Micro-arteriovenous fistula in patients with lower limb lymphedema

Hikaru Kono, Hisashi Sakuma, Shiho Watanabe, Takaya Murayama, Masashi Takemaru, Hikaru Kono, Hisashi Sakuma, Shiho Watanabe, Takaya Murayama, Masashi Takemaru

Abstract

Background: A micro-arteriovenous fistula (AVF) is a minute, short shunt between an artery and a vein that does not pass through a capillary. We investigated the association between micro-AVFs and lymphedema using computed tomography angiography (CTA) and venous blood gas analysis.

Methods: In 95 patients with lower limb lymphedema, the presence or absence of early venous return (EVR) was compared between patients with primary and secondary lymphedema. Furthermore, we investigated the difference in the timing of edema onset in patients with secondary lymphedema with or without EVR using CTA. In 20 patients with lower limb lymphedema with confirmed early EVR in a unilateral lower limb, the partial pressure of oxygen (PO2) was compared between the lower limb with EVR and the contralateral lower limb.

Results: Secondary lymphedema with or without EVR occurred at an average of 36.0±59.3 months and 93.5±136.1 months, respectively; however, no significant difference was noted. PO2 was 57.6±11.7 mmHg and 44.1±16.4 mmHg in the EVR and non-EVR limbs, respectively, which was a significant difference (P=0.005).

Conclusions: EVR and venous blood gas analysis suggested the presence of micro-AVFs in patients with lower extremity edema. Further research is warranted to examine the cause of micro-AVFs, to advance technology to facilitate the confirmation of micro-AVFs by angiography, and to improve lymphedema by ligation of micro-AVFs.

Keywords: Arteriovenous fistula; Computed tomography angiography; Lymphedema; Venous hypertension; Venous insufficiency.

Conflict of interest statement

Conflict of interest

No potential conflict of interest relevant to this article was reported.

Figures

Fig. 1.
Fig. 1.
Early venous return. (A, B) Computed tomography angiography showing early venous return. The red circle is the great saphenous vein. The images show observations in the arterial phase.
Fig. 2.
Fig. 2.
Hypothetical pathology of lymphedema exacerbation. Micro-arteriovenous fistula increases venous blood pressure owing to the backflow of arterial blood and increases leakage of plasma components. Chronic leakage leads to increased lymph production and fibrosis around the lymph duct.

References

    1. Haimovici H. Role of A-V shunting in varicose veins: therapeutic implications. J Cardiovasc Surg (Torino) 1995;36:109–15.
    1. Muneta K, Okubo Y, Sawada Y. Sclerosing panniculitis in a patient with arteriovenous fistula of the lower leg and summary of 13 cases. Jpn J Clin Dermat. 2017;71:419–23.
    1. Tanaka M, Serizawa F, Nagaoka Y, et al. Two cases of micro-arteriovenous fistula in the lower extremity with misdiagnosis of refractory cellulitis. Ann Vasc Dis. 2018;11:148–52.
    1. Serizawa F, Tanaka M, Shimizu T, et al. The epidemiology of micro-arteriovenous fistulas in the lower legs. Ann Vasc Surg. 2019;56:29–35.
    1. Sakuma H, Watanabe S, Kono H. A novel surgical approach for refractory secondary lymphedema of the lower extremity accompanying micro-arteriovenous fistula. Ann Vasc Surg. 2020;65:284.
    1. Honda K, Komai H, Juri M. Micro-arteriovenous fistula of the lower extremities with severe skin lesions. J Jpn Coll Angiol. 2006;46:73–8.
    1. Pratt GH. Arterial varices; a syndrome. Am J Surg. 1949;77:456–60.
    1. Blalock A. Oxygen content of blood in patients with varicose veins. Arch Surg. 1929;19:898–905.
    1. Fontaine R. Remarks concerning venous thrombosis and its sequelae. Surgery. 1957;41:6–25.
    1. Yoshida Y, Fujita M. Shunt flow of arteriovenous fistulas from plantar artery. Phlebology. 2011;26:32–4.
    1. Uehara A, Yamamoto K, Mishima T, et al. A case of venous reconstruction for common iliac vein occlusion and ipsilateral internal iliac arteriovenous fistulae. Jpn J Vasc Surg. 2008;17:575–80.
    1. Takase S, Pascarella L, Lerond L, et al. Venous hypertension, inflammation and valve remodeling. Eur J Vasc Endovasc Surg. 2004;28:484–93.

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