Arteriovenous Fistula

Hannah Jayroe; Katie Foley.

Author Information

Last Update: December 7, 2021.

Go to:

Continuing Education Activity

Arteriovenous fistulas (AVFs) are abnormal connections between arteries and veins. AVFs can be
surgically created, can occur as a result of a congenital or genetic anomaly, or be secondary to iatrogenic
injury or trauma. Other than the surgically created types of fistulas, these are quite rare. Due to the
pressure gradient between the arterial and venous systems, these can cause significant pathologic
effects on the body with the severity depending on the location of the fistula. This activity reviews the
role of the interprofessional team in the evaluation and management of arteriovenous fistulas.

Objectives:

 Summarize the pathophysiology of arteriovenous fistula.

 Describe the clinical presentation of patients with arteriovenous fistula.

 Outline the options available for the management of arteriovenous fistula.

 Review the role of the interprofessional team in ensuring the best outcomes for patients having
arteriovenous fistula.

Access free multiple choice questions on this topic.

Go to:

Introduction

Arteriovenous fistulas (AVFs) are abnormal connections between an artery and a vein.[1] In
certain contexts, these may also be referred to as arteriovenous malformations.[2] AVFs can exist almost
anywhere in the body, depending on the etiology. These can be divided into two groups, acquired or
congenital. Acquired fistulas can be further subdivided into surgically created, as in for hemodialysis, or
secondary to trauma, whether accidental or procedure-related. 

The anatomy of the fistula depends on the location in the body. AVFs for hemodialysis are typically
created in the extremities and the upper extremity is generally preferred over the lower extremity by
vascular surgeons. The cephalic and basilic veins are often used for the surgical creation of an AVF. The
radial artery at the volar wrist and the brachial artery at the antecubital fossa and medial upper arm are
typical anatomical locations for fistula creation, although the radio-cephalic AVF is the preferred initial
access for hemodialysis.[3] 

Two types of lower extremity surgical AVFs for hemodialysis have been described in the literature. The
superficial femoral vein or popliteal vein can be mobilized from the knee to anastomose with the
superficial femoral artery; this is called an SFV transposition. The saphenous vein can be used to create a
loop AVF on the anterior thigh, anastomosed with the common femoral artery.[4][5]

Although no type of congenital AV fistula is common, reported locations for congenital AVFs

include pulmonary, aortocaval, dural, carotid-cavernous, coronary, and hepatic.[6][7][8][9] While the
majority of neck fistulas do occur secondary to trauma, congenital vertebrovertebral fistulas
and carotid-jugular fistulas have been described in children.[10] 

AVFs as a result of iatrogenic injury are typically a result of surgical procedures, invasive line placement,
or needle biopsy. The literature demonstrates multiple reports of iatrogenic injury resulting years after
surgical procedures.[11][12] Traumatic AVF can essentially occur wherever there is trauma and these
can also have a late presentation.[13] Greater than 50% of traumatic AVFs happen in the lower
extremity, and about one-third occur in the femoral vessels, while 15% take place in the popliteal
vessels.[14]

Go to:

Etiology

Arteriovenous fistulas can be surgically created for hemodialysis access, can occur as a result of a
congenital anomaly, or be secondary to iatrogenic injury or trauma. Penetration of any mixed-type
vasculature can ultimately result in the healing of arteries and veins together, bypassing downstream
arteriole and capillary systems.

Iatrogenic Fistulas

These are most commonly reported as a result of percutaneous access of the femoral vein and femoral
artery during cardiac catheterization; although, subclavian and carotid fistulas have been reported
in association with the placement of central lines.[15] The most common AVFs described as a result of
percutaneous biopsy are renal; however, these are typically self-limited, and very few require
intervention.[16] 

Traumatic Fistulas

These are often associated with direct arterial trauma and long bone fractures, especially where an
artery and vein are in close communication. Ninety percent of traumatic AVFs are due to penetrating
trauma, the majority of which are gunshot wounds.[17] A small portion of neck AVFs can occur in
association with a hyperextension injury or spine surgery. Carotid-cavernous fistulas, typically due to
trauma, can be fatal and are most often associated with a basilar skull fracture, penetrating trauma to
the area, and ruptured aneurysms.[18] Two-thirds of traumatic AVFs are diagnosed within one week of
the injury; however, some may present weeks to years after the event.[19][20] 

Congenital Fistulas

These are not well-understood. Congenital AVFs of the central nervous system can be dural or carotid
cavernous. AVFs of the neck are mostly due to trauma; however, fibromuscular dysplasia,
neurofibromatosis, and other types of collagen disorders have been associated. Pulmonary vascular
malformations are typically simple and more similar to AVFs than to a true malformation.[21] Other
types of AVFs are very rare.
Go to:

