ARTERIOVENOUS FISTULA

Maria Joseph
114 batch
 ARTERIOVENOUS FISTULA (AVF)

 It is an abnormal communication between an

artery and vein.
 Have a structural and physiological effect

 Types
 Congenital—is arteriovenous malformation.
1. Acquired (Trauma is common cause).
1. High flow: >800 mL/ min
2. Normal flow: 400- 800 mL/min
3. Low flow: <400 mL/min
 Case Scenario

 25yr old male presents with dilated tortuous pulsatile

vessels along the entire left lower limb
 There is no history of trauma or any surgical procedure
 On examination,
 Increased length and girth of the limb
 Port wine discoloration of lateral part of left thigh
 On palpation,
Pulsationsof tortuous vessels which were
compressible and clinically appeared to be
veins
Continuous thrill over the vessels
Extremity was warmer and moist than
unaffected side
Collapsing radial pulse
 On auscultation,
Continuous machinery murmur(bruit) with
accentuation

 There was no evidence of cardiac failure.

 Diagnosis: Congenital Arteriovenous fistula

 Differential diagnosis for a compressible swelling:

Lymphatic cyst
Hemangioma
Aneurysm
Arteriovenous fistula
 To clinically differntiate these 4 conditions:
Lymphatic cyst will be brilliantly
transilluminated
Hemangioma is not transilluminant but partially
compressible
Aneurysm shows expansile pulsations and
systolic bruit
AVF shows continuous thrill on palpation and
continuous machinery murmur on auscultation
CONGENITAL ARTERIOVENOUS MALFORMATION
(FISTULA)—AVM (AVF)

 AV communications occur during developmental period.

 High flow type of vascular malformation.
 30% of all vascular malformation.
 90% of AVM contains both arterial and venous
components.
 Shunting of blood with thrill and bruit with
hyperdynamic circulation is common.
 SITES

 Limbs,either part or whole of the limb is involved. It

may be localised to toes or fingers.
 Lungs.
 Brain—in circle of Willis.
 Other organs like bowel, liver.
 CLINICAL FEATURES
Structural changes in the limb:
Limb is lengthened due to increase in blood flow since
developmental period.
 Limb girth is also increased.
 Local gigantism
 Limb is warm.
 Continuous thrill and continuous machinery murmur all
over the lesion.
Dilated arterialised varicose veins are seen due to
increased blood flow and also due to valvular
incompetence.
 Often there is bone erosion or extension of AVF into
the bone as such.

Physiological changes
 Because of the hyperdynamic circulation, there is
increased cardiac output and so often congestive
cardiac failure.
COMPLICATIONS

 Hemorrhage
 Thrombosis
 Congestive cardiac failure
INVESTIGATIONS

Angiogram—MR angiogram is ideal.

Doppler study.
X-ray of the part.
 ECG, echocardiography.
TREATMENT
 Conservative—sclerotherapy, compression,
avoiding injury.
 Indications for intervention
•Absolute: Haemorrhage, ischaemia, CCF.
•Relative: Pain, functional disability,
cosmesis, limb asymmetry.
•Emergency: Torrential bleeding usually after
trauma (RTA).
 Interventions

1. Surgical ligation of feeding vessels and

complete excision of the lesion. Often if
lesion is extending into deeper planes it is
technically difficult; but with usage of
tourniquet, careful meticulous dissection
and ligation of all vessels will lead into
successful excision of entire lesion.
2. Therapeutic embolisation/preoperative
embolisation hasten the proper surgical
excision.

3. In emergency bleeding, adequate transfusion

of blood, tourniquet usage, intraoperative
embolisation and then excision of entire lesion is
done. Occasionally when extensive AVM is present
often involving the entire limb, amputation is the
final option left as a life-saving procedure.
 CIRSOID ANEURYSM

 Itis actually a rare arteriovenous fistula /

malformation of the scalp usually of congenital origin
but occasionally can be traumatic. Cirsoid means
varix.
 Commonly seen in superficial temporal artery and its branches.
 Often the underlying bone gets thinned out due to pressure.
 Occasionally extends into the cranial cavity.
 Ulceration is the eventual problem which will lead to
uncontrollable haemorrhage.
 CLINCAL FEATURES

