Arteriovenous fistula
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 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 venupuncture with accidental piercing of the artery.[1][2][3]
- Congenital arteriovenous fistula (AVF) of the coronary arteries, a rare cardiac anomaly, was first described by Krause W. Uber, in 1865.[4][5][6]
Classification
- Arteriovenous fistula (AVF) can be classified into:
Vascular Access for Hemodialysis
Patients with end stage renal failure are treated with hemodialysis. In dialysis, blood is withdrawn from an artery or vein, purified, and returned to a vein. The volume of blood is too great for veins to handle, so a vein must be enlarged. An artery and vein, usually in the arm above or below the elbow, are sewn together, to create a fistula, and arterial pressure eventually enlarges the vein. The enlarged vein can accommodate a cannula or large needle.
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 (AVF) can lead to congestive heart failure associated with increased activity of vasoconstrictor neurohormonal systems, renin-angiotensin, sympathetic nervous system, endothelin system, and Arginine vasopressin.[11]
- 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.[12]
- The malformation can result in hemorrhage and the risk is significantly higher with small size malformation because of the significantly higher feeding artery pressures.[13]
Normal blood flow in the brachial artery is 85 to 110 milliliters per minute (mL/min). After the creation of a fistula, the blood flow increases to 400 to 500 mL/min immediately, and 700 to 1,000 mL/min within 1 month. A bracheocephalic fistula above the elbow has a greater flow rate than a radiocephalic fistula at the wrist. Both the artery and the vein dilate and elongate in response to the greater blood flow and shear stress, but the vein dilates more and becomes "arterialized". In one study, the cephalic vein increased from 2.3 mm to 6.3 mm diameter after 2 months. When the vein is large enough to allow cannulation, the fistula is defined as "mature."
Clinical Features
- In the case of coronary arteriovenous fistula (AVF) patients can be asymptomatic or present with:
- Fistulae involving the spinal vasculature can present with neurologic symptoms of the lower extremities which may include weakness and sensory disturbance.[16]
- Acquired arteriovenous fistula (AVF) can result in digital clubbing.[17]
- Patients on hemodialysis with arteriovenous fistula (AVF) can develop pseudo-Kaposi's sarcoma.[18]
- Abdominal arteriovenous fistulae can present with:
- Lower extremity edema with cyanosis
- Pulsatile varicose veins
- Scrotal edema[19]
- Ilio-iliac arteriovenous fistula (AVF) presents with progressive abdominal distention, dyspnea, and swollen leg, which makes it difficult to distinguish from deep venous thrombosis (DVT) and can lead to a delay in the diagnosis.[20]
- Tentorial dural arteriovenous fistula (AVF) can rarely manifest as trigeminal neuralgia.[21]
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:
- An ilio-iliac arteriovenous fistula (AVF) can lead to a misdiagnosis of deep venous thrombosis (DVT)[20]
Epidemiology and Demographics
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 predeliction for arteriovenous fistula (AVF).
Diagnosis
Doppler Echocardiography
(Images shown below are courtesy of RadsWiki)
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Renal arteriovenous fistula
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Renal arteriovenous fistula
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Renal arteriovenous fistula
Treatment
Congenital fistulas, if small, usually do not need treatment. Acquired fistulas can be treated by surgery.