Epidemiology

Arteriovenous fistulas were originally described by William Hunter as early as 1757.[14] Much of the

experience in managing AVFs originated out of traumatic injuries resulting in AVFs from the Second
World War, the Korean War, and Vietnam War. 215 AVFs and aneurysms were reported as a result of
the Korean War.[22] In the civilian population, traumatic AVFs of the abdomen and extremities are
equally distributed, unlike the military, where the majority of traumatic AVFs occur in the extremities.
[23][17] This difference is likely on account of body armor worn by the military. Demonstrably, traumatic
fistulas are much more common than congenital fistulas and are more frequently discussed. Congenital
fistulas are generally rare and found in case reports and small studies.[24]

The National Institute of Diabetes and Digestive and Kidney Diseases reported as of 2013, over 468,000
patients were on hemodialysis. Twenty percent of those patients receive dialysis via a surgically created
AVF. In the HEMO Study published in 2000, AVF prevalence varied between dialysis centers from 4-
77%. The authors discovered a decreased prevalence of AVF compared to other means of hemodialysis
in females, blacks, obese, elderly, and patients with peripheral arterial disease. Geographically, the rate
of AVF creation varies greatly, with the highest rates being in the Northeast and the lowest in the
Southwest of the United States.[25]

Go to:

History and Physical

The presentation of arteriovenous fistulas can vary depending on the location and etiology. Patients
with an AVF for hemodialysis will present with evidence of a surgical incision on the lateral wrist, volar
forearm, or upper arm. A working AVF will have a palpable thrill and continuous bruit. A patient with an
AVF with an outflow obstruction may present with a pulsatile fistula or prolonged bleeding from a
puncture site from hemodialysis. Superficial fistulas have a palpable thrill, a bruit, or even a pulsatile
mass. It may be possible to auscultate a machinery-like murmur over the fistula.[26]

Fistulas of the extremities, regardless of etiology, may present with signs of venous hypertension,
including varicosities, pain, and swelling. If there has been a long-standing fistula, there may be a
significant size discrepancy between the two limbs. If the patient reports a history of trauma, anywhere
from weeks to years after injury, in particular with long bone fractures or ongoing neurologic deficits,
the index of suspicion for AVF should be raised even in the event of a clinically normal exam.[17]

Patients with congenital AVF may not present until later in life, and a history of trauma should be ruled
out. Depending upon location, these fistulas may be low-flow at birth and become high-flow lesions in
adulthood. Patients with brain arteriovenous malformations can present with headaches, neurologic
deficits, seizures, or a combination. These patients can also be at risk for hemorrhage or ischemia to the
parenchyma surrounding the AVM/AVF due to steal syndrome.

In severe, chronic, or high flow fistulas, patients can present in high output cardiac failure, which results
in shunting of oxygenated blood back to the right heart. Due to the shortcut that the arterial blood takes
through the venous system, this results in decreased peripheral resistance. In order to maintain blood
pressure, the total circulating blood volume is increased, leading to heart failure. The Nicoladoni-Israel-
Branham sign is a finding of reflex bradycardia with compression of the fistula due to increased
afterload.[10]

Cutaneous AVFs can present with a pink stain, a mass, dilated veins, unequal limb size, or skin
ulceration. Patients may feel limb heaviness that aggravates with dependency and relieves with
elevation. Almost one-half of patients experience pain.[27]The pain may be because of ischemic tissues
or by compression effect on surrounding nerves. Some lesions can be tender, such as glomuvenous
malformations.

On examination, there could be an increase in the size of the limb, swelling, discoloration, or prominent

vessels with a murmur or palpable thrill. The lesions may also be pulsatile. Over the lesion, there could
be hyperhidrosis, hyperthermia, hypertrichosis, or a bruit. Limbs and joints may be functionally impaired
from mass effect or necrosis from prolonged tissue ischemia. Visceral AVFs can present with
hematemesis, hematuria, hemoptysis, or melena. Occasionally patients may have an initial presentation
of heart failure particularly in cases where the fistula is between a very large artery and vein.[28]

Go to:

Evaluation

Beyond the clinical evaluation from history and physical, a duplex ultrasound (US) is a non-invasive and
inexpensive way to confirm the diagnosis of AVF, given that the AVF is superficial. The duplex US will
demonstrate low resistance flow in the feeding artery. At the anastomosis or fistula, turbulence and
high-velocity flow are demonstrated. Thickened walls and high-velocity flow will be seen in the dilated
draining veins or venous plexus of the AVF. A pseudoaneurysm, venous aneurysm, or a dilated feeding
artery may also be demonstrated on the ultrasound exam.[15]

