2 Cases of Pulsatile Phlebitis Due to Micro-Arteriovenous Fistula

We report the 2 cases of pulsatile phlebitis due to micro-AVF and discuss the pathophysiology of micro-AVF.

Results:

In case 1, a 79-year-old female had been suffered from left leg swelling with pigmentation for a few years. Computed tomography angiography (CTA) findings of early venous return of lt leg superficial vein suggested the presence of micro-AVF. Ultrasound examination detected pulsatile prograde flow without reflux on saphenous veins, and we consider the micro-AVF as the cause of the symptom. Endovenous laser ablation (EVLA) by multiple direct punctures ablation (MDPA) method were performed and the symptom was improved. In case 2, a 70-year-old male had been suffered from leg swelling and ulcer at the left lower limb. Conservative therapies were performed, but the symptom had not been improved. Ultrasound examination revealed the arterialized waveforms and reflux in pulsed doppler and it diagnosed the presence of micro-AVF in the foot. EVLA for both GSV and SSV and sclerosing therapy were performed. It could treat that symptom, and his swelling leg and ulcer were improved. These 2 cases showed no reflux finding in saphenous veins and perforators.

Conclusions:

Micro-AVF is distinguished from congenital AVF and acquired AVF due to trauma and iatrogenicity. Micro-AVF exhibits venous excessive flow and shear stress, hypertension and it can be is considered to contribute to varicose veins, leg edema and statis dermatitis. Venous hypertension due to micro-AVF may induce dilatation and valve insufficiency of a perforating vein and allow regurgitation from the penetrating vein to the superficial vein. As a result, skin symptoms including a variety of resting pain, local color, dilation of superficial veins, edema, skin ulcer, etc. are exhibited.

In terms of diagnose of micro-AVF, CTA and ultrasound examination plays the important role. The arterialized waveforms and reflux by the doppler ultrasound examination is the important findings of micro-AVF.

There is a possibility that some cases of skin lesion in the lower extremities are related to micro-AVF, and it may not be so extremely rare as the physiology than we had expected. It is important to recognize that micro-AVF can cause the skin lesions and edema in the lower extremities.