Arteriovenous fistula: Difference between revisions
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==Overview== | ==Overview== | ||
An arteriovenous fistula is an abnormal connection or passageway between an [[artery]] and a [[vein]]. It may be [[congenital]], surgically created for [[hemodialysis]] treatments, or acquired due to [[pathology|pathologic]] process, such as [[Physical trauma|trauma]] or erosion of an arterial [[aneurysm]]. These communications can occur at any point in the vascular system; varying in size, length, location, and number. | An [[Arteriovenous fistulae|arteriovenous fistula (AVF)]] is an abnormal connection or passageway between an [[artery]] and a [[vein]]. It may be [[congenital]], surgically created for [[hemodialysis]] treatments, or acquired due to [[pathology|pathologic]] process, such as [[Physical trauma|trauma]] or erosion of an [[arterial]] [[aneurysm]]. These communications can occur at any point in the [[vascular system]]; varying in size, length, location, and number. | ||
==Historical Perspective== | ==Historical Perspective== | ||
*Arteriovenous fistula (AVF) was first discovered by William Hunter, in 1758, during a | *[[Arteriovenous fistulae|Arteriovenous fistula (AVF)]] was first discovered by William Hunter, in 1758, during a [[venipuncture]] with accidental piercing of the [[artery]]. | ||
*Congenital [[Arteriovenous fistulae|arteriovenous fistula (AVF)]] of the [[coronary arteries]], a rare [[cardiac]] anomaly, was first described by Krause W. Uber, in 1865. | |||
==Classification== | ==Classification== | ||
*Arteriovenous fistula (AVF) can be classified into: | *[[Arteriovenous fistulae|Arteriovenous fistula (AVF)]] can be classified into: | ||
:*Congenital, a developmental anomaly in which there are always multiple fistulas between the arteries and veins | :*[[Congenital]], a [[developmental]] [[anomaly]] in which there are always multiple [[Fistula|fistulas]] between the [[arteries]] and [[veins]]<ref name="pmid17865813">{{cite journal |vauthors=Yater WM |title=ACQUIRED ARTERIOVENOUS FISTULA |journal=Ann. Surg. |volume=87 |issue=1 |pages=19–31 |date=January 1928 |pmid=17865813 |pmc=1398373 |doi= |url=}}</ref> | ||
:*Acquired, usually a single communication, which can be the result of an injury or can be a part of treatment for the purpose of hemodialysis.<ref name="pmid17865813">{{cite journal |vauthors=Yater WM |title=ACQUIRED ARTERIOVENOUS FISTULA |journal=Ann. Surg. |volume=87 |issue=1 |pages=19–31 |date=January 1928 |pmid=17865813 |pmc=1398373 |doi= | :*[[Acquired]], usually a single communication, which can be the result of an [[injury]] or can be a part of treatment for the purpose of [[hemodialysis]].<ref name="pmid17865813">{{cite journal |vauthors=Yater WM |title=ACQUIRED ARTERIOVENOUS FISTULA |journal=Ann. Surg. |volume=87 |issue=1 |pages=19–31 |date=January 1928 |pmid=17865813 |pmc=1398373 |doi= |url=}}</ref> | ||
==Pathophysiology== | ==Pathophysiology== | ||
*The abnormal communication causes shunting of blood from high-pressure arterial side to the low-pressure venous side. | *The abnormal communication causes [[shunting]] of [[blood]] from high-pressure [[arterial]] side to the low-pressure [[venous]] side. | ||
* An arteriovenous fistula (AVF) involving a major artery such as the [[abdominal aorta]] can lead to a large decrease in [[peripheral resistance]], which in turn causes the heart to increase [[cardiac output]] in order to maintain proper blood flow to all tissues. | * An [[Arteriovenous fistulae|arteriovenous fistula (AVF)]] involving a major [[artery]] such as the [[abdominal aorta]] can lead to a large decrease in [[peripheral resistance]], which in turn causes the [[heart]] to increase [[cardiac output]] in order to maintain proper [[blood]] flow to all [[tissues]]. | ||
:*The physical manifestations of this would be a relatively normal systolic [[blood pressure]] with a decreased diastolic blood pressure resulting in a wide (large) [[pulse pressure]]. | :*The physical manifestations of this would be a relatively normal [[systolic]] [[blood pressure]] with a decreased [[diastolic]] [[blood pressure]] resulting in a wide (large) [[pulse pressure]]. | ||
*Large arteriovenous fistulae | *Large [[arteriovenous fistulae]] can lead to [[congestive heart failure]] associated with increased activity of [[vasoconstrictor]] neurohormonal systems, [[Renin-angiotensin system|renin-angiotensin]], [[sympathetic nervous system]], [[endothelin]] system, and [[Arginine vasopressin]]. | ||
*The increased activity of vasoconstrictor neurohormonal systems is in concurrence with compensatory activation of systemic and vasodilating systems, atrial natriuretic peptide (ANP) and nitric oxide (NO). | *The increased activity of [[vasoconstrictor]] neurohormonal systems is in concurrence with compensatory activation of [[systemic]] and [[Vasodilation|vasodilating]] systems, [[Atrial natriuretic peptide|atrial natriuretic peptide (ANP)]] and [[Nitric oxide|nitric oxide (NO)]]. | ||
*A fistula can progress to an aneurysm, usually in the setting of a trauma, carrying a risk of rupture and necessitating surgical intervention. | *A [[fistula]] can progress to an [[aneurysm]], usually in the setting of a [[trauma]], carrying a risk of [[rupture]] and necessitating [[Surgery|surgical]] intervention. | ||
*The malformation can result in hemorrhage and the risk is significantly higher with small size malformation because of the significantly higher feeding artery pressures. | *The [[malformation]] can result in [[hemorrhage]] and the risk is significantly higher with small size [[malformation]] because of the significantly higher feeding [[artery]] pressures. | ||
==Clinical Features== | ==Clinical Features== | ||
*In the case of coronary arteriovenous fistula (AVF) patients can be asymptomatic or can present with: | *In the case of [[coronary]] [[Arteriovenous fistulae|arteriovenous fistula (AVF)]] patients can be [[asymptomatic]] or can present with: | ||
:*Continuous murmur | :*[[Continuous murmur]] | ||
:*Cardiomegaly | :*[[Cardiomegaly]] | ||
:*Chest pain | :*[[Chest pain]] | ||
:*Fatigue | :*[[Fatigue]] | ||
:*Palpitation | :*[[Palpitation]] | ||
:*Angina | :*[[Angina]] | ||
:*Bacterial endocarditis | :*[[Bacterial endocarditis]] | ||
*Systemic hypotension | *[[Systemic hypotension]] | ||
*Fistulae involving the spinal vasculature can present with neurologic symptoms of the lower extremities which may include weakness and sensory disturbance. | *[[Fistula|Fistulae]] involving the spinal [[vasculature]] can present with [[neurologic]] [[symptoms]] of the [[lower extremities]] which may include [[weakness]] and [[sensory]] disturbance. | ||
*Acquired arteriovenous fistula (AVF) can result in digital clubbing. | *[[Acquired]] [[Arteriovenous fistula|arteriovenous fistula (AVF)]] can result in [[digital clubbing]]. | ||
*Patients on hemodialysis with arteriovenous fistula (AVF) can develop pseudo-Kaposi's sarcoma. | *Patients on [[hemodialysis]] with [[Arteriovenous fistula|arteriovenous fistula (AVF)]] can develop pseudo-Kaposi's sarcoma. | ||
*Abdominal arteriovenous fistulae can present with: | *[[Abdominal]] [[Arteriovenous fistula|arteriovenous fistulae]] can present with: | ||
:*Lower extremity edema with cyanosis | :*[[Lower extremity]] [[edema]] with [[cyanosis]] | ||
:*Pulsatile varicose veins | :*Pulsatile [[varicose veins]] | ||
:*Scrotal edema | :*Scrotal edema | ||
*Ilio-iliac arteriovenous fistula (AVF) presents with progressive abdominal distention, dyspnea, and | *[[Iliac|Ilio]]-[[iliac]] [[Arteriovenous fistulae|arteriovenous fistula (AVF)]] presents with progressive [[Abdominal distension|abdominal distention]], [[dyspnea]], and leg [[edema]], which makes it difficult to distinguish from [[Deep venous thrombosis|deep venous thrombosis (DVT)]] and can lead to a delay in the [[diagnosis]]. | ||