Computed tomography angiography (CTA) and magnetic resonance angiography (MRA) both show early
contrast filling in the arterial phase in the involved vein. While MRA may not be an option in trauma or
post-trauma patient due to residual metal, CTA is reliable, non-invasive, and accessible as an initial
diagnostic test. Disadvantages of CTA include streak artifact from metallic objects (which can be an issue
in penetrating trauma), motion artifact, and reliance on contrast timing in the fistula.[29] A
retrospective study conducted by Biswas et al observed four-dimensional (4D) CTA to be precise in
delineating AVMs and dural AVFs, providing findings that were relevant to the results of digital
subtraction angiography.[30] A study carried out by In 't veld et al draws a comparison between the
diagnostic precision of 4D-CTA and that of DSA. It was found that 4D CTA had much higher sensitivity
and specificity and it was less invasive than DSA.[31]

Selective angiography is the gold standard and has shown better accuracy over CTA. It is the most
invasive evaluation of an AVF but provides the exact point of arteriovenous communication surrounding
vascular anatomy, flow dynamics, and mechanism for treatment.[32] Cost, procedural delay, additional
arterial or venous access, and the need for a specially trained team are disadvantages of angiography. 

Patients presenting in need of vascular access for ESRD need to be evaluated for optimal placement of
an AVF. Given the preference of the upper extremity, non-dominant over dominant, forearm over the
upper arm, all patients should be evaluated with a duplex ultrasound scan, including patients presenting
for evaluation of an existing AVF. Criteria have been developed for optimal results and primary patency
rates. Clinical exam, in addition to vein mapping, has been shown to decrease primary failure rates and
decrease negative surgical exploration in first attempts to create AVFs.[33]

Blood gas analysis in an AVF shows a higher oxygen content in the venous side of the blood distal to the
fistula as opposed to normal venous blood. A flow-directed balloon catheter (Swan-Ganz catheter) can
assess hemodynamics and reveal increased cardiac output and decreased peripheral vascular resistance.
Extremely large AVFs may present with thrombocytopenia due to constant turbulence and trapping of
platelets.

Go to:

Treatment / Management

Most cases of arteriovenous fistulas in the past were treated conservatively in wartime and, later on,
were surgically managed if needed.[22] Early intervention, however, may deter complications of AVFs
that can be avoided, and post-traumatic fistulas should be closed as close to diagnosis as possible.
[26] The goal of AVF treatment is to isolate and close the fistula while attempting to maintain essential
blood flow. Repair may be completed by direct primary repair, reconstruction (autogenous or prosthetic
graft, or bypass), or endovascular.[14] 

Indications for Treatment

 Hemodynamic instability, availability of a surgical team, injury to

adjacent tissue, and unsuccessful endovascular repair are all indications for open surgical
intervention on a fistula. 

 In traumatic fistulas, failure of spontaneous regression within two weeks indicates repair.

 Congenital fistulas are typically repaired when they present due to sequelae in later life, as
many may remain asymptomatic until adulthood.

 Hemodialysis fistulas that are no longer functioning, no longer needed, have endured

multiple attempts at salvage, or fail to mature should be considered for ligation.

 Other important indications of surgical repair of AVFs are hemorrhage, pain with ischemia,
congestive cardiac failure, Limb-size inequality, nonhealing ulcers, and functional impairment.

Endovascular Management

 It is the preferred method of management for AVFs.

 The first endovascular repair was done in 1992 by Parodi of a traumatic subclavian AVF; a
covered stent was used.[34]

 The advantages of endovascular repair include rapid recovery, less post-operative pain, and less
disability compared with the open approach.

 Coils, stent-grafts, covered stents, cyanoacrylate glue, are among the options for closing the

fistula.[35]
  Stent grafts are used to exclude the fistula while preserving the essential artery and vein; coils
can be used when there is a low risk of complication to embolizing essential vessels. Endografts
designed for larger vessels, such as the aorta or iliac vessels, can be used similarly. Stent graft
patency rates at a one-year range between 88 and 100%.

 Complications involved with placement of covered stents include arterial dissection or rupture,
migration of the device, or embolization. In a review of patients with traumatic AVFs, the most
common reason for the failure of the endovascular intervention was the inability to advance the
guidewire.

 The patient may also develop intimal hyperplasia at the placement site of the stent or subacute
thrombosis, leading to occlusion and distal ischemia. If the patient does develop venous
thrombosis, anticoagulation should be initiated and continued for six months.

