Images in Clinical Medicine

Acquired Arteriovenous Fistula

Oren K. Steinmetz, M.D., and L.P. Palerme, M.D.

N Engl J Med 2004; 350:2180May 20, 2004

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Article

A 35-year-old man presented with high-output congestive heart failure. Fourteen years earlier, he had received a shrapnel wound to the left thigh in a car-bomb attack in Lebanon. As a consequence, a progressively enlarging pulsatile mass had developed in the left side of the groin. Angiography showed a large arteriovenous fistula involving the deep femoral artery and vein (Panel A, arrow). A computed tomographic scan showed a large, thrombosed false aneurysm associated with the fistula (Panel B, arrow); a shrapnel fragment was also present (arrowhead). At surgery, all inflow and outflow vessels associated with the fistula were ligated. After surgery, the mass was no longer pulsatile, and the congestive heart failure resolved promptly.

Oren K. Steinmetz, M.D.
L.P. Palerme, M.D.
McGill University Health Center, Montreal, QC H3A 1A1, Canada