Critical Limb Ischemia as a Consequence of Multiple Spontaneous Arteriovenous Fistulas and Peripheral Arterial Disease

Abstract

An arteriovenous fistula (AVF) is an abnormal connection between the arteries and veins. AVFs are usually caused by trauma or surgical intervention and may sometimes be congenital 1-3). There are few reports on the occurrence of spontaneous AVFs with peripheral artery disease (PAD) 4-6) , and only one report on multiple spontaneous AVFs with PAD in the femoral artery. Herein we describe our experience with a case of critical limb ischemia caused by spontaneous AVF and PAD in the lower limb. Case report An 83-year-old woman with a history of diabetes mellitus, hypertension, heart failure, spinal canal stenosis, and diabetic nephropathy visited our hospital. She had been diagnosed with diabetes mellitus for 10 years, but had not been treated. Moreover, she had been experiencing pain and muscle weakness in her legs while walking for about 20 years. There was no history of venous dilatation, pulsation, or bleeding in the legs, which are typical symptoms of arteriovenous malformation. She was referred to our hospital because of an ulcer on her left first toe, which had not healed for a month after surgery for an ingrown nail at another clinic (Fig. 1). Skin perfusion pressure (SPP) on the front and back sides of the left leg were 13 and 20 mmHg, respectively, and those on the dorsal and plantar sides of the left foot were 18 and 17 mmHg, respectively. The ankle-brachial pressure index of the left leg was 0.44. Arterial phase angiography revealed severe constriction and arteriosclerosis in the arteries of the lower leg