Contraindicated medications
Compensatory hypertension due to Arteriovenous fistula is considered an absolute contraindication to the use of the following medications:
Related Chapters
External Links
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2008 ACC/AHA Guidelines for the Management of Adults With Congenital Heart Disease (DO NOT EDIT)
Coronary Arteriovenous Fistula (DO NOT EDIT)[28]
| Class I |
| "1. If a continuous murmur is present, its origin should be defined either by echocardiography, MRI, CT angiography, or cardiac catheterization. (Level of Evidence: C)" |
| ”2. A large coronary arteriovenous fistula (CAVF), regardless of symptomatology, should be closed via either a transcatheter or surgical route after delineation of its course and its potential to fully obliterate the fistula. (Level of Evidence: C)" |
| ”3. A small to moderate CAVF in the presence of documented myocardial ischemia, arrhythmia, otherwise unexplained ventricular systolic or diastolic dysfunction or enlargement, or endarteritis should be closed via either a transcatheter or surgical approach after delineation of its course and its potential to fully obliterate the fistula. (Level of Evidence: C)" |
| Class III |
| "1. Patients with small, asymptomatic CAVF should not undergo closure of CAVF. (Level of Evidence: C)" |
| Class IIa |
| "1. Clinical follow-up with echocardiography every 3 to 5 years can be useful for patients with small, asymptomatic CAVF to exclude development of symptoms or arrhythmias or progression of size or chamber enlargement that might alter management. (Level of Evidence: C)" |
Management Strategies for CAVF(DO NOT EDIT)[28]
| Class I |
| "1. Surgeons with training and expertise in CHD should perform operations for management of patients with CAVF. (Level of Evidence: C)" |
| ”2. Transcatheter closure of CAVF should be performed only in centers with expertise in such procedures. (Level of Evidence: C)" |
| ”3. Transcatheter delineation of CAVF course and access to distal drainage should be performed in all patients with audible continuous murmur and recognition of CAVF. (Level of Evidence: C)" |
References
- ↑ Khodadad G (January 1973). "Arteriovenous malformations of the scalp". Ann. Surg. 177 (1): 79–85. PMC 1355509. PMID 4682507.
- ↑ Liu J, Shimada Y (2014). "A Case of Intractable Left Forearm Congenital Arteriovenous Fistula Ending with Amputation: Importance of New Medical Information Obtained via the Internet". J Rural Med. 9 (1): 37–9. doi:10.2185/jrm.2878. PMC 4310049. PMID 25650050.
- ↑ 3.0 3.1 3.2 Yater WM (January 1928). "ACQUIRED ARTERIOVENOUS FISTULA". Ann. Surg. 87 (1): 19–31. PMC 1398373. PMID 17865813.
- ↑ Albeyoglu S, Aldag M, Ciloglu U, Sargin M, Oz TK, Kutlu H, Dagsali S (2017). "Coronary Arteriovenous Fistulas in Adult Patients: Surgical Management and Outcomes". Braz J Cardiovasc Surg. 32 (1): 15–21. doi:10.21470/1678-9741-2017-0005. PMC 5382904. PMID 28423125.
- ↑ Lim WH, Kang SH, Jeon K, Cho I, Kim KH, Hwang SW, Kim HK, Sohn DW (September 2009). "Asymptomatic Right Coronary Artery-to-Pulmonary Artery Fistula Incidentally Detected by Transthoracic Echocardiography". J Cardiovasc Ultrasound. 17 (3): 106–9. doi:10.4250/jcu.2009.17.3.106. PMC 2889379. PMID 20661326.
- ↑ Jang SN, Her SH, Do KR, Kim JS, Yoon HJ, Lee JM, Jin SW (December 2008). "A case of congenital bilateral coronary-to-right ventricle fistula coexisting with variant angina". Korean J. Intern. Med. 23 (4): 216–8. doi:10.3904/kjim.2008.23.4.216. PMC 2687685. PMID 19119260.
- ↑ Luke JC (April 1940). "CONGENITAL ARTERIOVENOUS FISTULA". Can Med Assoc J. 42 (4): 341–5. PMC 537854. PMID 20321666.
- ↑ Robbs JV, Carrim AA, Kadwa AM, Mars M (September 1994). "Traumatic arteriovenous fistula: experience with 202 patients". Br J Surg. 81 (9): 1296–9. PMID 7953391.
- ↑ Nagpal K, Ahmed K, Cuschieri R (2008). "Diagnosis and management of acute traumatic arteriovenous fistula". Int. J. Angiol. 17 (4): 214–6. PMC 2728918. PMID 22477453.