*[[Tentorium|Tentorial]] [[Dura|dural]] [[Arteriovenous fistula|arteriovenous fistula (AVF)]] can rarely manifest as [[trigeminal neuralgia]]. | |||
==Differentiating Arteriovenous Fistula (AVF) from other Conditions== | ==Differentiating Arteriovenous Fistula (AVF) from other Conditions== | ||
*It is important to differentiate an arteriovenous fistula (AVF) from other conditions that cause a hyperdynamic circulation such as: | *It is important to differentiate an [[Arteriovenous fistulae|arteriovenous fistula (AVF)]] from other conditions that cause a [[hyperdynamic circulation]] such as: | ||
:* | :*[[Cirrhosis]] | ||
:*Graves | :*[[Graves ophthalmopathy]] | ||
:*Various sarcomas such as, angiosarcoma and leiomyosarcoma. | :*Various [[Sarcoma|sarcomas]] such as, [[angiosarcoma]] and [[leiomyosarcoma]]. | ||
:*Paget's disease of bone | :*[[Paget's disease of bone]] | ||
*An ilio-iliac arteriovenous fistula (AVF) can lead to a misdiagnosis of deep venous thrombosis (DVT)<ref name="pmid25432380">{{cite journal |vauthors=Li Y, Fu Q, Liu A, Zheng Z, Fan W, Zhu Z, Chen L, Dai W |title=[A case of iatrogenic ilio-iliac arteriovenous fistula initially misdiagnosed as deep venous thrombosis] |language=Chinese |journal=Zhong Nan Da Xue Xue Bao Yi Xue Ban |volume=39 |issue=11 |pages=1217–20 |date=November 2014 |pmid=25432380 |doi=10.11817/j.issn.1672-7347.2014.11.019 |url=}}</ref> | *An ilio-iliac arteriovenous fistula (AVF) can lead to a misdiagnosis of deep venous thrombosis (DVT)<ref name="pmid25432380">{{cite journal |vauthors=Li Y, Fu Q, Liu A, Zheng Z, Fan W, Zhu Z, Chen L, Dai W |title=[A case of iatrogenic ilio-iliac arteriovenous fistula initially misdiagnosed as deep venous thrombosis] |language=Chinese |journal=Zhong Nan Da Xue Xue Bao Yi Xue Ban |volume=39 |issue=11 |pages=1217–20 |date=November 2014 |pmid=25432380 |doi=10.11817/j.issn.1672-7347.2014.11.019 |url=}}</ref> | ||
==Epidemiology and Demographics== | ==Epidemiology and Demographics== | ||
*In a Scottish population-based study, the incidence of dural arteriovenous fistulae in adults was 0.16 per 100 000 per year. | *In a Scottish population-based study, the incidence of dural arteriovenous fistulae in adults was 0.16 per 100 000 per year. | ||
*In an Olmsted County, Minnesota-based study, the incidence and prevalence of dural arteriovenous fistulae from 1965-1992 are as follows: | *In an Olmsted County, Minnesota-based study, the incidence and prevalence of dural arteriovenous fistulae from 1965-1992 are as follows: | ||
:*From 1965-1992, the incidence was estimated to be 1.84 cases per 100,000 individuals. | :*From 1965-1992, the incidence was estimated to be 1.84 cases per 100,000 individuals. | ||
:*From 1985-1992, the incidence was estimated to be 2.75 cases per 100,000 individuals. | :*From 1985-1992, the incidence was estimated to be 2.75 cases per 100,000 individuals. | ||
:*On january 1, 1990, the prevalance of identified cases was 19.0 per 100,000 individuals. | :*On january 1, 1990, the prevalance of identified cases was 19.0 per 100,000 individuals. | ||
===Age=== | ===Age=== | ||
*Individuals of all age groups may acquire the condition. | *Individuals of all age groups may acquire the condition. | ||
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==Risk Factors== | ==Risk Factors== | ||
*Common risk factors for the development of an arteriovenous fistula (AVF): | *Common risk factors for the development of an arteriovenous fistula (AVF): | ||
:*Arterial catheterization | :*Arterial catheterization | ||
:*Venous catheterization | :*Venous catheterization | ||
:*Hypertension | :*Hypertension | ||
:*Intravenous (IV) drug abuse | :*Intravenous (IV) drug abuse | ||
==Natural History, Complications and Prognosis== | ==Natural History, Complications and Prognosis== | ||
*Patients can remain asymptomatic or can present with symptoms depending on the involved vasculature. | *Patients can remain asymptomatic or can present with symptoms depending on the involved vasculature. | ||
*Early clinical features include hypotension with hypoperfusion, skin changes, and can progress to include cardiac manifestations. | *Early clinical features include hypotension with hypoperfusion, skin changes, and can progress to include cardiac manifestations. | ||
*If left untreated, a large arteriovenous fistula can lead to compensated/decompensated heart failure. | *If left untreated, a large arteriovenous fistula can lead to compensated/decompensated heart failure. | ||
*Complications of arteriovenous fistula (AVF) include: | *Complications of arteriovenous fistula (AVF) include: | ||
:*High-output compensated heart failure | :*High-output compensated heart failure | ||
:*Decompensated heart failure | :*Decompensated heart failure | ||
:*Aneurysm formation | :*Aneurysm formation<ref name="pmid25623503">{{cite journal |vauthors=Soumer K, Benomrane S, Derbel B, Laribi J, Benmrad M, Elleuch N, Kalfat T, Khayati A |title=Popliteal pseudoaneurysm and arteriovenous fistula after acupuncture |journal=J Mal Vasc |volume=40 |issue=1 |pages=58–62 |date=February 2015 |pmid=25623503 |doi=10.1016/j.jmv.2014.11.001 |url=}}</ref> | ||
:*Hemorrhage | :*Hemorrhage | ||
:*Portal hypertension<ref name="pmid25632214">{{cite journal |vauthors=Liu YR, Huang B, Yuan D, Wu ZP, Zhao JC |title=Unusual case of digestive hemorrhage: celiac axis-portal vein arteriovenous fistula |journal=World J. Gastroenterol. |volume=21 |issue=4 |pages=1362–4 |date=January 2015 |pmid=25632214 |pmc=4306185 |doi=10.3748/wjg.v21.i4.1362 |url=}}</ref> | :*Portal hypertension<ref name="pmid25632214">{{cite journal |vauthors=Liu YR, Huang B, Yuan D, Wu ZP, Zhao JC |title=Unusual case of digestive hemorrhage: celiac axis-portal vein arteriovenous fistula |journal=World J. Gastroenterol. |volume=21 |issue=4 |pages=1362–4 |date=January 2015 |pmid=25632214 |pmc=4306185 |doi=10.3748/wjg.v21.i4.1362 |url=}}</ref> | ||
:*Venous stasis and thrombosis | :*Venous stasis and thrombosis | ||
:*Venous stenosis | :*Venous stenosis | ||
:*Intracranial hypertension | :*Intracranial hypertension | ||
:*Infective endocarditis<ref name="pmid26829963">{{cite journal |vauthors=Jonasson SA, Jøssang DE, Haaverstad R, Wendelbo Ø, Pedersen G |title=Arteriovenous fistula of the groin in a drug abuser with endocarditis |journal=J Surg Case Rep |volume=2016 |issue=2 |pages= |date=February 2016 |pmid=26829963 |pmc=5654361 |doi=10.1093/jscr/rjw001 | :*Infective endocarditis<ref name="pmid26829963">{{cite journal |vauthors=Jonasson SA, Jøssang DE, Haaverstad R, Wendelbo Ø, Pedersen G |title=Arteriovenous fistula of the groin in a drug abuser with endocarditis |journal=J Surg Case Rep |volume=2016 |issue=2 |pages= |date=February 2016 |pmid=26829963 |pmc=5654361 |doi=10.1093/jscr/rjw001 |url=}}</ref><ref name="pmid25044393">{{cite journal |vauthors=Jariwala U, Hasan RK, Thorn EM, Zakaria S |title=An unusual case of infective endocarditis involving a right coronary artery to superior vena cava fistula |journal=Catheter Cardiovasc Interv |volume=85 |issue=4 |pages=620–4 |date=March 2015 |pmid=25044393 |doi=10.1002/ccd.25597 |url=}}</ref> | ||
:*Ischemic heart disease and myocardial infarction | :*Ischemic heart disease and myocardial infarction<ref name="pmid25044393">{{cite journal |vauthors=Jariwala U, Hasan RK, Thorn EM, Zakaria S |title=An unusual case of infective endocarditis involving a right coronary artery to superior vena cava fistula |journal=Catheter Cardiovasc Interv |volume=85 |issue=4 |pages=620–4 |date=March 2015 |pmid=25044393 |doi=10.1002/ccd.25597 |url=}}</ref> | ||
