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Vascular/Cardiac » Peripheral Vascular
Iatrogenic arteriovenous fistula
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Author(s) :
Daniel Merton
 
Presentation This patient had a recent cardiac catheterization with vascular access through the right femoral artery. One day after the catheterization a bruit was detected in the patient’s right groin. An ultrasound study was performed.
 
 
 
Caption: Color Doppler image of the right groin
Description: This CDI demonstrates a typical color bruit artifact associated with tissue vibration. The color bruit artifact obscures underlying anatomical information.
 
 
 
Caption: Spectral Doppler from above the vascular access site.
Description: This spectral Doppler waveform was obtained from the femoral artery above the vascular access site.
 
 
 
Caption: Spectral Doppler from below the vascular access site.
Description: A spectral Doppler waveform obtained from the femoral artery below the vascular access site.
 
Differential Diagnosis
  • Arteriovenous fistula
  • Arterial stenosis
  • Pseudoaneurysm
  • Arterial dissection

 
Final Diagnosis Arteriovenous fistula
 
Discussion

Arteriovenous fistulas (AVFs) can result when there is puncture of an artery and vein with a direct communication between the two injured vessels. A significant pressure gradient will result in a focal area of significantly increased velocity at the site of the AVF with flow directed from the artery to the vein. Color Doppler imaging of AVFs will often demonstrate a bruit artifact and/or a thrill may be palpable. Spectral Doppler analysis of the effected artery above the AVF will demonstrate a mono-phasic continuous waveform with elevated systolic and diastolic velocities. Flow in the injured artery distal to the AVF will generally have normal pulsatility. Spectral Doppler analysis of the effected vein central to the AVF will demonstrate “arterialized flow” with pulsations during systole and a lack of respiratory phasicity.

Color Doppler imaging will often demonstrate a color bruit artifact (as shown in Image 1) in the region of a previous arterial catheterization. A CDI image of the region using a higher CDI PRF (scale) may help to eliminate the CDI bruit artifact and permits identification of the precise site of the AVF communication (see Image 4). The use of the higher CDI PRF permits more accurate placement of a pulsed Doppler sample volume (see Image 5) to obtain a waveform typical of an AVF (i.e., a monophasic-continuous waveform with significantly elevated velocities throughout the cardiac cycle).

 
Case References
  1. Liu JB, Merton DA, Mitchell DG, Needleman L, Kurtz AB, Goldberg BB: Color Doppler imaging of the iliofemoral region. Radiographics. 1990 10:403-412.

  2. Mitchell DG, Merton DA, Liu JB, Goldberg BB: Superficial masses with color flow Doppler imaging. J Clinical Ultrasound. 1991 19:555-560

  3. Helvie MA, Rubin J. Evaluation of traumatic groin arteriovenous fistulas with duplex Doppler sonography. J Ultrasound Med 1989;8:21.

  4. Roubidoux MA, Hertzberg BS, Carroll BA, et al. Color flow and image-directed Doppler ultrasound evaluation of iatrogenic arteriovenous fistulas in the groin. J Clin Ultrasound 1990;18:463.

  5. Fellmeth BD, Roberts AC, Bookstein JJ, Freischlag JA, Forsythe JR, Buckner NK, Hye RJ. Postangiographic femoral artery injuries: nonsurgical repair with US-guided compression. Radiology. 1991;178: 671–675  

  6. Coughlin BF, Paushter DM. Peripheral pseudoaneurysms: evaluation with duplex US. Radiology 1988;168:339.

  7. Helvie MA, Rubin JM, Silver TM, et al. The distinction between femoral artery pseudoaneurysms and other causes of groin masses: value of duplex Doppler sonography. AJR Am J Roentgenol 1988;150:1177.

  8. Fellmeth BD, Baron SB, Brown PR, et al. Repair of postcatheterization femoral pseudoaneurysms by color flow ultrasound guided compression. Am Heart J 1992;123:547.

  9. Polak JF, Donaldson MC, Whittemore AD, et al. Pulsatile masses surrounding vascular prostheses: real-time US color flow imaging. Radiology 1989;170:363.

  10. McCann RL, Schwartz LB, Pieper KS. Vascular complications of cardiac catheterization. J Vasc Surg 14:375, 1991.

  11. Kresowik TF, Khoury MD, Miller BV, et al. A prospective study of the incidence and natural history of femoral vascular complications after percutaneous transluminal coronary angioplasty. J Vasc Surg 1991;13:328

 
Technical Details

Philips Medical Systems IU-22 scanner with L8-4 flat linear array probe

 
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