 Embolization can be advantageous for complex AVFs with multiple feeding and draining
vessels. Deep-seated or intra-organ and adjacent to critical anatomy, AVFs are much more
amenable to endovascular management than open surgery.[36][37]

 Contraindications to endovascular management include contrast allergy.

 In the treatment of AVFs, many sclerosing agents, including injectible absolute ethanol, can be
administered. They may carry a risk of necrosis of the surrounding tissue. So they should be
used with caution.[38]

Open Surgery

 It is an option for repair when endovascular management fails.

 In addition to the need for surgical exposure of the fistula and increased risk of bleeding, high
morbidity is associated with an open approach, including venous stasis, limb (or distal) ischemia,
limb loss, venous thrombosis, and pulmonary embolism.

 Repairs can be made via autogenous (usually saphenous vein) grafts, synthetic grafts, venous
ligation (diameter dependent), bypass, or complex reconstruction involving one or more of the
above. 

 Limitations for using the saphenous vein autologous graft include needing a vein of 3-8 mm, no
lower extremity venous insufficiency, and no thrombophlebitis of the vein.[14]

 Conservative management is an option if no symptoms or complications exist or if the AVF

is expected to be self-limited.

Go to:

Differential Diagnosis

Differential diagnoses of AVF include other conditions that result in hyperdynamic circulation, such as
tachycardia, increased cardiac output, and decreased peripheral resistance.

 Arteriovenous malformation: These are congenital lesions from the failure of fetal vascular
differentiation. High flow or complex AVMs are more likely to have high resistance, similar to a
 capillary bed, and, therefore, are more likely to be asymptomatic.[39] AVMs can be
differentiated from AVFs with high resonance imaging (CTA or MRA). 

 Hemangioma: Hemangiomas, also known as vascular tumors, may have similar symptoms

to AVFs. However, these tend to present with overt bleeding. Hemangiomas have been found to
have mitotic activity and can rapidly involute.[39] Similar to AVMs, these can be ruled out with
CTA or MRA.

 Pseudoaneurysm: These may present as a pulsatile mass associated with a vascular access

procedure. Pseudoaneurysms, as well as true aneurysms, may have a thrill due to significant
turbulence through the area. Doppler US can differentiate these from a fistula.

 Malignancy: Malignant masses can require significant blood flow and present as a previously

unnoticed pulsatile mass if closer to a larger vessel. Doppler US and/or multiphasic imaging can
help to differentiate these.

 Cyst/Abscess/Hematoma: These are typically identified as simple hypodense lesions on the

duplex US and will not demonstrate flow.

Go to:

Prognosis

While some congenital arteriovenous fistulas can be fatal, leading to failure to

survive, the overall prognosis is good. Peripheral arteriovenous fistula does not typically incur systemic
hemodynamic effects, and around 15% of all AVFs do.[40]

The Schobinger Classification is a clinical staging system that serves to predict the success of treatment.
Stage 1 is of quiescence and is described as cutaneous blush and skin warmth at the site of the fistula.
The second stage demonstrates darkened skin, a pulsatile lesion with a bruit on auscultation, or
palpable thrill. This stage is called expansion. Stage 3, the destruction phase, is essentially steal
syndrome and is characterized by skin changes, ulceration, and distal ischemia. Stage 4 is the
decompensated phase, characterized by high output heart failure. While it has been shown that
decompensated heart failure can be completely reversed after a high-flow AVF is closed, the prognosis is
much better in patients who present earlier.[39]

Prompt recognition is crucial for favorable outcomes. Brinjikji et al observed spinal dural AVFs which are
either easily missed on imaging or misdiagnosed. These cases were diagnosed at their
institution.They stated that delays in establishing a diagnosis in these cases led to an increased incidence
of additional irreversible disability that frequently could not be corrected surgically or otherwise.[41]

Go to:

Complications

Chronic venous insufficiency/venous hypertension: Venous hypertension can present as swelling of the

affected extremity, which can be progressive and limit mobility. Insufficiency is demonstrated in the
development of stasis pigmentation of the skin, varicosities, and ulcerations. This complication is a direct
result of arterial pressure against the thinner venous walls and failure of one-way valves in the veins.
High cardiac output failure: In a study of 120 patients who suffered from high-output heart failure, 23%
were found to have an AV shunt, which includes congenital, traumatic, and HD fistulas. In all patients
with high-output cardiac failure, their increased stroke volume was secondary to decreased vascular
resistance, which is a mechanism found in patients with AVFs, particularly when these become high-
flow.[42]

