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Arteriovenous Fistulas: Treatment & Medication

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

Treatment

Medical Care

Most vascular tumors can be observed through their typical phases of development until they involute. Children should be evaluated for the extent of the tumors and involvement of vital structures. Lesions in endangering locations are best treated with intralesional corticosteroid injection, systemic corticosteroids, interferon alfa, laser ablation, and embolization therapy.5,6

Most arteriovenous malformations can be medically managed and controlled. Only a few arteriovenous malformations (AVMs) demonstrate progressive growth and require surgical intervention. Most of the symptoms of arteriovenous malformations (pain, heaviness, swelling) are due to venous hypertension. The cornerstone approach in managing lower extremity symptoms is elastic support hose. An elastic support stocking that provides 30-40 mm Hg of compression is usually sufficient to relieve leg symptoms.

Alcohol sclerotherapy may shrink the size of the arteriovenous malformation (AVM), but this treatment also places the patient at risk for peripheral nerve injury. The treatment of large arteriovenous malformations (AVMs) with alcohol needs to be performed by an experienced interventional radiologist, and these risks must be explained to patients when they consent to undergo therapy.

Surgical Care

Indications for surgical intervention of vascular malformations include hemorrhage, painful ischemia, congestive heart failure, nonhealing ulcers, functional impairment, or limb-length inequality.

Transcatheter embolization of vascular malformations became an extremely valuable option in the treatment of these frequently complex and deeply seeded anomalies. This modality can be effectively applied alone, prior to, or in combination with surgical resection when the vascularity of the malformation needs to be reduced. The procedure involves the percutaneous placement of a vascular catheter and the injection of coils or particulate matter into the malformation. Passage of emboli into the normal circulation occurs, but usually only poses a problem if it enters the cerebral or mesenteric vasculatures.7,8 They are especially useful in the treatment of arteriovenous malformations.

The common adverse effects are pain and tenderness near the malformation and a transient fever and leukocytosis. More worrisome complications include necrosis of healthy adjacent tissue and neurologic injury. Thorough angiographic imaging and clear delineation of the vessels helps to minimize most of these adverse effects. Embolization can provide a promising treatment option if it is carried out by an experienced interventional radiologist. In the treatment of venous malformations a number of sclerosing agents including absolute ethanol injections can be implemented. They can carry a risk of necrosis of adjacent tissue and should be used with caution.9

Most arteriovenous malformations (AVMs) are not amenable to complete surgical excision. A lesion must be well localized for a chance at complete resection. Resectability depends on the degree of extension into adjacent structures. Patients with disease that extends into the deep fascia or contiguous structures, such as muscle and bone, are usually not surgical candidates. Malformations that extend into the pelvis and gluteal region are also not surgically resectable. Those patients severely afflicted with malformations who are not candidates for local extirpation may be candidates for amputation and rehabilitation with a limb prosthesis.

In contrast to the congenital arteriovenous malformations (AVMs) that are difficult to treat, almost all acquired arteriovenous fistula (AVF) are amenable for either surgical or interventional treatment. Occlusion of the feeding vessel with coils can be done. If the arteriovenous fistula (AVF) is between a medium- or large-sized artery and vein, then occlusion of the artery may be hazardous. Surgical treatment is preferred. The fistulous communication is disconnected, and repair of the defect in the artery and vein is accomplished. Recently, vascular surgeons are able to treat some of these with the minimally invasive endovascular techniques. A covered stent graft is deployed in the artery, thus covering the site of communication between the artery and vein.

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

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  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].

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  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].

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  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].

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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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