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Arteriovenous Fistulas: Differential Diagnoses & Workup

Author: Igor A Laskowski, MD, Assistant Professor of Surgery, Section of Vascular Surgery, New York Medical College, Westchester Medical Center
Coauthor(s): Sateesh C Babu, MD, Professor of Clinical Surgery, New York Medical College; Associate Director, Vascular Surgery, Co-chief Endovascular Surgery, Westchester Medical Center, Valhalla NY; Mark D Morasch, MD, Clinical Practice Director, Division of Vascular Surgery, Assistant Professor of Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine; Dipen Maun, MD, Staff Physician, Department of Surgery, Mount Sinai School of Medicine
Contributor Information and Disclosures

Updated: Dec 15, 2008

Differential Diagnoses

Cirrhosis

Other Problems to Be Considered

Differential diagnosis of arteriovenous fistula (AVF) includes other conditions that may cause hyperdynamic circulation (increased heart rate, increased cardiac output, and low peripheral resistance). Cirrhosis, hyperthyroidism, Paget disease of the bone, and, occasionally, vary large highly vascular tumors like sarcomas.

Workup

Laboratory Studies

  • Blood gas analysis in an arteriovenous fistula (AVF) reveals a higher oxygen saturation in the venous blood immediately distal to the fistula as compared with normal venous blood.
  • Hemodynamic assessment with flow directed balloon catheter (Swan-Ganz catheter) reveals high cardiac output and low peripheral vascular resistance (PVR).
  • Extremely large arteriovenous fistulas (AVFs) or arteriovenous malformations (AVMs) may present with low platelet count (due to turbulence and trapping of platelets), and occasionally, with laboratory findings of consumptive coagulopathy such as low platelets, elevated prothrombin time (PT) and partial thromboplastin time (PTT), increased bleeding time, low fibrinogen, and elevated euglobulin clot lysis time, signs of fibrinolysis.

Imaging Studies

  • Plain films may demonstrate soft tissue masses or abnormalities within bony structures.
  • Duplex ultrasonography is usually the initial study to delineate the extent and flow characteristics of the malformation. The Doppler can be used preoperatively and intraoperatively. However, ultrasound does not have any therapeutic use. Duplex scan will show reversal of flow in the artery distal to the arteriovenous fistula (AVF), the steal phenomenon, or proximal flow augmentation in mixed arteriovenous malformations.
  • Contrast-enhanced CT scans are useful to locate the abnormality, to evaluate for aneurysm formation, and to identify bony involvement.
  • MRI has become the new criterion standard in the preoperative evaluation of patients with arteriovenous malformations (AVMs). MRI generates multiplanar views and can be used to accurately define tissue planes and to identify critical flow characteristics. MRI is the best modality to define local soft tissue and adjacent organ involvement, which helps with preintervention planning. Magnetic resonance (MR) sequences can be postprocessed into MR angiogram images, which help to define the malformation more clearly.3,4
  • Contrast angiography is the most important method for investigating arteriovenous malformations (AVMs) or arteriovenous fistulas (AVFs), at the same time providing for therapeutic interventions. It is an excellent method to delineate the number, location, and extent of the arteriovenous connections. Angiographic signs include early filling of veins, hypertrophied and tortuous arteries proximal to the malformation, and varicose and dilated veins distal to the fistula.
  • Radiolabeled studies can determine the shunt fraction, which is the proportion of blood being shunted through the fistulous tract.

Other Tests

  • Plethysmography is useful for quantifying flow in a whole limb, but assessing blood flow through circumscribed areas is difficult. Ideally, plethysmography data are compared with normal data from the contralateral limb.
  • Thermography determines heat loss from a region. However, results are of limited clinical value because they do not reveal the location of the lesion accurately, and the data cannot be used to differentiate among various types of vascular malformations.
  • In arteriovenous fistula (AVF) of limbs, segmental limb pressure measurements can document a significant drop in pressure distal to the fistula. This can be used before and after surgical correction of the fistula to confirm that the fistula has been eliminated

Procedures

  • Percutaneous biopsy is never indicated in the workup of a known vascular malformation; bleeding that is difficult to control may result. Biopsy should be indicated if the suspected lesion is solid and falls into the category of vascular tumors.
  • Invasive and noninvasive cardiac evaluation may be indicated in patients with congestive heart failure because cardiac output can be markedly elevated in patients with large proximal arteriovenous malformations (AVMs). Cardiac output is best measured with invasive right heart catheter techniques but can be evaluated noninvasively with echocardiography. In order to document success, measurement of cardiac output is indicated before and after surgical or interventional procedures to reduce the size of these larger arteriovenous malformations (AVMs).

