An asymptomatic 82-year-old male status post femoral-peroneal in situ saphenous vein bypass presented to vascular surgery clinic for routine follow up. Duplex exam demonstrated abnormal flow in the bypass at the level of the distal thigh suggestive of an arteriovenous fistula (figure 1). Digital subtraction angiograms demonstrated a severely diseased superficial femoral artery which occluded in the mid thigh and a patent venous bypass with filling of the superficial femoral vein (figure 2). More distally, the origin of the abnormal venous connection was noted to be an arteriovenous fistula of a nonligated branch of the venous bypass (figure 3).

1) When would you treat this fistula? May the fistula be protective?

2) Would embolization or ligation be the treatment of choice?

3) What would you use to embolize the fistula with?

References:

1. Skudder PA Jr; Rhodes GA. Hemodynamics of in situ vein bypass: the role of side branch fistulae. Ann Vasc Surg 1986 Nov;1(3):335-9.

2. Lundell A; Nyborg K. Do residual arteriovenous fistulae after in situ saphenous vein bypass grafting influence patency? J Vasc Surg 1999 Jul;30(1):99-10.

4. Nielsen TG; Djurhuus C; Pedersen EM; Laustsen J; Hasenkam JM; Schroeder TV. Arteriovenous fistulas aggravate the hemodynamic effect of vein bypass stenoses: an in vitro study. J Vasc Surg 1996 Dec;24(6):1043-9.