DOI:10.2214/AJR.05.0777
AJR 2007; 188:W547-W549
© American Roentgen Ray Society
Acquired Arteriovenous Fistula at an Unusual Site
Nira Beck-Razi1,
Michalle Soudack and
Diana E. Gaitini
1 All authors: Department of Medical Imaging, Rambam Medical Center, Ha'aliya
Hashniya 8, Haifa, Israel 31096.
Received May 6, 2005;
accepted after revision July 7, 2005.
Address correspondence to D. E. Gaitini
(d_gaitini{at}rambam.health.gov.il).
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Keywords: arteriovenous fistula • color Doppler sonography • Doppler sonography • femoral catheterization • fistula • sonography
Introduction
Arteriovenous fistula (AVF) is a known complication of femoral
catheterization. These fistulas are almost always located at the common or
superficial femoral vessels, and diagnosis can be made using Doppler
sonography. In this article, we report an AVF involving the inferior
epigastric vessels.
Case Report
A 72-year-old woman presented with right inguinal swelling 2 days after
coronary angiography via a femoral artery. A thrill and bruit were felt and
heard at the inguinal area. Sonography, performed with a multifrequency
5–12 MHz linear array transducer (HDI 5000, Philips Medical Systems),
revealed normal common and superficial femoral vessels on gray-scale, color
Doppler, and duplex examinations. However, when the transducer was placed
above the site of maximum bruit, an artery with a high-resistance waveform was
seen (Fig. 1A) that was
followed by a low-resistance waveform, leading to a turbulent high-velocity
flow on spectral display and a mosaic pattern on color Doppler imaging
(Fig. 1B). By tracing the
vessel to its origin at the common iliac artery, it was proven to be the
inferior epigastric artery. Moving forward from the origin of the inferior
epigastric artery, a classical arterialized flow was seen in the draining vein
(Fig. 1C).
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Fig. 1A —72-year-old woman presented with right inguinal swelling 2
days after coronary angiography via femoral artery. Thrill and bruit were felt
and heard at inguinal area. Spectral display of inferior epigastric artery
proximal to fistula shows high-resistant waveform that is typical of artery
supplying muscles.
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Fig. 1B —72-year-old woman presented with right inguinal swelling 2
days after coronary angiography via femoral artery. Thrill and bruit were felt
and heard at inguinal area. Color Doppler and duplex sonography show turbulent
high-velocity flow on spectral display and mosaic pattern (arrowhead)
at fistula site.
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Fig. 1C —72-year-old woman presented with right inguinal swelling 2
days after coronary angiography via femoral artery. Thrill and bruit were felt
and heard at inguinal area. Image reveals that flow in inferior epigastric
vein is showing arterialized waveform.
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These findings suggested an AVF. In addition, perivascular soft-tissue
speckling color artifact was seen surrounding the fistula. This artifact is
caused by perivascular tissue vibration due to turbulent continuous blood flow
between the feeding artery and the draining vein
(Fig. 1D). These findings were
consistent with an AVF of the inferior epigastric vessels. The patient was
discharged, and the fistula closed spontaneously.
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Fig. 1D —72-year-old woman presented with right inguinal swelling 2
days after coronary angiography via femoral artery. Thrill and bruit were felt
and heard at inguinal area. Color Doppler image shows artifact in soft tissues
surrounding fistula due to perivascular tissue vibration.
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Discussion
AVF is a direct connection between an artery and a vein. Like hematomas and
pseudoaneurysms, AVFs can be spontaneous, but they are often the result of
penetrating trauma [1,
2]. Almost 1% of patients
undergoing cardiac catheterization develop a femoral AVF
[3]. AVFs have become more
common since large catheters started being used for and anticoagulation
treatment started being used after vascular interventional procedures
[1]. Other risk factors for AVF
have been identified, including arterial hypertension, female sex, and complex
interventions [3].
AVFs are rarely located above the femoral bifurcation because at that level
the femoral artery and vein are side by side and therefore are difficult to
puncture simultaneously. Below the bifurcation, the vein travels behind the
artery so there is a higher risk of simultaneous puncturing
[1]. An AVF is usually
asymptomatic, although large AVFs can cause high cardiac output stress or
ischemic changes in the involved extremity
[1,
4]. Physical examination can
reveal slight swelling or ecchymosis and a palpable thrill is often present. A
bruit can be heard on local auscultation.
Gray-scale sonography is not diagnostic unless the AVF is chronic and the
high-flow state has caused dilatation of the vein and the artery
[1,
3]. The diagnosis is based on
findings from color Doppler and duplex examinations
[2]. In the extremities, normal
arterial waveforms have a typical triphasic high-resistance pattern with an
anterograde systolic peak, a brief early diastolic retrograde peak, and an end
anterograde diastolic peak [2].
In the presence of an AVF, the arterial flow pattern turns to a very
low-resistance one.
Major and minor criteria have been postulated for the diagnosis of AVF by
color Doppler and duplex sonography
[2]. Major diagnostic criteria
include a junction of low- and high-resistance flow in the supplying artery,
high velocity arterialized waveform in the draining vein, and turbulent
high-velocity flow spectrum at the junction of the artery and vein. The
described minor diagnostic criteria included a direct communication seen
between the artery and vein, significant change in the diameter of the
supplying artery, a focal point of venous dilatation, and focal perivascular
color artifact. One third of iatrogenic femoral AVFs close spontaneously
within 1 year [3]. Compression
repair is usually not successful in closing these AVFs. Percutaneous placement
of a covered stent or surgical repair may be indicated
[3].
To the best of out knowledge, an acquired inferior epigastric AVF has been
reported only once in the literature
[4]. In that case, the fistula
was secondary to placement of a drain during surgery and coexisted with a
pseudoaneurysm [4]. The
inferior epigastric artery arises from the anteromedial aspect of the external
iliac artery just above the inguinal ligament; it pierces the transverse
fascia passing anterior to the arcuate line and courses with the inferior
epigastric vein inside the rectus sheath behind the rectus muscle
(Fig. 2). The artery continues
in the retrosternal space with the internal mammary artery. The epigastric
vessels run side by side, so simultaneous damage can occur during a very high
and medial groin puncture. A fistula in the inferior epigastric vessels may
cause discomfort and the development of abdominal varices due to reflux of
flow into the contributory vessels of the epigastric vein
[4].
A more frequently known but still quite rare traumatic injury to the
inferior epigastric artery is a pseudoaneurysm. It has been described as a
complication of surgery and retention sutures, paracentesis, and catheter
placement for peritoneal dialysis and in spontaneous instances
[5,
6]. Hemorrhage of the inferior
epigastric artery due to laceration during catheterization has been reported
rarely [7]. Diagnosis of any
kind of arterial injury may be performed by color Doppler and Doppler
sonography [8].
By presenting this case report, we emphasize that when evaluating the
postcatheterization groin the possibility of an inferior epigastric AVF should
not be overlooked. Although treatment is conservative, achieving the correct
diagnosis will obviate further diagnostic workup and reduce patient
anxiety.
We conclude that color Doppler and duplex examinations of the
postcatheterization groin should include the femoral vessels and the
peripheral and superficial areas to exclude vascular injuries in uncommon
arterial sites for AVFs.
References
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Accessed April 4, 2007
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Introduction
Case Report
