Arteriovenous Fistulas Treatment & Management

Updated: Nov 10, 2017
  • Author: Sateesh C Babu, MD; Chief Editor: Vincent Lopez Rowe, MD  more...
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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 corticosteroids (injected intralesionally or administered systemically), interferon alfa, laser ablation, and embolization therapy. [15, 16]

Most arteriovenous malformations (AVMs) can be medically managed and controlled; only a few demonstrate progressive growth and warrant surgical intervention. Most of the symptoms of AVMs (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 AVM, but this treatment also places the patient at risk for peripheral nerve injury. The treatment of large AVMs with alcohol must be performed by an experienced interventional radiologist, and these risks must be explained to patients when they consent to undergo therapy.

Various newer treatments (eg, photodynamic therapy, antiangiogenic therapy, and new methods of sclerotherapy) are available that may offer options worth considering. [17]

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Surgical Care

Indications for surgical intervention of vascular malformations include the following:

  • Hemorrhage
  • Painful ischemia
  • Congestive heart failure
  • Nonhealing ulcers
  • Functional impairment
  • Limb-length inequality

Transcatheter embolization of vascular malformations became an extremely valuable option in the treatment of these frequently complex and deeply seeded anomalies. [18] This modality can be effectively applied alone, prior to, or in combination with surgical resection when the vascularity of the malformation must 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. [19, 20] The procedure is especially useful in the treatment of AVMs.

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 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. [21]

Most 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 (eg, muscle and bone) usually are not surgical candidates. Malformations that extend into the pelvis and gluteal region also are 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 congenital AVMs, which are difficult to treat, almost all acquired arteriovenous fistulas (AVFs) are amenable to either surgical or interventional treatment. Occlusion of the feeding vessel with coils can be done. If the AVF is between a medium-sized or large artery and a 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.

Some of these problems can be addressed with minimally invasive endovascular techniques. [22, 23] A covered stent graft is deployed in the artery, thus covering the site of communication between the artery and vein.

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