:*Cardiac arrhythmias<ref name="pmid25044393">{{cite journal |vauthors=Jariwala U, Hasan RK, Thorn EM, Zakaria S |title=An unusual case of infective endocarditis involving a right coronary artery to superior vena cava fistula |journal=Catheter Cardiovasc Interv |volume=85 |issue=4 |pages=620–4 |date=March 2015 |pmid=25044393 |doi=10.1002/ccd.25597 |url=}}</ref> | :*Cardiac arrhythmias<ref name="pmid25044393">{{cite journal |vauthors=Jariwala U, Hasan RK, Thorn EM, Zakaria S |title=An unusual case of infective endocarditis involving a right coronary artery to superior vena cava fistula |journal=Catheter Cardiovasc Interv |volume=85 |issue=4 |pages=620–4 |date=March 2015 |pmid=25044393 |doi=10.1002/ccd.25597 |url=}}</ref> | ||
:*Paradoxical embolism (causing stroke and pulmonary embolism) | :*Paradoxical embolism (causing stroke and pulmonary embolism) | ||
:*Angiosarcoma (at the arteriovenous fistula site for hemodialysis) | :*Angiosarcoma (at the arteriovenous fistula site for hemodialysis)<ref name="pmid26482509">{{cite journal |vauthors=Oskrochi Y, Razi K, Stebbing J, Crane J |title=Angiosarcoma and Dialysis-related Arteriovenous Fistulae: A Comprehensive Review |journal=Eur J Vasc Endovasc Surg |volume=51 |issue=1 |pages=127–33 |date=January 2016 |pmid=26482509 |doi=10.1016/j.ejvs.2015.08.016 |url=}}</ref> | ||
:*Pseudo-Kaposi's sarcoma<ref name="pmid10606867">{{cite journal |vauthors=Hwang SM, Lee SH, Ahn SK |title=Pincer nail deformity and pseudo-Kaposi's sarcoma: complications of an artificial arteriovenous fistula for haemodialysis |journal=Br. J. Dermatol. |volume=141 |issue=6 |pages=1129–32 |date=December 1999 |pmid=10606867 |doi= | :*Pseudo-Kaposi's sarcoma<ref name="pmid10606867">{{cite journal |vauthors=Hwang SM, Lee SH, Ahn SK |title=Pincer nail deformity and pseudo-Kaposi's sarcoma: complications of an artificial arteriovenous fistula for haemodialysis |journal=Br. J. Dermatol. |volume=141 |issue=6 |pages=1129–32 |date=December 1999 |pmid=10606867 |doi= |url=}}</ref><ref name="pmid">{{cite journal |vauthors=Stewart WM |title=[Pseudo-angiosarcomatosis (kaposi) and arterio-venous fistulae (author's transl)] |language=French |journal= |volume=104 |issue=5 |pages=391–6 |date=May 1977 |pmid= |doi= |url=}}</ref> | ||
:*Steal phenomenon | :*Steal phenomenon | ||
:*Leiomyosarcoma<ref name="pmid6861080">{{cite journal |vauthors=Weinreb W, Steinfeld A, Rodil J, Esparza A, Trebbin W |title=Leiomyosarcoma arising in an arteriovenous fistula |journal=Cancer |volume=52 |issue=2 |pages=390–2 |date=July 1983 |pmid=6861080 |doi= | :*Leiomyosarcoma<ref name="pmid6861080">{{cite journal |vauthors=Weinreb W, Steinfeld A, Rodil J, Esparza A, Trebbin W |title=Leiomyosarcoma arising in an arteriovenous fistula |journal=Cancer |volume=52 |issue=2 |pages=390–2 |date=July 1983 |pmid=6861080 |doi= |url=}}</ref> | ||
*Prognosis of arteriovenous fistulae is dependent on the system involved with many congenital fistulae undergoing regression and large fistulae may progress to cardiac decompensation and death. | *Prognosis of arteriovenous fistulae is dependent on the system involved with many congenital fistulae undergoing regression and large fistulae may progress to cardiac decompensation and death. | ||
==Diagnosis== | ==Diagnosis== | ||
===Diagnostic Criteria=== | ===Diagnostic Criteria=== | ||
*An arteriovenous fistula (AVF) can be detected by a stethoscope and can present with a machinery murmur. | *An arteriovenous fistula (AVF) can be detected by a stethoscope and can present with a machinery murmur.<ref name="pmid26711922">{{cite journal |vauthors=Asada D, Itoi T, Hamaoka K |title=Asymptomatic spinal arteriovenous fistula presenting only as continuous murmur |journal=Pediatr Int |volume=57 |issue=6 |pages=1208–10 |date=December 2015 |pmid=26711922 |doi=10.1111/ped.12716 |url=}}</ref> | ||
*A more superficial fistula can also be detected by palpation, presenting as continuous vibration. | *A more superficial fistula can also be detected by palpation, presenting as continuous vibration. | ||
*Imaging is the modality of choice to effectively diagnose an arteriovenous fistula (AVF) and it includes: | *Imaging is the modality of choice to effectively diagnose an arteriovenous fistula (AVF) and it includes: | ||
:*Duplex ultrasound<ref name="pmid25623503">{{cite journal |vauthors=Soumer K, Benomrane S, Derbel B, Laribi J, Benmrad M, Elleuch N, Kalfat T, Khayati A |title=Popliteal pseudoaneurysm and arteriovenous fistula after acupuncture |journal=J Mal Vasc |volume=40 |issue=1 |pages=58–62 |date=February 2015 |pmid=25623503 |doi=10.1016/j.jmv.2014.11.001 | :*Duplex ultrasound<ref name="pmid25623503">{{cite journal |vauthors=Soumer K, Benomrane S, Derbel B, Laribi J, Benmrad M, Elleuch N, Kalfat T, Khayati A |title=Popliteal pseudoaneurysm and arteriovenous fistula after acupuncture |journal=J Mal Vasc |volume=40 |issue=1 |pages=58–62 |date=February 2015 |pmid=25623503 |doi=10.1016/j.jmv.2014.11.001 |url=}}</ref> | ||
:*Computed tomography angiography (CTA)<ref name="pmid26614386">{{cite journal |vauthors=Tsai LK, Yeh SJ, Tang SC, Hsieh YL, Chen YA, Liu HM, Jeng JS |title=Validity of Carotid Duplex Sonography in Screening for Intracranial Dural Arteriovenous Fistula among Patients with Pulsatile Tinnitus |journal=Ultrasound Med Biol |volume=42 |issue=2 |pages=407–12 |date=February 2016 |pmid=26614386 |doi=10.1016/j.ultrasmedbio.2015.10.013 | :*Computed tomography angiography (CTA)<ref name="pmid26614386">{{cite journal |vauthors=Tsai LK, Yeh SJ, Tang SC, Hsieh YL, Chen YA, Liu HM, Jeng JS |title=Validity of Carotid Duplex Sonography in Screening for Intracranial Dural Arteriovenous Fistula among Patients with Pulsatile Tinnitus |journal=Ultrasound Med Biol |volume=42 |issue=2 |pages=407–12 |date=February 2016 |pmid=26614386 |doi=10.1016/j.ultrasmedbio.2015.10.013 |url=}}</ref> | ||
:*Magnetic resonance angiography (MRA)<ref name="pmid29188304">{{cite journal |vauthors=Lin YH, Wang YF, Liu HM, Lee CW, Chen YF, Hsieh HJ |title=Diagnostic accuracy of CTA and MRI/MRA in the evaluation of the cortical venous reflux in the intracranial dural arteriovenous fistula DAVF |journal=Neuroradiology |volume=60 |issue=1 |pages=7–15 |date=January 2018 |pmid=29188304 |doi=10.1007/s00234-017-1948-2 | :*Magnetic resonance angiography (MRA)<ref name="pmid29188304">{{cite journal |vauthors=Lin YH, Wang YF, Liu HM, Lee CW, Chen YF, Hsieh HJ |title=Diagnostic accuracy of CTA and MRI/MRA in the evaluation of the cortical venous reflux in the intracranial dural arteriovenous fistula DAVF |journal=Neuroradiology |volume=60 |issue=1 |pages=7–15 |date=January 2018 |pmid=29188304 |doi=10.1007/s00234-017-1948-2 |url=}}</ref><ref name="pmid27185610">{{cite journal |vauthors=Lin YH, Lin HH, Liu HM, Lee CW, Chen YF |title=Diagnostic performance of CT and MRI on the detection of symptomatic intracranial dural arteriovenous fistula: a meta-analysis with indirect comparison |journal=Neuroradiology |volume=58 |issue=8 |pages=753–63 |date=August 2016 |pmid=27185610 |doi=10.1007/s00234-016-1696-8 |url=}}</ref> | ||
===Symptoms=== | ===Symptoms=== | ||
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*Symptoms may include: | *Symptoms may include: | ||
:*Low blood pressure and dizziness<ref name="pmid21725657">{{cite journal |vauthors=Mise N, Uchida L, Tanaka M, Tanaka S, Nakajima H, Sugimoto T |title=Acute systemic hypotension after arteriovenous fistula construction in a patient with severe aortic stenosis |journal=Clin. Exp. Nephrol. |volume=15 |issue=5 |pages=788–790 |date=October 2011 |pmid=21725657 |doi=10.1007/s10157-011-0484-3 |url=}}</ref> | :*Low blood pressure and dizziness<ref name="pmid21725657">{{cite journal |vauthors=Mise N, Uchida L, Tanaka M, Tanaka S, Nakajima H, Sugimoto T |title=Acute systemic hypotension after arteriovenous fistula construction in a patient with severe aortic stenosis |journal=Clin. Exp. Nephrol. |volume=15 |issue=5 |pages=788–790 |date=October 2011 |pmid=21725657 |doi=10.1007/s10157-011-0484-3 |url=}}</ref> | ||
:*Swelling in limbs/body | :*Swelling in limbs/body | ||
