Difficult Femoral Arteriovenous Fistula in a Child

Abstract

G Khougeer, AHB Okda, Difficult Femoral Arteriovenous Fistula in a Child. 2000; 20(2): 150-152 An arteriovenous (AV) fistula is an abnormal communication between the arterial and venous systems, and can be congenital or acquired. The majority of peripheral fistulas are the result of trauma.1,2 The extent of clinical manifestations is related to the size, duration, and the precise location of the fistula, varying from local changes to central changes due to stress on the entire cardiovascular system. Chronic peripheral fistulas are typically associated with dilatation and elongation of the feeding artery, 4 as well as proximal dilatation of the venous system. Venous hypertension, valve incompetence, and venous hypertrophy commonly lead to distal swelling, dermatitis and ulceration, similar to that seen in the post-phlebitic state (Figure 1).Although physical diagnosis is easy when these fistulas are located in the extremities, arteriography is important in delineating the anatomy in order to plan the appropriate management of the patient. However, with the invasive techniques currently available, there should be few chronic traumatic AV fistulas in the practice of vascular surgery. 5 Case ReportA three-year-old girl presented with skin ulcer over the left lower leg, which had been debrided several times and skin grafted (Figure 1). The patient was the product of a 32-week gestation pregnancy, and was admitted to the nursery unit. She was diagnosed with left leg lymphangiectasia, based on previous clinical positive lymphangiography findings and recurrent cellulitis. During one of the debridement sessions of the leg ulcer, considerable bleeding occurred which required suturing. The suspicion of AV malformation was raised when MRI showed significant dilated vessels, both superficial and intramuscular. The patient was referred to the vascular surgery service.Physical examination showed an ill-looking child with low-grade fever, but normal cardiorespiratory system. Abdominal examination was also normal. The whole left lower limb was swollen (Figure 1). There was no sign of a previous injury in the left groin, but there was evidence of dermatitis and ulcer on the lower medial aspect of the leg. A thrill and murmur were elicited over the femoral vessels.