- ↑ Laberge JM (December 2004). "Interventional management of renal transplant arteriovenous fistula". Semin Intervent Radiol. 21 (4): 239–46. doi:10.1055/s-2004-861558. PMC 3036239. PMID 21331135.
- ↑ Abassi ZA, Winaver J, Hoffman A (October 2003). "Large A-V fistula: pathophysiological consequences and therapeutic perspectives". Curr Vasc Pharmacol. 1 (3): 347–54. PMID 15320481.
- ↑ 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.
- ↑ Spetzler RF, Hargraves RW, McCormick PW, Zabramski JM, Flom RA, Zimmerman RS (June 1992). "Relationship of perfusion pressure and size to risk of hemorrhage from arteriovenous malformations". J. Neurosurg. 76 (6): 918–23. doi:10.3171/jns.1992.76.6.0918. PMID 1588424.
- ↑ Zamani H, Meragi M, Arabi Moghadam MY, Alizadeh B, Babazadeh K, Mokhtari-Esbuie F (2015). "Clinical presentation of coronary arteriovenous fistula according to age and anatomic orientation". Caspian J Intern Med. 6 (2): 108–12. PMC 4478461. PMID 26221510.
- ↑ Sapin P, Frantz E, Jain A, Nichols TC, Dehmer GJ (March 1990). "Coronary artery fistula: an abnormality affecting all age groups". Medicine (Baltimore). 69 (2): 101–13. PMID 2319939.
- ↑ 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.
- ↑ Leb DE, Sharma JK (July 1978). "Clubbing secondary to an arteriovenous fistula used for hemodialysis". JAMA. 240 (2): 142–3. PMID 660832.
- ↑ 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.
- ↑ Scruggs J, Bennett DD (June 2011). "Cutaneous manifestations of abdominal arteriovenous fistulas". Cutis. 87 (6): 284–6. PMID 21838084.
- ↑ 20.0 20.1 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.
- ↑ Lu X, Qin X, Ni L, Chen J, Xu F (November 2013). "Tentorial dural arteriovenous fistula manifesting as contralateral trigeminal neuralgia: resolution after transarterial Onyx embolization". BMJ Case Rep. 2013. doi:10.1136/bcr-2013-010984. PMC 3847479. PMID 24285803.
- ↑ Fernández-Rodriguez CM, Prieto J, Zozaya JM, Quiroga J, Guitián R (April 1993). "Arteriovenous shunting, hemodynamic changes, and renal sodium retention in liver cirrhosis". Gastroenterology. 104 (4): 1139–45. PMID 8462804.
- ↑ Celik O, Buyuktas D, Islak C, Sarici AM, Gundogdu AS (July 2013). "The association of carotid cavernous fistula with Graves' ophthalmopathy". Indian J Ophthalmol. 61 (7): 349–51. doi:10.4103/0301-4738.109533. PMC 3759106. PMID 23571267.
- ↑ 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.
- ↑ 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.
- ↑ Putschar WG (October 1972). "Circulation in Paget's disease of bone". N. Engl. J. Med. 287 (14): 717–8. doi:10.1056/NEJM197210052871410. PMID 5055421.
- ↑ STORSTEEN KA, JANES JM (February 1954). "Arteriography and vascular studies in Paget's disease of bone". J Am Med Assoc. 154 (6): 472–4. PMID 13117640.
- ↑ 28.0 28.1 Warnes CA, Williams RG, Bashore TM, Child JS, Connolly HM, Dearani JA; et al. (2008). "ACC/AHA 2008 guidelines for the management of adults with congenital heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Develop Guidelines on the Management of Adults With Congenital Heart Disease). Developed in Collaboration With the American Society of Echocardiography, Heart Rhythm Society, International Society for Adult Congenital Heart Disease, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons". J Am Coll Cardiol. 52 (23): e1–121. doi:10.1016/j.jacc.2008.10.001. PMID 19038677.