:*Pain at the acquired arteriovenous fistula (AVF) site<ref name="pmid28779783">{{cite journal |vauthors=Kamyar MM, Saeed Modaghegh MH, Kazemzadeh G |title=Limb complaints after autogenous arteriovenous fistula creation in chronic hemodialysis patients |journal=Semin Vasc Surg |volume=29 |issue=4 |pages=172–177 |date=December 2016 |pmid=28779783 |doi=10.1053/j.semvascsurg.2016.11.002 |url=}}</ref> | :*Pain at the acquired arteriovenous fistula (AVF) site<ref name="pmid28779783">{{cite journal |vauthors=Kamyar MM, Saeed Modaghegh MH, Kazemzadeh G |title=Limb complaints after autogenous arteriovenous fistula creation in chronic hemodialysis patients |journal=Semin Vasc Surg |volume=29 |issue=4 |pages=172–177 |date=December 2016 |pmid=28779783 |doi=10.1053/j.semvascsurg.2016.11.002 |url=}}</ref> | ||
:*Dyspnea and fatigue | :*Dyspnea and fatigue | ||
:*Skin changes<ref name="pmid15874939">{{cite journal |vauthors=Huang W, Villavicencio JL, Rich NM |title=Delayed treatment and late complications of a traumatic arteriovenous fistula |journal=J. Vasc. Surg. |volume=41 |issue=4 |pages=715–7 |date=April 2005 |pmid=15874939 |doi=10.1016/j.jvs.2005.01.049 | :*Skin changes<ref name="pmid15874939">{{cite journal |vauthors=Huang W, Villavicencio JL, Rich NM |title=Delayed treatment and late complications of a traumatic arteriovenous fistula |journal=J. Vasc. Surg. |volume=41 |issue=4 |pages=715–7 |date=April 2005 |pmid=15874939 |doi=10.1016/j.jvs.2005.01.049 |url=}}</ref> | ||
:*Palpable thrill<ref name="pmid15874939">{{cite journal |vauthors=Huang W, Villavicencio JL, Rich NM |title=Delayed treatment and late complications of a traumatic arteriovenous fistula |journal=J. Vasc. Surg. |volume=41 |issue=4 |pages=715–7 |date=April 2005 |pmid=15874939 |doi=10.1016/j.jvs.2005.01.049 |url=}}</ref><ref name="pmid25569414">{{cite journal |vauthors=Kim JH, Yoon SM, Choi HJ |title=Iatrogenic arteriovenous fistula of the superficial temporal artery after reduction malarplasty |journal=J Craniofac Surg |volume=26 |issue=1 |pages=e50–1 |date=January 2015 |pmid=25569414 |doi=10.1097/SCS.0000000000001312 |url=}}</ref> | :*Palpable thrill<ref name="pmid15874939">{{cite journal |vauthors=Huang W, Villavicencio JL, Rich NM |title=Delayed treatment and late complications of a traumatic arteriovenous fistula |journal=J. Vasc. Surg. |volume=41 |issue=4 |pages=715–7 |date=April 2005 |pmid=15874939 |doi=10.1016/j.jvs.2005.01.049 |url=}}</ref><ref name="pmid25569414">{{cite journal |vauthors=Kim JH, Yoon SM, Choi HJ |title=Iatrogenic arteriovenous fistula of the superficial temporal artery after reduction malarplasty |journal=J Craniofac Surg |volume=26 |issue=1 |pages=e50–1 |date=January 2015 |pmid=25569414 |doi=10.1097/SCS.0000000000001312 |url=}}</ref> | ||
:*Melena | :*Melena | ||
:*Hemoptysis | :*Hemoptysis | ||
===Physical Examination=== | ===Physical Examination=== | ||
*Patients with an arteriovenous fistula (AVF) usually appear normal. | *Patients with an arteriovenous fistula (AVF) usually appear normal. | ||
*Physical examination may be remarkable for: | *Physical examination may be remarkable for: | ||
:*Increased size of the limb | :*Increased size of the limb | ||
:*Skin temperature and color alteration | :*Skin temperature and color alteration | ||
:*Prominent veins<ref name="pmid2917907">{{cite journal |vauthors=Parks AH, Guy BL, Rawlings CA, Constantino MJ |title=Lameness in a mare with signs of arteriovenous fistula |journal=J. Am. Vet. Med. Assoc. |volume=194 |issue=3 |pages=379–80 |date=February 1989 |pmid=2917907 |doi= |url=}}</ref> | :*Prominent veins<ref name="pmid2917907">{{cite journal |vauthors=Parks AH, Guy BL, Rawlings CA, Constantino MJ |title=Lameness in a mare with signs of arteriovenous fistula |journal=J. Am. Vet. Med. Assoc. |volume=194 |issue=3 |pages=379–80 |date=February 1989 |pmid=2917907 |doi= |url=}}</ref> | ||
:*Audible murmur<ref name="pmid26711922">{{cite journal |vauthors=Asada D, Itoi T, Hamaoka K |title=Asymptomatic spinal arteriovenous fistula presenting only as continuous murmur |journal=Pediatr Int |volume=57 |issue=6 |pages=1208–10 |date=December 2015 |pmid=26711922 |doi=10.1111/ped.12716 |url=}}</ref> | :*Audible murmur<ref name="pmid26711922">{{cite journal |vauthors=Asada D, Itoi T, Hamaoka K |title=Asymptomatic spinal arteriovenous fistula presenting only as continuous murmur |journal=Pediatr Int |volume=57 |issue=6 |pages=1208–10 |date=December 2015 |pmid=26711922 |doi=10.1111/ped.12716 |url=}}</ref> | ||
:*Palpable thrill<ref name="pmid2917907">{{cite journal |vauthors=Parks AH, Guy BL, Rawlings CA, Constantino MJ |title=Lameness in a mare with signs of arteriovenous fistula |journal=J. Am. Vet. Med. Assoc. |volume=194 |issue=3 |pages=379–80 |date=February 1989 |pmid=2917907 |doi= |url=}}</ref> | :*Palpable thrill<ref name="pmid2917907">{{cite journal |vauthors=Parks AH, Guy BL, Rawlings CA, Constantino MJ |title=Lameness in a mare with signs of arteriovenous fistula |journal=J. Am. Vet. Med. Assoc. |volume=194 |issue=3 |pages=379–80 |date=February 1989 |pmid=2917907 |doi= |url=}}</ref> | ||
:*Nicoladoni-Branham sign | :*Nicoladoni-Branham sign<ref name="pmid2917907">{{cite journal |vauthors=Parks AH, Guy BL, Rawlings CA, Constantino MJ |title=Lameness in a mare with signs of arteriovenous fistula |journal=J. Am. Vet. Med. Assoc. |volume=194 |issue=3 |pages=379–80 |date=February 1989 |pmid=2917907 |doi= |url=}}</ref> | ||
:*Mass effect | :*Mass effect | ||
:*Pain and numbness | :*Pain and numbness | ||
:*Extremity weakness | :*Extremity weakness | ||
:*Cyanosis<ref name="pmid10405695">{{cite journal |vauthors=Swanson KL, Prakash UB, Stanson AW |title=Pulmonary arteriovenous fistulas: Mayo Clinic experience, 1982-1997 |journal=Mayo Clin. Proc. |volume=74 |issue=7 |pages=671–80 |date=July 1999 |pmid=10405695 |doi=10.4065/74.7.671 |url=}}</ref><ref name="pmid8678732">{{cite journal |vauthors=Fourcade L, Vahdat B, Panagides D, Yvorra S, Bonnet JL, Bory M |title=[Pulmonary arteriovenous fistula. A rare cause of dyspnea and cyanosis in an adult] |language=French |journal=Arch Mal Coeur Vaiss |volume=89 |issue=1 |pages=103–6 |date=January 1996 |pmid=8678732 |doi= |url=}}</ref> | :*Cyanosis<ref name="pmid10405695">{{cite journal |vauthors=Swanson KL, Prakash UB, Stanson AW |title=Pulmonary arteriovenous fistulas: Mayo Clinic experience, 1982-1997 |journal=Mayo Clin. Proc. |volume=74 |issue=7 |pages=671–80 |date=July 1999 |pmid=10405695 |doi=10.4065/74.7.671 |url=}}</ref><ref name="pmid8678732">{{cite journal |vauthors=Fourcade L, Vahdat B, Panagides D, Yvorra S, Bonnet JL, Bory M |title=[Pulmonary arteriovenous fistula. A rare cause of dyspnea and cyanosis in an adult] |language=French |journal=Arch Mal Coeur Vaiss |volume=89 |issue=1 |pages=103–6 |date=January 1996 |pmid=8678732 |doi= |url=}}</ref> | ||
| Line 136: | Line 136: | ||
:*Polycythemia<ref name="pmid10405695">{{cite journal |vauthors=Swanson KL, Prakash UB, Stanson AW |title=Pulmonary arteriovenous fistulas: Mayo Clinic experience, 1982-1997 |journal=Mayo Clin. Proc. |volume=74 |issue=7 |pages=671–80 |date=July 1999 |pmid=10405695 |doi=10.4065/74.7.671 |url=}}</ref> | :*Polycythemia<ref name="pmid10405695">{{cite journal |vauthors=Swanson KL, Prakash UB, Stanson AW |title=Pulmonary arteriovenous fistulas: Mayo Clinic experience, 1982-1997 |journal=Mayo Clin. Proc. |volume=74 |issue=7 |pages=671–80 |date=July 1999 |pmid=10405695 |doi=10.4065/74.7.671 |url=}}</ref> | ||
:*Decreased arterial PO2 | :*Decreased arterial PO2 | ||
:*Decreased oxygen saturation | :*Decreased oxygen saturation | ||
:*Increased venous oxygen content | :*Increased venous oxygen content | ||
:*Decreased platelets and fibrinogen in the case of large fistulae | :*Decreased platelets and fibrinogen in the case of large fistulae | ||