Arterial insufficiency: Steal syndrome can occur in up to 6% of patients with an AVF or arteriovenous

graft for hemodialysis. It is a result of a high-flow fistula causing distal ischemia.[39] These patients can
present with severe pain associated with the use or during hemodialysis. They may also have swelling
or signs of ischemia distal to the fistula, such as cool skin, discolored fingers or toes, diminished distal
pulses, hair loss, or atrophy. A normal compensatory mechanism to the fistula is to increase overall flow
to the affected extremity which will provide adequate blood flow to the higher
resistance distal capillary beds; when this mechanism fails, steal syndrome results which draw blood
through the lower resistance fistula instead of supplying distal tissue. Inflow stenosis of the arterial
supply can be a cause of or worsen steal. In the evaluation for steal syndrome, compression of the
fistula will increase inflow to the symptomatic distal extremity.[43]

Hemorrhage: Hemorrhage is a much rarer complication than those above. Due to the high flow through
the venous system, dilatations can occur throughout the venous drainage system. These can become
thin-walled and be at risk for rupture. This can be especially problematic with hemodialysis fistulas
which are repetitively accessed through the venous side causing ulcerations to the vein and overlying
skin. High flow through the fistula and outflow stenosis can make obtaining hemostasis challenging after
dialysis.[44]

Go to:

Consultations

The consultation need for the management of the arteriovenous fistula depends on the location and
nature of the fistula. Specialties required to be involved can include:

 Vascular surgery 

 Interventional radiology 

 Interventional cardiology

 Neurosurgery

 Interventional neurology

Go to:

Deterrence and Patient Education

While AVFs may be unavoidable for patients with end-stage renal disease, the best way to prevent the
development of an AVF is to avoid unnecessary trauma or procedures that may lead to their
development. Congenital AVF etiology is poorly understood, and thus, there is little to do in terms of
prevention.
Patients who are diagnosed with an AVF or who think they may have an AVF should see their primary
care provider first. After a thorough work-up, these patients may be referred to see one of the
specialists mentioned above for management and potential repair of the fistula. Important things to
write down before any appointment include any symptoms experienced, any changes in the extremity
or area of concern, and any significant history, such as trauma or procedures in the same area. A fistula
can arise from prior injury at any point in your lifetime.

Expectations from your provider can include further labs and imaging, including an ultrasound, a CT, or
MRI. Your provider will look at, listen to, and feel the area to start the evaluation. In addition to your
questions and the provision of symptoms, your provider will likely ask you further questions to help with
the diagnosis of this problem.

Go to:

Enhancing Healthcare Team Outcomes

Patients presenting with signs and symptoms of arteriovenous fistulas require an interprofessional
approach to the workup. As with any condition, this starts with a thorough history and physical exam.
Involving the appropriate surgical team early in the process can help direct the evaluation such that
imaging obtained can be used in surgical planning. Early warnings to trauma patients with injuries to the
extremities, particularly involving an arterial or venous injury, should help to prevent late presentations
of high-flow AVFs. Surgeons, interventionalist, and intensivists should be aware of arteriovenous fistulas
as a potential complication of bedside procedures for venous access and biopsies.

Go to:

Review Questions

 Access free multiple choice questions on this topic.

 Comment on this article.

Figure

Top Left 2 images - A Cognard type 3 dural arteriovenous fistula is seen on cerebral catheter
angiography with arterial phase right common carotid injections, lateral view (top) and anteroposterior
view (bottom). Bottom 2 Images - A cerebral catheter (more...)
Figure

Diagram of arteriovenous fistula. Created by Bruce Blaus, Blausen.com staff (2014). "Medical gallery of
Blausen Medical 2014". WikiJournal of Medicine 1 (2). DOI:10.15347/wjm/2014.010. ISSN 2002-4436.
Used under Creative Commons Attribution 3.0, https://creativecommons.org/licenses/by/3.0/ (more...)

Go to:

References

1.

Gonzalez-Araiza G, Haddad L, Patel S, Karageorgiou J. Percutaneous Embolization of a Postsurgical

Prostatic Artery Pseudoaneurysm and Arteriovenous Fistula. J Vasc Interv Radiol. 2019 Feb;30(2):269-
271. [PubMed]

2.

Faughnan ME, Lui YW, Wirth JA, Pugash RA, Redelmeier DA, Hyland RH, White RI. Diffuse pulmonary
arteriovenous malformations: characteristics and prognosis. Chest. 2000 Jan;117(1):31-8. [PubMed]

3.

