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 Sciences Center - Dallas Campus
- 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.)
- Kron J, Sutherland D, Rosch J, et al. Arteriovenous fistula: a rare complication of arterial puncture for cardiac catheterization. Am J Cardiol 1985; 55:1445.
- Glaser RL, McKellar D, Scher KS. Arteriovenous fistulas after cardiac catheterization. Arch Surg 1989; 124:1313.
- Schaub F, Theiss W, Heinz M, et al. New aspects in ultrasound-guided compression repair of postcatheterization femoral artery injuries. Circulation 1994; 90:1861.
- Sako Y, Varco RL. Arteriovenous fistula: results of management of congenital and acquired forms, blood flow measurements, and observations on proximal arterial degeneration. Surgery 1970; 67:40.
- Shumacker HB Jr. Aneurysm development and degenerative changes in dilated artery proximal to arteriovenous fistula. Surg Gynecol Obstet 1970; 130:636.
- Kotelis D, Klemm K, von Tengg-Kobligk H, et al. Intermittent claudication secondary to a traumatic arteriovenous fistula. Vasa 2007; 36:285.
- Kim D, Orron DE, Skillman JJ, et al. Role of superficial femoral artery puncture in the development of pseudoaneurysm and arteriovenous fistula complicating percutaneous transfemoral cardiac catheterization. Cathet Cardiovasc Diagn 1992; 25:91.
- Oweida SW, Roubin GS, Smith RB 3rd, Salam AA. Postcatheterization vascular complications associated with percutaneous transluminal coronary angioplasty. J Vasc Surg 1990; 12:310.
- Nasser TK, Mohler ER 3rd, Wilensky RL, Hathaway DR. Peripheral vascular complications following coronary interventional procedures. Clin Cardiol 1995; 18:609.
- Lamar R, Berg R, Rama K. Femoral arteriovenous fistula as a complication of percutaneous transluminal coronary angioplasty. A report of five cases. Am Surg 1990; 56:702.
- Altin RS, Flicker S, Naidech HJ. Pseudoaneurysm and arteriovenous fistula after femoral artery catheterization: association with low femoral punctures. AJR Am J Roentgenol 1989; 152:629.
- Muller DW, Shamir KJ, Ellis SG, Topol EJ. Peripheral vascular complications after conventional and complex percutaneous coronary interventional procedures. Am J Cardiol 1992; 69:63.
- Vaz C, Matos A, Oliveira J, et al. Iatrogenic arteriovenous fistula following endovenous laser therapy of the short saphenous vein. Ann Vasc Surg 2009; 23:412.e15.
- Pagnotta P, Briguori C, Presbitero P. Arteriovenous fistula complicating directional atherectomy of the popliteal artery. J Cardiovasc Med (Hagerstown) 2009; 10:798.
- Noory E, Rastan A, Schwarzwälder U, et al. Retrograde transpopliteal recanalization of chronic superficial femoral artery occlusion after failed re-entry during antegrade subintimal angioplasty. J Endovasc Ther 2009; 16:619.
- Kelm M, Perings SM, Jax T, et al. Incidence and clinical outcome of iatrogenic femoral arteriovenous fistulas: implications for risk stratification and treatment. J Am Coll Cardiol 2002; 40:291.
- Perings SM, Kelm M, Jax T, Strauer BE. A prospective study on incidence and risk factors of arteriovenous fistulae following transfemoral cardiac catheterization. Int J Cardiol 2003; 88:223.
- Meyerson SL, Feldman T, Desai TR, et al. Angiographic access site complications in the era of arterial closure devices. Vasc Endovascular Surg 2002; 36:137.
- Omoigui NA, Califf RM, Pieper K, et al. Peripheral vascular complications in the Coronary Angioplasty Versus Excisional Atherectomy Trial (CAVEAT-I). J Am Coll Cardiol 1995; 26:922.
- Lebreton G, Uzel AP, Celerien J, et al. Popliteal arteriovenous fistula due to a gunshot injury. Ann Vasc Surg 2010; 24:952.e17.
- Paulson EK, Kliewer MA, Hertzberg BS, et al. Ultrasonographically guided manual compression of femoral artery injuries. J Ultrasound Med 1995; 14:653.
- Toursarkissian B, Allen BT, Petrinec D, et al. Spontaneous closure of selected iatrogenic pseudoaneurysms and arteriovenous fistulae. J Vasc Surg 1997; 25:803.
- Miller-Thomas MM, West OC, Cohen AM. Diagnosing traumatic arterial injury in the extremities with CT angiography: pearls and pitfalls. Radiographics 2005; 25 Suppl 1:S133.
- Waigand J, Uhlich F, Gross CM, et al. Percutaneous treatment of pseudoaneurysms and arteriovenous fistulas after invasive vascular procedures. Catheter Cardiovasc Interv 1999; 47:157.
- Kirsch JD, Reading CC, Charboneau JW. Ultrasound-guided compression and repair of postangiographic femoral arteriovenous fistulas. Mayo Clin Proc 1993; 68:612.
- Fellmeth BD, Roberts AC, Bookstein JJ, et al. Postangiographic femoral artery injuries: nonsurgical repair with US-guided compression. Radiology 1991; 178:671.
- Ruebben A, Tettoni S, Muratore P, et al. Arteriovenous fistulas induced by femoral arterial catheterization: percutaneous treatment. Radiology 1998; 209:729.
- Thalhammer C, Kirchherr AS, Uhlich F, et al. Postcatheterization pseudoaneurysms and arteriovenous fistulas: repair with percutaneous implantation of endovascular covered stents. Radiology 2000; 214:127.
- Baltacioğlu F, Cimşit NC, Cil B, et al. Endovascular stent-graft applications in latrogenic vascular injuries. Cardiovasc Intervent Radiol 2003; 26:434.
- Lemaire JM, Dondelinger RF. Percutaneous coil embolization of iatrogenic femoral arteriovenous fistula or pseudo-aneurysm. Eur J Radiol 1994; 18:96.
- Brewster DC, Cambria RP, Moncure AC, et al. Aortocaval and iliac arteriovenous fistulas: recognition and treatment. J Vasc Surg 1991; 13:253.
- 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