*Swan-Ganz catheter findings in pulmonary arteriovenous fistula (AVF) include decreased arterial oxygenation and shunting of cardiac output. | *Swan-Ganz catheter findings in pulmonary arteriovenous fistula (AVF) include decreased arterial oxygenation and shunting of cardiac output. | ||
*Swan-Ganz catheter findings in aorto-caval fistula include higher vena caval pressure and higher than normal oxygen content.<ref name="pmid871003">{{cite journal |vauthors=Kwaan JH, McCart PM, Jones SA, Connolly JE |title=Aortocaval fistula detection using a Swan-Ganz catheter |journal=Surg Gynecol Obstet |volume=144 |issue=6 |pages=919–21 |date=June 1977 |pmid=871003 |doi= |url=}}</ref> | *Swan-Ganz catheter findings in aorto-caval fistula include higher vena caval pressure and higher than normal oxygen content.<ref name="pmid871003">{{cite journal |vauthors=Kwaan JH, McCart PM, Jones SA, Connolly JE |title=Aortocaval fistula detection using a Swan-Ganz catheter |journal=Surg Gynecol Obstet |volume=144 |issue=6 |pages=919–21 |date=June 1977 |pmid=871003 |doi= |url=}}</ref> | ||
*Patients on hemodialysis suffering from occlusive and thrombotic events of the arteriovenous fistula (AVF) may exhibit significant increase of platelet surface glycoproteins GPIb and GPIIb/IIIa. | *Patients on hemodialysis suffering from occlusive and thrombotic events of the arteriovenous fistula (AVF) may exhibit significant increase of platelet surface glycoproteins GPIb and GPIIb/IIIa. | ||
*Large fistulae can also present with laboratory findings of consumptive coagulopathy such as, low platelets, increased bleeding time, elevated prothrombin time (PT) and partial thromboplastin time (PTT), and signs of enhanced fibrinolysis.<ref name="pmid4690101">{{cite journal |vauthors=Rhodes GR, Cox CB, Silver D |title=Arteriovenous fistula and false aneurysm as the cause of consumption coagulopathy |journal=Surgery |volume=73 |issue=4 |pages=535–40 |date=April 1973 |pmid=4690101 | *Large fistulae can also present with laboratory findings of consumptive coagulopathy such as, low platelets, increased bleeding time, elevated prothrombin time (PT) and partial thromboplastin time (PTT), and signs of enhanced fibrinolysis.<ref name="pmid4690101">{{cite journal |vauthors=Rhodes GR, Cox CB, Silver D |title=Arteriovenous fistula and false aneurysm as the cause of consumption coagulopathy |journal=Surgery |volume=73 |issue=4 |pages=535–40 |date=April 1973 |pmid=4690101 |doi= |url=}}</ref> | ||
===Imaging Findings=== | ===Imaging Findings=== | ||
*Computed tomography angiography (CTA) and magnetic resonance angiogrpahy (MRA) are the imaging modalities of choice for arteriovenous fistula (AVF) with modest evidence that computed tomography angiography (CTA) is better than magnetic resonance (MR) angiogrpahy.<ref name="pmid29188304">{{cite journal |vauthors=Lin YH, Wang YF, Liu HM, Lee CW, Chen YF, Hsieh HJ |title=Diagnostic accuracy of CTA and MRI/MRA in the evaluation of the cortical venous reflux in the intracranial dural arteriovenous fistula DAVF |journal=Neuroradiology |volume=60 |issue=1 |pages=7–15 |date=January 2018 |pmid=29188304 |doi=10.1007/s00234-017-1948-2 |url=}}</ref> | *Computed tomography angiography (CTA) and magnetic resonance angiogrpahy (MRA) are the imaging modalities of choice for arteriovenous fistula (AVF) with modest evidence that computed tomography angiography (CTA) is better than magnetic resonance (MR) angiogrpahy.<ref name="pmid29188304">{{cite journal |vauthors=Lin YH, Wang YF, Liu HM, Lee CW, Chen YF, Hsieh HJ |title=Diagnostic accuracy of CTA and MRI/MRA in the evaluation of the cortical venous reflux in the intracranial dural arteriovenous fistula DAVF |journal=Neuroradiology |volume=60 |issue=1 |pages=7–15 |date=January 2018 |pmid=29188304 |doi=10.1007/s00234-017-1948-2 |url=}}</ref> | ||
*On plain radiograph, an arteriovenous fistula (AVF) is characterized by a round or oval lobulated homogeneous mass and the identification of feeding and draining vessels can also be be possible. | *On plain radiograph, an arteriovenous fistula (AVF) is characterized by a round or oval lobulated homogeneous mass and the identification of feeding and draining vessels can also be be possible. | ||
*On ultrasound, an arteriovenous fistula (AVF) is characterized by a pseudoaneurysm, high flow velocity, increased diastolic arterial flow, abnormal arterial pulsitility in the vein, and enlargement of the downstream vein. | *On ultrasound, an arteriovenous fistula (AVF) is characterized by a pseudoaneurysm, high flow velocity, increased diastolic arterial flow, abnormal arterial pulsitility in the vein, and enlargement of the downstream vein. | ||
*On computed tomography angiogrphy (CTA) and magnetic resonance angiography (MRA), an arteriovenous fistula is characterized by abnormal dilatation along with early and flow-related enhancements. | *On computed tomography angiogrphy (CTA) and magnetic resonance angiography (MRA), an arteriovenous fistula is characterized by abnormal dilatation along with early and flow-related enhancements.<ref name="pmid29188304">{{cite journal |vauthors=Lin YH, Wang YF, Liu HM, Lee CW, Chen YF, Hsieh HJ |title=Diagnostic accuracy of CTA and MRI/MRA in the evaluation of the cortical venous reflux in the intracranial dural arteriovenous fistula DAVF |journal=Neuroradiology |volume=60 |issue=1 |pages=7–15 |date=January 2018 |pmid=29188304 |doi=10.1007/s00234-017-1948-2 |url=}}</ref> | ||
*On digital subtraction arteriography (DSA), an arteriovenous fistula (AVF) is characterized by abnormal early filling of an adjacent vein in the region of the fistula. | *On digital subtraction arteriography (DSA), an arteriovenous fistula (AVF) is characterized by abnormal early filling of an adjacent vein in the region of the fistula. | ||
===Other Diagnostic Studies=== | ===Other Diagnostic Studies=== | ||
*An arteriovenous fistula (AVF) involving the heart and pulmonary vasculature in some cases, can also be diagnosed via echocardiography. | *An arteriovenous fistula (AVF) involving the heart and pulmonary vasculature in some cases, can also be diagnosed via echocardiography. | ||
*Findings on echocardiography may include, dilated lumen and abnormal unidirectional continuous flow signals with broad velocity spectra<ref name="pmid6721946">{{cite journal |vauthors=Miyatake K, Okamoto M, Kinoshita N, Fusejima K, Sakakibara H, Nimura Y |title=Doppler echocardiographic features of coronary arteriovenous fistula. Complementary roles of cross sectional echocardiography and the Doppler technique |journal=Br Heart J |volume=51 |issue=5 |pages=508–18 |date=May 1984 |pmid=6721946 |pmc=481541 |doi= |url=}}</ref> | *Findings on echocardiography may include, dilated lumen and abnormal unidirectional continuous flow signals with broad velocity spectra<ref name="pmid6721946">{{cite journal |vauthors=Miyatake K, Okamoto M, Kinoshita N, Fusejima K, Sakakibara H, Nimura Y |title=Doppler echocardiographic features of coronary arteriovenous fistula. Complementary roles of cross sectional echocardiography and the Doppler technique |journal=Br Heart J |volume=51 |issue=5 |pages=508–18 |date=May 1984 |pmid=6721946 |pmc=481541 |doi= |url=}}</ref> | ||
*An aorto-caval fistula may also be diagnosed using Swan-Ganz catheter, demonstrating higher vena caval pressure and higher than normal oxygen content.<ref name="pmid871003">{{cite journal |vauthors=Kwaan JH, McCart PM, Jones SA, Connolly JE |title=Aortocaval fistula detection using a Swan-Ganz catheter |journal=Surg Gynecol Obstet |volume=144 |issue=6 |pages=919–21 |date=June 1977 |pmid=871003 |doi= |url=}}</ref> | *An aorto-caval fistula may also be diagnosed using Swan-Ganz catheter, demonstrating higher vena caval pressure and higher than normal oxygen content.<ref name="pmid871003">{{cite journal |vauthors=Kwaan JH, McCart PM, Jones SA, Connolly JE |title=Aortocaval fistula detection using a Swan-Ganz catheter |journal=Surg Gynecol Obstet |volume=144 |issue=6 |pages=919–21 |date=June 1977 |pmid=871003 |doi= |url=}}</ref> | ||