Antoniou GA, Lazarides MK, Georgiadis GS, Sfyroeras GS, Nikolopoulos ES, Giannoukas AD. Lower-
extremity arteriovenous access for haemodialysis: a systematic review. Eur J Vasc Endovasc Surg. 2009
Sep;38(3):365-72. [PubMed]

4.

Nepal S, Annamaraju P. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Sep 21, 2021.
Coronary Arteriovenous Fistula. [PubMed]

5.

Demirci O, Celayir A. Prenatal diagnosis and treatment of intrahepatic arteriovenous fistulas: case
reports and the literature review. J Matern Fetal Neonatal Med. 2020 Apr 02;:1-9. [PubMed]

6.

Jha AK, Sunder A. An unusual case of pulmonary arterio-venous fistula (PAVF). J Family Med Prim
Care. 2019 Oct;8(10):3408-3411. [PMC free article] [PubMed]

7.

Kandemirli SG, Kizilkaya MH, Erdemli Gursel B, Akca T, Bostan OM. Congenital arteriovenous fistula
between descending aorta and the left innominate vein. Surg Radiol Anat. 2020 Apr;42(4):401-
404. [PubMed]

8.

Reynolds MR, Lanzino G, Zipfel GJ. Intracranial Dural Arteriovenous Fistulae. Stroke. 2017

May;48(5):1424-1431. [PMC free article] [PubMed]
9.

Kléber AG. Consequences of acute ischemia for the electrical and mechanical function of the ventricular
myocardium. A brief review. Experientia. 1990 Dec 01;46(11-12):1162-7. [PubMed]

10.

Guneyli S, Cinar C, Bozkaya H, Korkmaz M, Oran I. Endovascular management of congenital

arteriovenous fistulae in the neck. Diagn Interv Imaging. 2016 Sep;97(9):871-5. [PubMed]

11.

Ying A, Al-Asady R, Vicaretti M. Endovascular treatment of a large iatrogenic popliteal arteriovenous

fistula. J Vasc Surg Cases Innov Tech. 2020 Mar;6(1):129-132. [PMC free article] [PubMed]

12.

Petrov I, Tasheva I, Stankov Z, Polomski P, Georgieva G, Marinov K. Uneventful Follow-Up 2 Years after
Endovascular Treatment of a High-Flow Iatrogenic Aortocaval Fistula Causing Pulmonary Hypertension
and Right Heart Failure. Methodist Debakey Cardiovasc J. 2019 Apr-Jun;15(2):152-155. [PMC free article]
[PubMed]

13.

Farshidmehr P, Zafarghandi MR, Sadat A, Sayarifard A. Coil Embolization of an Iatrogenic Arteriovenous

Fistula between the Superior Mesenteric Artery and Vein: A Case Report. J Tehran Heart Cent. 2019
Jan;14(1):37-39. [PMC free article] [PubMed]

14.

Şahin M, Yücel C, Kanber EM, İlal Mert FT, Bıçakhan B. Management of traumatic arteriovenous fistulas:
A tertiary academic center experience. Ulus Travma Acil Cerrahi Derg. 2018 May;24(3):234-
238. [PubMed]

15.

Davison BD, Polak JF. Arterial injuries: a sonographic approach. Radiol Clin North Am. 2004
Mar;42(2):383-96. [PubMed]

16.

Van den Broecke M, Vereecke E, De Visschere P. Renal Arteriovenous Fistula. J Belg Soc Radiol. 2020 Jan
31;104(1):10. [PMC free article] [PubMed]

17.

Fox CJ, Gillespie DL, O'Donnell SD, Rasmussen TE, Goff JM, Johnson CA, Galgon RE, Sarac TP, Rich NM.
Contemporary management of wartime vascular trauma. J Vasc Surg. 2005 Apr;41(4):638-44. [PubMed]

18.
Kim JW, Kim SJ, Kim MR. Traumatic carotid-cavernous sinus fistula accompanying abducens nerve (VI)
palsy in blowout fractures: missed diagnosis of 'white-eyed shunt'. Int J Oral Maxillofac Surg. 2013
Apr;42(4):470-3. [PubMed]

19.

Stathis A, Gan J. Traumatic arteriovenous fistula: a 25-year delay in presentation. J Surg Case Rep. 2020
Mar;2020(3):rjaa042. [PMC free article] [PubMed]

20.

Cuoco JA, Guilliams EL, Klein BJ, Malaty GR, Witcher MR, Entwistle JJ. N-butyl cyanoacrylate
embolization of a traumatic pseudoaneurysm and arteriovenous fistula of the middle meningeal
artery. Radiol Case Rep. 2020 Apr;15(4):321-325. [PMC free article] [PubMed]

21.

