Contemporary management of giant renal and visceral arteriovenous fistulae

Purpose: To evaluate our experience with treatment of giant arteriovenous fistulae (AVFs) involving the renal and visceral vasculature and assess outcomes. Methods: Clinical data from 12 consecutive patients (10 women; median age 58 years, range 37-79) undergoing intervention for 14 giant renal/visceral AVFs over a 15-year period (1994-2008) were retrospectively reviewed. Only patients with extra-parenchymal, wide arteriovenous communications were included. Thirteen were located in the renal artery and one in the splenic artery. The etiology was most likely post-traumatic/iatrogenic in 6 patients, idiopathic in 4 (1 bilateral), congenital in 1 (bilateral), and one was associated with fibromuscular dysplasia. In 4 cases, the lesion was asymptomatic. Results: Two large renal AVFs were treated with open surgery: one elective AV fistula repair early in our experience and the other an emergent nephrectomy for rupture. Twelve AV fistulae were closed successfully using endovascular techniques performed solely through the feeding vessel without cannulating the draining vein. All symptomatic patients, except one with continued dyspnea from cardiac causes, had complete symptomatic relief. There was no mortality. Morbidity included 2 access site hematomas that were managed conservatively. Loss of renal parenchyma ranged from 5% to 30%, but median serum creatinine levels remained stable. Conclusion: Endovascular treatment of giant renal/visceral AVFs is challenging but feasible and safe, with good organ preservation. Endovascular techniques have replaced open surgical repair as a first-line treatment for these challenging lesions.