| Line 157: | Line 157: | ||
===Medical Therapy=== | ===Medical Therapy=== | ||
*There is no medical treatment for an arteriovenous fistula (AVF). | *There is no medical treatment for an arteriovenous fistula (AVF). | ||
*Iatrogenic arteriovenous fistulae, presenting only as pain, can resolve after a trial of compression and observation. | *Iatrogenic arteriovenous fistulae, presenting only as pain, can resolve after a trial of compression and observation.<ref name="pmid25404936">{{cite journal |vauthors=Miller RJ, MacRae JM, Mustata S |title=Conservative management of an iatrogenic arteriovenous fistula |journal=Nephron Extra |volume=4 |issue=3 |pages=155–8 |date=September 2014 |pmid=25404936 |pmc=4224231 |doi=10.1159/000366451 |url=}}</ref> | ||
*Asymptomatic fistulae can resolve spontaneously and most lesions can be monitored after detection especially if the size of the lesion is small and they do not cause adverse effects. | *Asymptomatic fistulae can resolve spontaneously and most lesions can be monitored after detection especially if the size of the lesion is small and they do not cause adverse effects. | ||
*Conservative management has been tried with a successful outcome in the case of an arteriovenous fistula (AVF) as a complication of vascular catheterization.<ref name="pmid25404936">{{cite journal |vauthors=Miller RJ, MacRae JM, Mustata S |title=Conservative management of an iatrogenic arteriovenous fistula |journal=Nephron Extra |volume=4 |issue=3 |pages=155–8 |date=September 2014 |pmid=25404936 |pmc=4224231 |doi=10.1159/000366451 |url=}}</ref> | *Conservative management has been tried with a successful outcome in the case of an arteriovenous fistula (AVF) as a complication of vascular catheterization.<ref name="pmid25404936">{{cite journal |vauthors=Miller RJ, MacRae JM, Mustata S |title=Conservative management of an iatrogenic arteriovenous fistula |journal=Nephron Extra |volume=4 |issue=3 |pages=155–8 |date=September 2014 |pmid=25404936 |pmc=4224231 |doi=10.1159/000366451 |url=}}</ref> | ||
===Surgery=== | ===Surgery=== | ||
*Surgery is the mainstay of therapy for an arteriovenous fistula (AVF). | *Surgery is the mainstay of therapy for an arteriovenous fistula (AVF). | ||
*Endovascular embolization is the most common approach to the treatment of an arteriovenous fistula (AVF), where a catheter is inserted into an artery and, guided by fluoroscopic or x-ray imaging, contrast is injected to visualize the vasculature followed by the injection of an embolization material (such as, particles, liquid embolics, embolization glue, detachable balloons, vascular plugs, and coils) into the exact location where the artery and the vein meet. | *Endovascular embolization is the most common approach to the treatment of an arteriovenous fistula (AVF), where a catheter is inserted into an artery and, guided by fluoroscopic or x-ray imaging, contrast is injected to visualize the vasculature followed by the injection of an embolization material (such as, particles, liquid embolics, embolization glue, detachable balloons, vascular plugs, and coils) into the exact location where the artery and the vein meet. | ||
*Microsurgery, with or without endovascular embolization, is the most appropriate treatment for dural, brain, or spinal arteriovenous fistulae, where a titanium clip is placed to cut off the connection between the artery and the vein.<ref name="pmid27015132">{{cite journal |vauthors=Bagherpour AN, Rodriguez GJ, Moorthy C, Trier TT, Maud A |title=Combined surgical and endovascular treatment of complex high-flow conus medullaris arteriovenous fistula associated with Parkes Weber syndrome: case report |journal=J Neurosurg Spine |volume=25 |issue=2 |pages=234–8 |date=August 2016 |pmid=27015132 |doi=10.3171/2016.1.SPINE151156 | *Microsurgery, with or without endovascular embolization, is the most appropriate treatment for dural, brain, or spinal arteriovenous fistulae, where a titanium clip is placed to cut off the connection between the artery and the vein.<ref name="pmid27015132">{{cite journal |vauthors=Bagherpour AN, Rodriguez GJ, Moorthy C, Trier TT, Maud A |title=Combined surgical and endovascular treatment of complex high-flow conus medullaris arteriovenous fistula associated with Parkes Weber syndrome: case report |journal=J Neurosurg Spine |volume=25 |issue=2 |pages=234–8 |date=August 2016 |pmid=27015132 |doi=10.3171/2016.1.SPINE151156 |url=}}</ref> | ||
*Stereotactic radiosurgery, the treatment of choice to successfully obliterate an arteriovenous fistula (AVF) with low complication rates and hence preferred over endovascular embolization and microsurgery in the case of an arteriovenous fistula close to important brain structures. | *Stereotactic radiosurgery, the treatment of choice to successfully obliterate an arteriovenous fistula (AVF) with low complication rates and hence preferred over endovascular embolization and microsurgery in the case of an arteriovenous fistula close to important brain structures.<ref name="pmid24093576">{{cite journal |vauthors=Yen CP, Lanzino G, Sheehan JP |title=Stereotactic radiosurgery of intracranial dural arteriovenous fistulas |journal=Neurosurg. Clin. N. Am. |volume=24 |issue=4 |pages=591–6 |date=October 2013 |pmid=24093576 |doi=10.1016/j.nec.2013.05.008 |url=}}</ref> | ||
*Open surgical repair | *Open surgical repair<ref name="pmid25304908">{{cite journal |vauthors=Takahashi S, Katayama K, Tatsugawa T, Sueda T |title=A successful hybrid repair for vertebral arteriovenous fistula with extracranial vertebral artery aneurysm |journal=Ann Vasc Surg |volume=29 |issue=1 |pages=126.e5–8 |date=January 2015 |pmid=25304908 |doi=10.1016/j.avsg.2014.07.038 |url=}}</ref> | ||
===Prevention=== | ===Prevention=== | ||
*There are no specific primary prevention measures available for an arteriovenous fistula. | *There are no specific primary prevention measures available for an arteriovenous fistula. | ||
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==References== | ==References== | ||
<div class="references-small"><references /></div> | <div class="references-small"> | ||
<references /></div> | |||
==External links== | ==External links== | ||
Revision as of 21:13, 6 November 2018
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sabawoon Mirwais, M.B.B.S, M.D.[2]
Overview
An arteriovenous fistula (AVF) is an abnormal connection or passageway between an artery and a vein. It may be congenital, surgically created for hemodialysis treatments, or acquired due to pathologic process, such as trauma or erosion of an arterial aneurysm. These communications can occur at any point in the vascular system; varying in size, length, location, and number.
Historical Perspective
- Arteriovenous fistula (AVF) was first discovered by William Hunter, in 1758, during a venipuncture with accidental piercing of the artery.
- Congenital arteriovenous fistula (AVF) of the coronary arteries, a rare cardiac anomaly, was first described by Krause W. Uber, in 1865.
Classification
- Arteriovenous fistula (AVF) can be classified into:
- Congenital, a developmental anomaly in which there are always multiple fistulas between the arteries and veins[1]
- Acquired, usually a single communication, which can be the result of an injury or can be a part of treatment for the purpose of hemodialysis.[1]
Pathophysiology
- The abnormal communication causes shunting of blood from high-pressure arterial side to the low-pressure venous side.
- An arteriovenous fistula (AVF) involving a major artery such as the abdominal aorta can lead to a large decrease in peripheral resistance, which in turn causes the heart to increase cardiac output in order to maintain proper blood flow to all tissues.