Dickey KW, Pollak JS, Meier GH, Denny DF, White RI. Management of large high-flow arteriovenous
malformations of the shoulder and upper extremity with transcatheter embolotherapy. J Vasc Interv
Radiol. 1995 Sep-Oct;6(5):765-73. [PubMed]

22.

HUGHES CW. Arterial repair during the Korean war. Ann Surg. 1958 Apr;147(4):555-61. [PMC free
article] [PubMed]

23.

Baldini M, Catania A, Orsatti A, Manfredi MG, Motta P, Cantalamessa L. Inhibitory effect of somatostatin
on abnormal GH response to TRH in primary hypothyroidism. Exp Clin Endocrinol. 1992;99(2):80-
3. [PubMed]

24.

Zamani H, Meragi M, Arabi Moghadam MY, Alizadeh B, Babazadeh K, Mokhtari-Esbuie F. Clinical

presentation of coronary arteriovenous fistula according to age and anatomic orientation. Caspian J
Intern Med. 2015 Spring;6(2):108-12. [PMC free article] [PubMed]

25.

Allon M, Ornt DB, Schwab SJ, Rasmussen C, Delmez JA, Greene T, Kusek JW, Martin AA, Minda S. Factors
associated with the prevalence of arteriovenous fistulas in hemodialysis patients in the HEMO study.
Hemodialysis (HEMO) Study Group. Kidney Int. 2000 Nov;58(5):2178-85. [PubMed]

26.

Nagpal K, Ahmed K, Cuschieri R. Diagnosis and management of acute traumatic arteriovenous fistula. Int
J Angiol. 2008 Winter;17(4):214-6. [PMC free article] [PubMed]

27.
Bernhard SM, Tuleja A, Laine JE, Haupt F, Häberli D, Hügel U, Rössler J, Schindewolf M, Baumgartner I.
Clinical presentation of simple and combined or syndromic arteriovenous malformations. J Vasc Surg
Venous Lymphat Disord. 2021 Oct 11; [PubMed]

28.

Hashimoto O, Miyazaki T, Hosokawa J, Shimura Y, Okuyama H, Endo M. A case of high-output heart

failure caused by a femoral arteriovenous fistula after endovenous laser ablation treatment of the
saphenous vein. Phlebology. 2015 May;30(4):290-2. [PubMed]

29.

Miller-Thomas MM, West OC, Cohen AM. Diagnosing traumatic arterial injury in the extremities with CT
angiography: pearls and pitfalls. Radiographics. 2005 Oct;25 Suppl 1:S133-42. [PubMed]

30.

Biswas S, Chandran A, Radon M, Puthuran M, Bhojak M, Nahser HC, Das K. Accuracy of four-dimensional
CT angiography in detection and characterisation of arteriovenous malformations and dural
arteriovenous fistulas. Neuroradiol J. 2015 Aug;28(4):376-84. [PMC free article] [PubMed]

31.

In 't Veld M, Fronczek R, Dos Santos MP, van Walderveen MAA, Meijer FJA, Willems PWA. High
sensitivity and specificity of 4D-CTA in the detection of cranial arteriovenous shunts. Eur Radiol. 2019
Nov;29(11):5961-5970. [PMC free article] [PubMed]

32.

Ares WJ, Jankowitz BT, Tonetti DA, Gross BA, Grandhi R. A comparison of digital subtraction angiography
and computed tomography angiography for the diagnosis of penetrating cerebrovascular
injury. Neurosurg Focus. 2019 Nov 01;47(5):E16. [PubMed]

33.

Georgiadis GS, Charalampidis DG, Argyriou C, Georgakarakos EI, Lazarides MK. The Necessity for Routine
Pre-operative Ultrasound Mapping Before Arteriovenous Fistula Creation: A Meta-analysis. Eur J Vasc
Endovasc Surg. 2015 May;49(5):600-5. [PubMed]

34.

Marin ML, Veith FJ, Panetta TF, Cynamon J, Barone H, Schonholz C, Parodi JC. Percutaneous
transfemoral insertion of a stented graft to repair a traumatic femoral arteriovenous fistula. J Vasc
Surg. 1993 Aug;18(2):299-302. [PubMed]

35.

Numan F, Omeroglu A, Kara B, Cantaşdemir M, Adaletli I, Kantarci F. Embolization of peripheral vascular

malformations with ethylene vinyl alcohol copolymer (Onyx). J Vasc Interv Radiol. 2004 Sep;15(9):939-
46. [PubMed]

36.
Zaki Ghali G, Zaki Ghali MG, Zaki Ghali E. Transvenous embolization of arteriovenous malformations. Clin
Neurol Neurosurg. 2019 Mar;178:70-76. [PubMed]

37.