Histologic Findings

Histology documents arterialization of the thickening of the wall of the vein, including its muscular layer, and thinning of the artery in large, long-standing arteriovenous fistulas.

More on Arteriovenous Fistulas

Overview: Arteriovenous Fistulas
Differential Diagnoses & Workup: Arteriovenous Fistulas
Treatment & Medication: Arteriovenous Fistulas
Follow-up: Arteriovenous Fistulas
Multimedia: Arteriovenous Fistulas
References
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References

  1. Enjolras O, Mulliken JB. Vascular tumors and vascular malformations (new issues). Adv Dermatol. 1997;13:375-423. [Medline].

  2. Brouillard P, Boon LM, Mulliken JB, et al. Mutations in a novel factor, glomulin, are responsible for glomuvenous malformations ("glomangiomas"). Am J Hum Genet. Apr 2002;70(4):866-74. [Medline].

  3. Pearce WH, Rutherford RB, Whitehill TA, et al. Nuclear magnetic resonance imaging: its diagnostic value in patients with congenital vascular malformations of the limbs. J Vasc Surg. Jul 1988;8(1):64-70. [Medline].

  4. Dobson MJ, Hartley RW, Ashleigh R, et al. MR angiography and MR imaging of symptomatic vascular malformations. Clin Radiol. Aug 1997;52(8):595-602. [Medline].

  5. Sloan GM, Reinisch JF, Nichter LS, et al. Intralesional corticosteroid therapy for infantile hemangiomas. Plast Reconstr Surg. Mar 1989;83(3):459-67. [Medline].

  6. Ricketts RR, Hatley RM, Corden BJ, et al. Interferon-alpha-2a for the treatment of complex hemangiomas of infancy and childhood. Ann Surg. Jun 1994;219(6):605-12; discussion 612-4. [Medline].

  7. Palmaz JC, Newton TH, Reuter SR, et al. Particulate intraarterial embolization in pelvic arteriovenous malformations. AJR Am J Roentgenol. Jul 1981;137(1):117-22. [Medline].

  8. White RI Jr, Pollak J, Persing J, et al. Long-term outcome of embolotherapy and surgery for high-flow extremity arteriovenous malformations. J Vasc Interv Radiol. Nov-Dec 2000;11(10):1285-95. [Medline].

  9. Lee BB, Kim DI, Huh S, et al. New experiences with absolute ethanol sclerotherapy in the management of a complex form of congenital venous malformation. J Vasc Surg. Apr 2001;33(4):764-72. [Medline].

  10. Yakes WF, Krauth L, Ecklund J, et al. Ethanol endovascular management of brain arteriovenous malformations: initial results. Neurosurgery. Jun 1997;40(6):1145-52; discussion 1152-4. [Medline].

  11. Widlus DM, Murray RR, White RI Jr, et al. Congenital arteriovenous malformations: tailored embolotherapy. Radiology. Nov 1988;169(2):511-6. [Medline].

  12. Gillebert C, Van Hoof R, Van de Werf F, et al. Coronary artery fistulas in an adult population. Eur Heart J. May 1986;7(5):437-43. [Medline].

  13. Phillips AW, Chaudhuri A, Meyer FJ. Bilateral long saphenous bruits: a marker of aortocaval fistula. Eur J Vasc Endovasc Surg. Nov 2006;32(5):529-31. [Medline].

  14. Reidy JF, Anjos RT, Qureshi SA, et al. Transcatheter embolization in the treatment of coronary artery fistulas. J Am Coll Cardiol. Jul 1991;18(1):187-92. [Medline].

  15. Said SA, el Gamal MI, van der Werf T. Coronary arteriovenous fistulas: collective review and management of six new cases--changing etiology, presentation, and treatment strategy. Clin Cardiol. Sep 1997;20(9):748-52. [Medline].

  16. Said SA, Landman GH. Coronary-pulmonary fistula: long-term follow-up in operated and non-operated patients. Int J Cardiol. May 1990;27(2):203-10. [Medline].

  17. Sherwood MC, Rockenmacher S, Colan SD, et al. Prognostic significance of clinically silent coronary artery fistulas. Am J Cardiol. Feb 1 1999;83(3):407-11. [Medline].

