Acquired arteriovenous fistula of the lower extremity
- Emile R Mohler III, MD
Emile R Mohler III, MD
- Section Editor — Vascular Medicine
- Professor of Medicine
- University of Pennsylvania School of Medicine
- Section Editors
- Denis L Clement, MD, PhD
Denis L Clement, MD, PhD
- Section Editor — Vascular Medicine
- Emeritus Professor of Cardiology-Angiology
- University of Ghent, Belgium
- John F Eidt, MD
John F Eidt, MD
- Section Editor — Vascular and Endovascular Surgery
- Professor of Surgery, Texas A&M Health Science Center
- Vice Chair of Vascular Surgical Services, Baylor Heart and Vascular Hospital at Dallas
- Joseph L Mills, Sr, MD
Joseph L Mills, Sr, MD
- Section Editor — Vascular and Endovascular Surgery
- Professor and Chief
- Division of Vascular Surgery and Endovascular Therapy
- Baylor College of Medicine
Arteriovenous fistulas (AVFs) are abnormal connections between the arterial and venous system that bypass the normal anatomic capillary beds. They can be located anywhere in the body, single or multiple, and congenital or acquired (eg, trauma) (table 1). Acquired AVF of the lower extremity is by far the most commonly occurring AVF due to the frequency of the groin as a site for percutaneous arterial and venous access.
AVFs of the lower extremity will be reviewed here. AVFs affecting other sites, such as the brain and lungs, and patent ductus arteriosus are discussed separately. (See "Vascular malformations of the central nervous system" and "Pulmonary arteriovenous malformations: Epidemiology, etiology, and pathology in adults" and "Clinical manifestations and diagnosis of patent ductus arteriosus in term infants, children, and adults".)
Throughout the body, arteries and veins are closely associated with one another. Most arteries have laterally paired veins which have intervenous communications (ie, venae comitantes) that pass anterior or posterior to the artery. Larger arteries may have one closely associated vein, or the second vein may be diminutive in size. Venous tributaries also often pass anterior to the artery before emptying into a larger vein.
Any device, implement or projectile that traverses an artery and vein has the potential to lead to AVF. The direction may be from artery to vein or vein to artery. During percutaneous access, lateral or medial needle deviation or needle placement through vena comitantes or venous tributary can lead to combined artery and vein puncture. In many cases, the errant needle placement is noticed (eg, dark blood during arterial puncture, pulsatile blood during venous puncture) and the needle is withdrawn. In most cases, the communication between the artery and vein will spontaneously seal. However, in the face of certain risk factors, the communication between the artery and vein may not seal and AVF will result.
Long-standing AVFs can lead to limb edema, high-output cardiac failure, or aneurysmal degeneration of the artery [1-5]. Large common femoral AVFs can result in hemodynamic shifts due to the diversion of blood from the high resistance arterial circulation to the low resistance venous circuit. The shunt increases venous volume and pressure and decreases peripheral vascular resistance. The ensuing increase in stroke volume and heart rate may lead to a dramatic rise in cardiac output. Another consequence of high flow AVF is reduced blood flow to the lower extremity, which, in the face of pre-existing peripheral artery disease (PAD), can lead to the onset or worsening of lower extremity ischemic symptoms . (See 'Clinical evaluation' below.)
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- Risk factors
- Percutaneous groin access
- CLINICAL EVALUATION
- Noninvasive vascular laboratory examination
- - Duplex ultrasonography
- - ABI and lower extremity physiologic studies
- - Arteriography
- Ultrasound-guided compression
- Endovascular repair
- SUMMARY AND RECOMMENDATIONS