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Renal Arteriovenous Fistula and AV Malformations

Definitions

Renal arteriovenous fistula:

A pathological direct communication between a renal artery and a renal vein without an intervening capillary bed, usually caused by trauma, an iatrogenic event, or degeneration.

Renal arteriovenous malformation:

A vascular nidus composed of multiple pathological arteriovenous shunts. Arteriovenous malformations are usually congenital (Cura et al., 2010).

Epidemiology

Congenital renal arteriovenous malformations are rare; a prevalence of 40 per 100,000 was reported in an autopsy study. Women are affected more often than men (3:1). Acquired renal arteriovenous fistulas arise predominantly as iatrogenic lesions after renal biopsy or urologic procedures. After partial nephrectomy or percutaneous nephrolithotomy, the overall incidence of iatrogenic vascular lesions, most commonly pseudoaneurysms and less frequently arteriovenous fistulas, is approximately 1–2%.

Signs and Symptoms

• Loud bruit
• Arterial hypertension
• Left ventricular hypertrophy and failure
• Hematuria
• Flank pain
• Asymptomatic incidental findings are possible

Diagnostic Workup

Laboratory tests (complete blood count, serum creatinine, urinalysis, and coagulation studies), renal ultrasonography with Doppler, CT angiography, or MR angiography. Digital subtraction angiography is the diagnostic gold standard because it precisely delineates morphology and hemodynamics while simultaneously allowing endovascular treatment.

Treatment of Renal AV Fistula

In small, asymptomatic, iatrogenic arteriovenous fistulas, initial conservative management with clinical and sonographic follow-up is reasonable. Endovascular intervention is the treatment of first choice: selective embolization, coil occlusion, or placement of a covered stent. Open surgery is required in difficult cases and when complications are present. Partial nephrectomy should be pursued when renal function is adequate. (Laparoscopic) nephrectomy is necessary when renal function is absent or when large arteriovenous fistulas cannot be controlled without nephrectomy. When present, hypertension and heart failure should be treated medically before surgery.

References

Cura, M.; Elmerhi, F.; Suri, R.; Bugnone, A. & Dalsaso, T. Vascular malformations and arteriovenous fistulas of the kidney.
Acta Radiol, 2010, 51, 144-149.

  Deutsche Version: Arteriovenöse Fistel der Nierengefäße

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