 Pulsatile swelling in relation to superficial temporal

artery, which is warm, compressible, with arterialisation
of adjacent veins and with bone thinning (due to
erosion). It feels like a ‘pulsating bag of worms’.
INVESTIGATIONS

 Doppler study
 CT scan.
 Angiogram
 X-ray of the part
TREATMENT

 Ligation of feeding artery and excision of lesion,

often requires preliminary ligation of external
carotid artery.
 Intracranialextension requires formal
neurosurgical approach.
 Endovascular therapy is also useful
Case Scenario
30 yr old male patient presented with swelling of veins
in his left upper limb for the last 3 years.
 Patienthad a history of trauma in his left upper limb
3 years back due to fall from a height.
 Fifteendays following the trauma patient noticed
swelling of veins in his forearm which is gradually
increasing in size and numbers and also extends
upward in the arm and dorsum of hand. Patient
complains of palpitation on exertion for last 6 months
 On examination:

 Pulse is 90 beats per minutes, high volume

collapsing in character.
Blood pressure is 130/40 mm Hg.
On local examination, there are dilated tortuous
veins on the left forearm and dorsum of hand of
the patient.
 Right upper limb feels warmer than the
left.
A thrill is palpable at the lower end of the
forearm over the site of the arteriovenous
fistula
 On
auscultation, there is a continuous
machinery murmur which is audible.
 Branham’s sign is positive.

 Diagnosis: Traumatic arteriovenous fistula

in left upper limb.
ACQUIRED ARTERIOVENOUS FISTULA(AVF)
Causes

Trauma in (most common cause):

Femoral region.
Popliteal region.
Brachial region.
Wrist.
Aorta—vena caval.
Abdomen
It may be following road traffic accidents, penetrating wounds,
cock-fight injury (common in South India).
 After surgical intervention of major vessels.

 Therapeutic: For renal dialysis, AVF is created

(Cimino fistula) to achieve arterialisation of veins
and also to have hyperdynamic circulation. It is
done to have easy and adequate venous access for
long time haemodialysis. Common sites are
wrist, brachial, and femoral region
 PATHOPHYSIOLOGY

 Physiological changes: Cardiac failure due to

hyperdynamic circulation.

 Structural changes
STRUCTURAL CHANGES

Changes at the Level of Fistula

Blood flows from high pressure artery to low pressure
vein causing diversion of most of the blood. Between the
artery and vein, at the site of fistula, dilatation develops
with formation of fibrous sac called as aneurysmal sac.
This presents as warm, pulsatile, smooth, soft,
compressible swelling at the site with continuous thrill
and continuous machinery murmur.
 Changes Below the Level of the Fistula:

Because of diversion of arterial blood distal part

becomes ischaemic. Because of high pressure
arterialisation of veins and valvular incompetence
occurs causing varicose veins.
 Changes Proximal to the Fistula :

 Hyperdynamic circulation causes cardiac failure.

Cardiac failure may be very severe in traumatic AVF
(often resistant to drug therapy).
 If pressure is applied to the artery proximal to the
fistula, swelling will reduce in size, thrill and bruit will
disappear, pulse rate and pulse pressure becomes
normal. This is called as Nicoladoni’s sign or Branham’s
sign.
INVESTIGATIONS

 Doppler, angiogram.

 ECG, echocardiography.
 TREATMENT
 Excision of fistula and reconstruction of artery and vein
with graft.
Done in early stages—larger vessels. Venous or Dacron
graft is used
 In emergency situation, quadruple ligation, i.e. both
artery and vein above and below are ligated without
touching the fistula and sac. Patient recovers well from
cardiac failure.
 Therapeutic embolisation may be tried
 Hunter’s ligation should be avoided. It is used as life-
saving measure because it invariably causes limb
ischaemia and gangrene even though patient recovers
from cardiac failure. It is ligation of artery proximally
so as to make cardiac function normal. But it invariably
steals the blood from the limb leading to gangrene
 What are the indications of amputation in a case of
arteriovenous fistula?
 Cases with severe pain and ischemic gangrene.
 Cases with intractable cardiac failure due to
hyperdynamic circulation.
 Giant limb incapacitating the patient.
 Failure of surgical treatment by ligation or embolization
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