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Arteriovenous Fistula

by James D. Douketis, MD

An arteriovenous fistula is an abnormal communication between an artery and a vein.

An arteriovenous fistula may be congenital (usually affecting smaller vessels) or acquired as a result of trauma (eg, a bullet or stab wound) or erosion of an arterial aneurysm into an adjacent vein.

The fistula may cause symptoms and signs of arterial insufficiency (eg, ulceration due to reduced arterial flow or ischemia) or chronic venous insufficiency due to high-pressure arterial flow in the affected veins (eg, peripheral edema, varicose veins, stasis pigmentation). Emboli (eg, causing ulceration) may pass from the venous to the arterial circulation, although pressure differences make this unlikely. If the fistula is near the surface, a mass can be felt, and the affected area is usually swollen and warm with distended, often pulsating superficial veins. A thrill can be palpated over the fistula, and a continuous loud, to-and-fro (machinery) murmur with accentuation during systole can be heard during auscultation. Rarely, if a significant portion of cardiac output is diverted through the fistula to the right heart, high-output heart failure develops.

Congenital fistulas need no treatment unless significant complications develop (eg, leg lengthening in a growing child). When necessary, percutaneous vascular techniques can be used to place coils or plugs into the vessels to occlude the fistula. Treatment is seldom completely successful, but complications are often controlled. Acquired fistulas usually have a single large connection and can be effectively treated by surgery.

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