- The physical manifestations of this would be a relatively normal systolic blood pressure with a decreased diastolic blood pressure resulting in a wide (large) pulse pressure.
- Large arteriovenous fistulae can lead to congestive heart failure associated with increased activity of vasoconstrictor neurohormonal systems, renin-angiotensin, sympathetic nervous system, endothelin system, and Arginine vasopressin.
- The increased activity of vasoconstrictor neurohormonal systems is in concurrence with compensatory activation of systemic and vasodilating systems, atrial natriuretic peptide (ANP) and nitric oxide (NO).
- A fistula can progress to an aneurysm, usually in the setting of a trauma, carrying a risk of rupture and necessitating surgical intervention.
- The malformation can result in hemorrhage and the risk is significantly higher with small size malformation because of the significantly higher feeding artery pressures.
Clinical Features
- In the case of coronary arteriovenous fistula (AVF) patients can be asymptomatic or can present with:
- Systemic hypotension
- Fistulae involving the spinal vasculature can present with neurologic symptoms of the lower extremities which may include weakness and sensory disturbance.
- Acquired arteriovenous fistula (AVF) can result in digital clubbing.
- Patients on hemodialysis with arteriovenous fistula (AVF) can develop pseudo-Kaposi's sarcoma.
- Abdominal arteriovenous fistulae can present with:
- Lower extremity edema with cyanosis
- Pulsatile varicose veins
- Scrotal edema
- Ilio-iliac arteriovenous fistula (AVF) presents with progressive abdominal distention, dyspnea, and leg edema, which makes it difficult to distinguish from deep venous thrombosis (DVT) and can lead to a delay in the diagnosis.
- Tentorial dural arteriovenous fistula (AVF) can rarely manifest as trigeminal neuralgia.
Differentiating Arteriovenous Fistula (AVF) from other Conditions
- It is important to differentiate an arteriovenous fistula (AVF) from other conditions that cause a hyperdynamic circulation such as:
- Cirrhosis
- Graves ophthalmopathy
- Various sarcomas such as, angiosarcoma and leiomyosarcoma.
- Paget's disease of bone
- An ilio-iliac arteriovenous fistula (AVF) can lead to a misdiagnosis of deep venous thrombosis (DVT)[2]
Epidemiology and Demographics
- In a Scottish population-based study, the incidence of dural arteriovenous fistulae in adults was 0.16 per 100 000 per year.
- In an Olmsted County, Minnesota-based study, the incidence and prevalence of dural arteriovenous fistulae from 1965-1992 are as follows:
- From 1965-1992, the incidence was estimated to be 1.84 cases per 100,000 individuals.
- From 1985-1992, the incidence was estimated to be 2.75 cases per 100,000 individuals.
- On january 1, 1990, the prevalance of identified cases was 19.0 per 100,000 individuals.
Age
- Individuals of all age groups may acquire the condition.
- Congenital type of arteriovenous fistula (AVF) is present at birth and may manifest early or later in life.
Gender
- Arteriovenous fistula (AVF) is observed in both men and women equally.
Race
- There is no racial predilection for arteriovenous fistula (AVF).
Risk Factors
- Common risk factors for the development of an arteriovenous fistula (AVF):
- Arterial catheterization
- Venous catheterization
- Hypertension
- Intravenous (IV) drug abuse
Natural History, Complications and Prognosis
- Patients can remain asymptomatic or can present with symptoms depending on the involved vasculature.
- Early clinical features include hypotension with hypoperfusion, skin changes, and can progress to include cardiac manifestations.
- If left untreated, a large arteriovenous fistula can lead to compensated/decompensated heart failure.
- Complications of arteriovenous fistula (AVF) include:
- High-output compensated heart failure
- Decompensated heart failure
- Aneurysm formation[3]
- Hemorrhage
- Portal hypertension[4]
- Venous stasis and thrombosis
- Venous stenosis
- Intracranial hypertension
- Infective endocarditis[5][6]
- Ischemic heart disease and myocardial infarction[6]
- Cardiac arrhythmias[6]
- Paradoxical embolism (causing stroke and pulmonary embolism)
- Angiosarcoma (at the arteriovenous fistula site for hemodialysis)[7]
- Pseudo-Kaposi's sarcoma[8][9]
- Steal phenomenon
- Leiomyosarcoma[10]
- Prognosis of arteriovenous fistulae is dependent on the system involved with many congenital fistulae undergoing regression and large fistulae may progress to cardiac decompensation and death.
Diagnosis
Diagnostic Criteria
- An arteriovenous fistula (AVF) can be detected by a stethoscope and can present with a machinery murmur.[11]
- A more superficial fistula can also be detected by palpation, presenting as continuous vibration.
- Imaging is the modality of choice to effectively diagnose an arteriovenous fistula (AVF) and it includes:
Symptoms
- An arteriovenous fistula (AVF) can be asymptomatic.
- Symptoms may include:
Physical Examination
- Patients with an arteriovenous fistula (AVF) usually appear normal.
- Physical examination may be remarkable for:
Laboratory Findings
- Laboratory findings associated with an arteriovenous fistula (AVF) can include the following:
- Polycythemia[20]
- Decreased arterial PO2
- Decreased oxygen saturation
- Increased venous oxygen content
- Decreased platelets and fibrinogen in the case of large fistulae
- Swan-Ganz catheter findings in pulmonary arteriovenous fistula (AVF) include decreased arterial oxygenation and shunting of cardiac output.
- Swan-Ganz catheter findings in aorto-caval fistula include higher vena caval pressure and higher than normal oxygen content.[22]
- Patients on hemodialysis suffering from occlusive and thrombotic events of the arteriovenous fistula (AVF) may exhibit significant increase of platelet surface glycoproteins GPIb and GPIIb/IIIa.
- Large fistulae can also present with laboratory findings of consumptive coagulopathy such as, low platelets, increased bleeding time, elevated prothrombin time (PT) and partial thromboplastin time (PTT), and signs of enhanced fibrinolysis.[23]
Imaging Findings
- Computed tomography angiography (CTA) and magnetic resonance angiogrpahy (MRA) are the imaging modalities of choice for arteriovenous fistula (AVF) with modest evidence that computed tomography angiography (CTA) is better than magnetic resonance (MR) angiogrpahy.[13]
- On plain radiograph, an arteriovenous fistula (AVF) is characterized by a round or oval lobulated homogeneous mass and the identification of feeding and draining vessels can also be be possible.
- On ultrasound, an arteriovenous fistula (AVF) is characterized by a pseudoaneurysm, high flow velocity, increased diastolic arterial flow, abnormal arterial pulsitility in the vein, and enlargement of the downstream vein.
- On computed tomography angiogrphy (CTA) and magnetic resonance angiography (MRA), an arteriovenous fistula is characterized by abnormal dilatation along with early and flow-related enhancements.[13]
- On digital subtraction arteriography (DSA), an arteriovenous fistula (AVF) is characterized by abnormal early filling of an adjacent vein in the region of the fistula.
Other Diagnostic Studies
- An arteriovenous fistula (AVF) involving the heart and pulmonary vasculature in some cases, can also be diagnosed via echocardiography.
- Findings on echocardiography may include, dilated lumen and abnormal unidirectional continuous flow signals with broad velocity spectra[24]
- An aorto-caval fistula may also be diagnosed using Swan-Ganz catheter, demonstrating higher vena caval pressure and higher than normal oxygen content.[22]
Treatment
Medical Therapy
- There is no medical treatment for an arteriovenous fistula (AVF).
- Iatrogenic arteriovenous fistulae, presenting only as pain, can resolve after a trial of compression and observation.[25]
- Asymptomatic fistulae can resolve spontaneously and most lesions can be monitored after detection especially if the size of the lesion is small and they do not cause adverse effects.
- Conservative management has been tried with a successful outcome in the case of an arteriovenous fistula (AVF) as a complication of vascular catheterization.[25]
Surgery
- Surgery is the mainstay of therapy for an arteriovenous fistula (AVF).
- Endovascular embolization is the most common approach to the treatment of an arteriovenous fistula (AVF), where a catheter is inserted into an artery and, guided by fluoroscopic or x-ray imaging, contrast is injected to visualize the vasculature followed by the injection of an embolization material (such as, particles, liquid embolics, embolization glue, detachable balloons, vascular plugs, and coils) into the exact location where the artery and the vein meet.
- Microsurgery, with or without endovascular embolization, is the most appropriate treatment for dural, brain, or spinal arteriovenous fistulae, where a titanium clip is placed to cut off the connection between the artery and the vein.[26]
- Stereotactic radiosurgery, the treatment of choice to successfully obliterate an arteriovenous fistula (AVF) with low complication rates and hence preferred over endovascular embolization and microsurgery in the case of an arteriovenous fistula close to important brain structures.[27]
- Open surgical repair[28]
Prevention
- There are no specific primary prevention measures available for an arteriovenous fistula.
- The acquired type, caused by trauma, can be prevented by avoiding trauma and also using caution while performing vascular access procedures.