  18. Tkebuchava T, Von Segesser LK, Vogt PR, et al. Congenital coronary fistulas in children and adults: diagnosis, surgical technique and results. J Cardiovasc Surg (Torino). Feb 1996;37(1):29-34. [Medline].

  19. Yamanaka O, Hobbs RE. Coronary artery anomalies in 126,595 patients undergoing coronary arteriography. Cathet Cardiovasc Diagn. Sep 1990;21(1):28-40. [Medline].

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Further Reading

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Keywords

arteriovenous fistulas, vascular malformations, arteriovenous fistula, hemangioma, vascular anomalies, angiomas, birthmarks, port-wine stains, AVF, acquired singular communication between an artery and a vein, arteriovenous malformations, AVM, congenital abnormal communication between an artery and a vein, fistula, vascular birthmarks, vascular birthmark

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Contributor Information and Disclosures

Author

Igor A Laskowski, MD, Assistant Professor of Surgery, Section of Vascular Surgery, New York Medical College, Westchester Medical Center
Igor A Laskowski, MD is a member of the following medical societies: American College of Surgeons, American Hepato-Pancreato-Biliary Association, Peripheral Vascular Surgery Society, Society for Vascular Surgery, and Transplantation Society
Disclosure: Nothing to disclose.

Coauthor(s)

Sateesh C Babu, MD, Professor of Clinical Surgery, New York Medical College; Associate Director, Vascular Surgery, Co-chief Endovascular Surgery, Westchester Medical Center, Valhalla NY
Sateesh C Babu, MD is a member of the following medical societies: American College of Surgeons, American Heart Association, American Institute of Ultrasound in Medicine, American Medical Association, Eastern Vascular Society, International Society of Endovascular Specialists, New York Academy of Sciences, Royal Society of Medicine, Society for Vascular Surgery, and Stroke Council of the American Heart Association
Disclosure: Nothing to disclose.

Mark D Morasch, MD, Clinical Practice Director, Division of Vascular Surgery, Assistant Professor of Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine
Mark D Morasch, MD is a member of the following medical societies: American College of Surgeons, American Heart Association, and Central Surgical Association
Disclosure: Nothing to disclose.

Dipen Maun, MD, Staff Physician, Department of Surgery, Mount Sinai School of Medicine
Dipen Maun, MD is a member of the following medical societies: Alpha Omega Alpha, American Medical Association, and American Medical Student Association/Foundation
Disclosure: Nothing to disclose.

Medical Editor

William H Pearce, MD, Chief, Division of Vascular Surgery, Violet and Charles Baldwin Professor of Vascular Surgery, Department of Surgery, Northwestern University School of Medicine
William H Pearce, MD is a member of the following medical societies: American College of Surgeons, American Heart Association, American Surgical Association, Association for Academic Surgery, Association of VA Surgeons, Central Surgical Association, New York Academy of Sciences, Society for Vascular Surgery, Society of Critical Care Medicine, Society of University Surgeons, and Western Surgical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Vincent Lopez Rowe, MD, Assistant Professor of Surgery, Department of Surgery, Division of Vascular Surgery, University of Southern California Medical Center
Vincent Lopez Rowe, MD is a member of the following medical societies: American College of Surgeons, Association for Academic Surgery, Peripheral Vascular Surgery Society, Society for Clinical Vascular Surgery, and Society for Vascular Surgery
Disclosure: Nothing to disclose.

CME Editor

Paolo Zamboni, MD, Professor of Surgery, Chief of Day Surgery Unit, Chair of Vascular Diseases Center, University of Ferrara, Italy
Paolo Zamboni, MD is a member of the following medical societies: American Venous Forum and New York Academy of Sciences
Disclosure: Nothing to disclose.

Chief Editor

William H Pearce, MD, Chief, Division of Vascular Surgery, Violet and Charles Baldwin Professor of Vascular Surgery, Department of Surgery, Northwestern University School of Medicine
William H Pearce, MD is a member of the following medical societies: American College of Surgeons, American Heart Association, American Surgical Association, Association for Academic Surgery, Association of VA Surgeons, Central Surgical Association, New York Academy of Sciences, Society for Vascular Surgery, Society of Critical Care Medicine, Society of University Surgeons, and Western Surgical Association
Disclosure: Nothing to disclose.

 
 
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