Guo H, Wang C, Yang M, Tong X, Wang J, Guan H, Song L, Zou Y. Management of iatrogenic renal
arteriovenous fistula and renal arterial pseudoaneurysm by transarterial embolization: A single center
analysis and outcomes. Medicine (Baltimore). 2017 Oct;96(40):e8187. [PMC free article] [PubMed]

38.

Lee BB, Kim DI, Huh S, Kim HH, Choo IW, Byun HS, Do YS. New experiences with absolute ethanol
sclerotherapy in the management of a complex form of congenital venous malformation. J Vasc
Surg. 2001 Apr;33(4):764-72. [PubMed]

39.

Nosher JL, Murillo PG, Liszewski M, Gendel V, Gribbin CE. Vascular anomalies: A pictorial review of
nomenclature, diagnosis and treatment. World J Radiol. 2014 Sep 28;6(9):677-92. [PMC free article]
[PubMed]

40.

CREECH O, GANTT J, WREN H. TRAUMATIC ARTERIOVENOUS FISTULA AT UNUSUAL SITES. Ann

Surg. 1965 Jun;161:908-20. [PMC free article] [PubMed]

41.

Brinjikji W, Nasr DM, Morris JM, Rabinstein AA, Lanzino G. Clinical Outcomes of Patients with Delayed
Diagnosis of Spinal Dural Arteriovenous Fistulas. AJNR Am J Neuroradiol. 2016 Feb;37(2):380-6. [PMC
free article] [PubMed]

42.

Reddy YNV, Melenovsky V, Redfield MM, Nishimura RA, Borlaug BA. High-Output Heart Failure: A 15-
Year Experience. J Am Coll Cardiol. 2016 Aug 02;68(5):473-482. [PubMed]

43.

Reddy SN, Boros MC, Horrow MM. Approach to the Swollen Arm With Chronic Dialysis Access: It's Not
Just Deep Vein Thrombosis. J Ultrasound Med. 2015 Oct;34(10):1901-10. [PubMed]

44.

Handlos P, Marecová K, Smatanová M, Dvořáček I, Dobiáš M. Fatal Hemorrhage from an Arteriovenous

Fistula. J Forensic Sci. 2018 Sep;63(5):1577-1581. [PubMed]

Copyright © 2022, StatPearls Publishing LLC.

This book is distributed under the terms of the Creative Commons Attribution 4.0 International License
(http://creativecommons.org/licenses/by/4.0/), which permits use, duplication, adaptation, distribution,
and reproduction in any medium or format, as long as you give appropriate credit to the original
author(s) and the source, a link is provided to the Creative Commons license, and any changes made are
indicated.

Bookshelf ID: NBK559213PMID: 32644639

 Share on Facebook

 Share on Twitter

 Share on Google+

Views

 PubReader

 Print View

 Cite this Page

In this Page

 Continuing Education Activity

 Introduction

 Etiology

 Epidemiology

 History and Physical

 Evaluation

 Treatment / Management

 Differential Diagnosis

 Prognosis

 Complications

 Consultations

 Deterrence and Patient Education

 Enhancing Healthcare Team Outcomes

 Review Questions

 References

Related information

 PMC

 PubMed
Similar articles in PubMed

 Comparison of forearm versus upper arm basilic transposition arteriovenous fistulas

demonstrates equivalent satisfactory patency.[J Vasc Surg. 2019]

 Brachial vein transposition arteriovenous fistulas for hemodialysis access. [J Vasc Surg. 2009]

 Analyses of hemodialysis arteriovenous fistula geometric configuration and its associations with
maturation and reintervention.[J Vasc Surg. 2021]

 Arteriovenous fistula construction in the thigh with transposed superficial femoral vein: our
initial experience.[J Vasc Surg. 2001]

 Review Traumatic penetrating arteriovenous fistulas: a collective review. [Eur J Trauma Emerg

Surg. 2022]

See reviews...See all...

Recent Activity

ClearTurn Off

 Arteriovenous Fistula - StatPearls

 Cystitis - StatPearls

 Pneumonia Pathology - StatPearls

 Acute Pancreatitis - StatPearls

 Causes of dysregulation of lipid metabolism in chronic renal failure

See more...

FOLLOW NCBI

Connect with NLM

National Library of Medicine

8600 Rockville Pike
Bethesda, MD 20894

Web Policies
FOIA
HHS Vulnerability Disclosure
Help
Accessibility
Careers

 NLM

 NIH

 HHS

 USA.gov