References
- ↑ 1.0 1.1 Yater WM (January 1928). "ACQUIRED ARTERIOVENOUS FISTULA". Ann. Surg. 87 (1): 19–31. PMC 1398373. PMID 17865813.
- ↑ Li Y, Fu Q, Liu A, Zheng Z, Fan W, Zhu Z, Chen L, Dai W (November 2014). "[A case of iatrogenic ilio-iliac arteriovenous fistula initially misdiagnosed as deep venous thrombosis]". Zhong Nan Da Xue Xue Bao Yi Xue Ban (in Chinese). 39 (11): 1217–20. doi:10.11817/j.issn.1672-7347.2014.11.019. PMID 25432380.
- ↑ 3.0 3.1 Soumer K, Benomrane S, Derbel B, Laribi J, Benmrad M, Elleuch N, Kalfat T, Khayati A (February 2015). "Popliteal pseudoaneurysm and arteriovenous fistula after acupuncture". J Mal Vasc. 40 (1): 58–62. doi:10.1016/j.jmv.2014.11.001. PMID 25623503.
- ↑ Liu YR, Huang B, Yuan D, Wu ZP, Zhao JC (January 2015). "Unusual case of digestive hemorrhage: celiac axis-portal vein arteriovenous fistula". World J. Gastroenterol. 21 (4): 1362–4. doi:10.3748/wjg.v21.i4.1362. PMC 4306185. PMID 25632214.
- ↑ Jonasson SA, Jøssang DE, Haaverstad R, Wendelbo Ø, Pedersen G (February 2016). "Arteriovenous fistula of the groin in a drug abuser with endocarditis". J Surg Case Rep. 2016 (2). doi:10.1093/jscr/rjw001. PMC 5654361. PMID 26829963.
- ↑ 6.0 6.1 6.2 Jariwala U, Hasan RK, Thorn EM, Zakaria S (March 2015). "An unusual case of infective endocarditis involving a right coronary artery to superior vena cava fistula". Catheter Cardiovasc Interv. 85 (4): 620–4. doi:10.1002/ccd.25597. PMID 25044393.
- ↑ Oskrochi Y, Razi K, Stebbing J, Crane J (January 2016). "Angiosarcoma and Dialysis-related Arteriovenous Fistulae: A Comprehensive Review". Eur J Vasc Endovasc Surg. 51 (1): 127–33. doi:10.1016/j.ejvs.2015.08.016. PMID 26482509.
- ↑ Hwang SM, Lee SH, Ahn SK (December 1999). "Pincer nail deformity and pseudo-Kaposi's sarcoma: complications of an artificial arteriovenous fistula for haemodialysis". Br. J. Dermatol. 141 (6): 1129–32. PMID 10606867.
- ↑ Stewart WM (May 1977). "[Pseudo-angiosarcomatosis (kaposi) and arterio-venous fistulae (author's transl)]" (in French). 104 (5): 391–6.
- ↑ Weinreb W, Steinfeld A, Rodil J, Esparza A, Trebbin W (July 1983). "Leiomyosarcoma arising in an arteriovenous fistula". Cancer. 52 (2): 390–2. PMID 6861080.
- ↑ 11.0 11.1 Asada D, Itoi T, Hamaoka K (December 2015). "Asymptomatic spinal arteriovenous fistula presenting only as continuous murmur". Pediatr Int. 57 (6): 1208–10. doi:10.1111/ped.12716. PMID 26711922.
- ↑ Tsai LK, Yeh SJ, Tang SC, Hsieh YL, Chen YA, Liu HM, Jeng JS (February 2016). "Validity of Carotid Duplex Sonography in Screening for Intracranial Dural Arteriovenous Fistula among Patients with Pulsatile Tinnitus". Ultrasound Med Biol. 42 (2): 407–12. doi:10.1016/j.ultrasmedbio.2015.10.013. PMID 26614386.
- ↑ 13.0 13.1 13.2 Lin YH, Wang YF, Liu HM, Lee CW, Chen YF, Hsieh HJ (January 2018). "Diagnostic accuracy of CTA and MRI/MRA in the evaluation of the cortical venous reflux in the intracranial dural arteriovenous fistula DAVF". Neuroradiology. 60 (1): 7–15. doi:10.1007/s00234-017-1948-2. PMID 29188304.
- ↑ Lin YH, Lin HH, Liu HM, Lee CW, Chen YF (August 2016). "Diagnostic performance of CT and MRI on the detection of symptomatic intracranial dural arteriovenous fistula: a meta-analysis with indirect comparison". Neuroradiology. 58 (8): 753–63. doi:10.1007/s00234-016-1696-8. PMID 27185610.
- ↑ Mise N, Uchida L, Tanaka M, Tanaka S, Nakajima H, Sugimoto T (October 2011). "Acute systemic hypotension after arteriovenous fistula construction in a patient with severe aortic stenosis". Clin. Exp. Nephrol. 15 (5): 788–790. doi:10.1007/s10157-011-0484-3. PMID 21725657.
- ↑ Kamyar MM, Saeed Modaghegh MH, Kazemzadeh G (December 2016). "Limb complaints after autogenous arteriovenous fistula creation in chronic hemodialysis patients". Semin Vasc Surg. 29 (4): 172–177. doi:10.1053/j.semvascsurg.2016.11.002. PMID 28779783.
- ↑ 17.0 17.1 Huang W, Villavicencio JL, Rich NM (April 2005). "Delayed treatment and late complications of a traumatic arteriovenous fistula". J. Vasc. Surg. 41 (4): 715–7. doi:10.1016/j.jvs.2005.01.049. PMID 15874939.
- ↑ Kim JH, Yoon SM, Choi HJ (January 2015). "Iatrogenic arteriovenous fistula of the superficial temporal artery after reduction malarplasty". J Craniofac Surg. 26 (1): e50–1. doi:10.1097/SCS.0000000000001312. PMID 25569414.
- ↑ 19.0 19.1 19.2 Parks AH, Guy BL, Rawlings CA, Constantino MJ (February 1989). "Lameness in a mare with signs of arteriovenous fistula". J. Am. Vet. Med. Assoc. 194 (3): 379–80. PMID 2917907.
- ↑ 20.0 20.1 20.2 Swanson KL, Prakash UB, Stanson AW (July 1999). "Pulmonary arteriovenous fistulas: Mayo Clinic experience, 1982-1997". Mayo Clin. Proc. 74 (7): 671–80. doi:10.4065/74.7.671. PMID 10405695.
- ↑ Fourcade L, Vahdat B, Panagides D, Yvorra S, Bonnet JL, Bory M (January 1996). "[Pulmonary arteriovenous fistula. A rare cause of dyspnea and cyanosis in an adult]". Arch Mal Coeur Vaiss (in French). 89 (1): 103–6. PMID 8678732.
- ↑ 22.0 22.1 Kwaan JH, McCart PM, Jones SA, Connolly JE (June 1977). "Aortocaval fistula detection using a Swan-Ganz catheter". Surg Gynecol Obstet. 144 (6): 919–21. PMID 871003.
- ↑ Rhodes GR, Cox CB, Silver D (April 1973). "Arteriovenous fistula and false aneurysm as the cause of consumption coagulopathy". Surgery. 73 (4): 535–40. PMID 4690101.
- ↑ Miyatake K, Okamoto M, Kinoshita N, Fusejima K, Sakakibara H, Nimura Y (May 1984). "Doppler echocardiographic features of coronary arteriovenous fistula. Complementary roles of cross sectional echocardiography and the Doppler technique". Br Heart J. 51 (5): 508–18. PMC 481541. PMID 6721946.
- ↑ 25.0 25.1 Miller RJ, MacRae JM, Mustata S (September 2014). "Conservative management of an iatrogenic arteriovenous fistula". Nephron Extra. 4 (3): 155–8. doi:10.1159/000366451. PMC 4224231. PMID 25404936.
- ↑ Bagherpour AN, Rodriguez GJ, Moorthy C, Trier TT, Maud A (August 2016). "Combined surgical and endovascular treatment of complex high-flow conus medullaris arteriovenous fistula associated with Parkes Weber syndrome: case report". J Neurosurg Spine. 25 (2): 234–8. doi:10.3171/2016.1.SPINE151156. PMID 27015132.
- ↑ Yen CP, Lanzino G, Sheehan JP (October 2013). "Stereotactic radiosurgery of intracranial dural arteriovenous fistulas". Neurosurg. Clin. N. Am. 24 (4): 591–6. doi:10.1016/j.nec.2013.05.008. PMID 24093576.
- ↑ Takahashi S, Katayama K, Tatsugawa T, Sueda T (January 2015). "A successful hybrid repair for vertebral arteriovenous fistula with extracranial vertebral artery aneurysm". Ann Vasc Surg. 29 (1): 126.e5–8. doi:10.1016/j.avsg.2014.07.038. PMID 25304908.