year-old man presented with painful leg ulceration due to steal phenomenon from a groin arteriovenous fistula (AVF) 10 years following a coronary angiogram. The diagnosis of the AVF was confirmed by duplex examination of the groin vessels which demonstrated characteristic flow pattern in the femoral arterial and venous system. Angiography further confirmed the site of the fistulous communication and this was managed by a covered stent graft. We discuss the incidence of AVF, risk factors for its development, relevant diagnostic investigations and management options along with strategies to reduce the incidence of AVF following percutaneous punctures.

Iatrogenic arteriovenous fistula in the groin presenting as cardiac failure

A patient presented with cardiac failure and investigations revealed a right femoral arteriovenous fistula (AVF) 5 weeks after the insertion of a femoral dialysis catheter for haemodialysis. No ultrasound had been used for catheter insertion. The iatrogenic AVF was repaired, and her episodes of cardiac failure ceased. It is recommended that femoral dialysis catheters are inserted using ultrasound guidance to avoid inadvertent arterial puncture.

Synchronous spontaneous arteriovenous fistula and aneurysm of the deep femoral artery incidentally found in a patient with aortic aneurysmal dissection

The patient was a 77-year-old man with sudden-onset chest and back pain. Computed tomography angiography (CTA) from the abdomen to the proximal thigh showed an aortic aneurysmal dissection (AAD) and a left deep femoral artery (DFA) aneurysm. The AAD was conservatively managed as there was no sign of increase. The left DFA aneurysm was surgically resected to avoid complications such as rupture, thromboembolism, and limb ischemia. On follow-up CTA obtained 3 weeks later, a spontaneous AVF in a varicose vein of the right DFA was noted. There were no symptoms associated with the AVF, and he was conservatively managed. However, the varicose vein gradually increased, and he underwent successful transarterial catheter embolization (TAE) with metal coils without any complications. After vascular repair of the aneurysm and the AVF of the right DFA, there was no sign of recurrence.

Transvenous Embolization of a Spontaneous Femoral AVF 5 Years After an Incomplete Treatment with Arterial Stent-Grafts

A 66-year-old man with complex left femoral arterio-venous fistula (AVF) was first diagnosed after a deep venous thrombosis incident approximately 5 years ago. Partial treatment was performed by means of endografts along the superficial femoral artery, which remained patent for 5 years. The patient had been doing well until a couple of months ago when he developed severe venous stasis and ulcers of the left cruris, due to a high-flow nonhealing complex AVF with additional iliac vein occlusion. Therefore; the definitive treatment was performed by a unique endovascular technique combined with surgical venous bypass (femoro-femoral crossover saphenous bypass, the Palma operation). A novel percutaneous transvenous technique for occlusion of a complex high-flow AVF is reported with a review of the literature. The case is unique with spontaneous AVF, transvenous embolization with detachable coils and ONYX, and the hybrid treatment technique as well as the long-term patency of superficial femoral artery stent-grafts.

Stent-Graft Repair of Peroneal Arteriovenous Fistula

Arteriovenous fistulas (AVFs) are infrequently seen in the civilian health-care system; traditionally, these lesions have been treated with ligation, or direct surgical repair with concomitant revascularization. We describe a rare case of a peroneal AVF treated with a stent-graft.

Lower Limb Arteriovenous Communications in Diabetes Mellitus: A Potential Reason for Aggravation of Ischemic Symptoms

The aim of this study was to assess the prevalence and to evaluate the clinical associations of arteriovenous communications in patients with diabetes mellitus (DM) and lower limb peripheral arterial ischemia. Peripheral arteriography of DM patients from an eight-year period (1993-2000) was evaluated retrospectively by two observers. The presence of arteriovenous communications, defined as occurring without evidence of a preceding precipitating event, and the distribution and severity of the vascular disease were evaluated. The type (non-insulin-dependent DM or insulin-dependent DM) and the duration of the DM, the presenting symptoms, and the presence of a peripheral neuropathy were documented by a review of the clinical records. A total of 348 arteriography studies in 285 DM patients were evaluated (duration of DM: median, 16 years; range, 7-42 years); an arteriovenous communication was present in 14/285 patients (4.9%), 9 male and 5 female (median age, 71 years; range, 17-84 years). Symptoms were those of a peripheral leg ulcer (n = 11), claudication (n = 3), and gangrene (n = 1), with symptoms ipsilateral to the side of the arteriovenous communication in 13/14 patients. The sites of the arteriovenous communications were infra popliteal (n = 7), popliteal (n = 3), superficial femoral artery (n = 3), and common femoral artery (n = 1). Features of a peripheral neuropathy were found in 12/14 and ipsilateral to the side of the communication in 11/12. Arteriovenous communications in the peripheral femoral arterial system of patients with DM is an uncommon finding. Although not proven in the current study, arteriovenous communications might be associated with more severe symptoms than that attributable to the underlying vascular disease alone.